Emergency medicine journal : EMJ
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Frequent use of emergency medical services (EMS) is recognised to be a global phenomenon, although paediatric frequent use is poorly understood. This systematic review aimed to understand how paediatric frequent use of EMS is currently defined, identify factors associated with paediatric frequent use of EMS and determine effectiveness of interventions for paediatric patients who frequently use EMS. ⋯ The broad range of reasons for frequent use suggests that a single intervention is unlikely to be effective at addressing the causes of frequent use. There is a need for further research to better identify the underlying reasons for frequent EMS use among paediatric patients and to develop interventions in this population.
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Patients with lower limb injuries are commonly discharged from the ED with the affected area immobilised. Rigid casting of the lower limb is known to be a risk factor for the development of venous thromboembolism (VTE), making thromboprophylaxis in this population an important consideration for clinicians in the ED. The use of structured risk assessment methods (RAMs) to evaluate VTE risk and recommend thromboprophylaxis to those at higher risk is widespread in the UK. However, the evidence informing this practice is nearly exclusively based on studies of patients with rigid lower limb casts but many patients with knee injuries, including some with significant thrombotic risk factors, are managed in semi-rigid ('cricket') knee splints. These are both removable and allow free movement of the ankle, but the baseline risk of VTE and the performance of different RAMs in this population are not known. ⋯ In our cohort of patients managed in semi-rigid removable knee splints, the risk of symptomatic VTE was low, about 1 in 250, and current methods of VTE risk assessment did not prove clinically useful.
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Observational Study
The association between vital signs and clinical outcomes in emergency department patients of different age categories.
Appropriate interpretation of vital signs is essential for risk stratification in the emergency department (ED) but may change with advancing age. In several guidelines, risk scores such as the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) scores, commonly used in emergency medicine practice (as well as critical care) specify a single cut-off or threshold for each of the commonly measured vital signs. Although a single cut-off may be convenient, it is unknown whether a single cut-off for vital signs truly exists and if the association between vital signs and in-hospital mortality differs per age-category. ⋯ For SBP, DBP, SpO2 and HR, no single cut-off existed. The impact of changing vital sign categories on prognosis was larger in older patients. Our results have implications for the interpretation of vital signs in existing risk stratification tools and acute care guidelines.
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Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method. ⋯ Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.
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We sought to evaluate the effect of adult procedural sedation on cerebral oxygenation measured by near-infrared spectroscopy (rSo2 levels), and to assess whether respiratory depression occurring during procedural sedation was associated with decreases in cerebral oxygenation. ⋯ Cerebral oximetry may represent a useful tool for procedural sedation safety research to detect potential subclinical changes that may be associated with risk, but appears neither sensitive nor specific for routine use in clinical practice.