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The European Society of Cardiology issued updated syncope guidelines in 2018 which included recommendations for managing syncope in the emergency department (ED) setting. However, these guidelines lack detailed process-oriented instructions regarding the fact that ED syncope patients initially present with a transient loss of consciousness (TLOC), which can have a broad spectrum of causes. This study aims to establish a European consensus on the general process of the workup and care for patients with suspected syncope and provides rules for sufficient and systematic management of the broad group of syncope (initially presenting as TLOC) patients in the ED. A variety of European diagnostic and therapeutic standards for syncope patients were reviewed and summarized in three rounds of a modified Delphi process by the European Society for Emergency Medicine syncope group. Based on a consensus statement, a detailed process pathway is created. The primary outcome of this work is the presentation of a universal process pathway for the structured management of syncope patients in European EDs. The here presented extended event process chain (eEPC) summarizes and homogenizes the process management of European ED syncope patients. Additionally, an exemplary translation of the eEPC into a practice-based flowchart algorithm, which can be used as an example for practical use in the ED, is provided in this work. Syncope patients, initially presenting with TLOC, are common and pose challenges in the ED. Despite variations in process management across Europe, the development of a universally applicable syncope eEPC in the ED was successfully achieved. Key features of the consensus and eEPC include ruling out life-threatening causes, distinguishing syncope from nonsyncopal TLOCs, employing syncope risk stratification categories and based on this, making informed decisions regarding admission or discharge., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Importance: In 2018, the European Society of Cardiology (ESC) produced syncope guidelines that for the first-time incorporated Emergency Department (ED) management. However, very little is known about the characteristics and management of this patient group across Europe., Objectives: To examine the prevalence, clinical presentation, assessment, investigation (ECG and laboratory testing), management and ESC and Canadian Syncope Risk Score (CSRS) categories of adult European ED patients presenting with transient loss of consciousness (TLOC, undifferentiated or suspected syncope)., Design: Prospective, multicentre, observational cohort study., Settings and Participants: Adults (≥18 years) presenting to European EDs with TLOC, either undifferentiated or thought to be of syncopal origin., Main Results: Between 00:01 Monday, September 12th to 23:59 Sunday 25 September 2022, 952 patients presenting to 41 EDs in 14 European countries were enrolled from 98 301 ED presentations (n = 40 sites). Mean age (SD) was 60.7 (21.7) years and 487 participants were male (51.2%). In total, 379 (39.8%) were admitted to hospital and 573 (60.2%) were discharged. 271 (28.5%) were admitted to an observation unit first with 143 (52.8%) of these being admitted from this. 717 (75.3%) participants were high-risk according to ESC guidelines (and not suitable for discharge from ED) and 235 (24.7%) were low risk. Admission rate increased with increasing ESC high-risk factors; 1 ESC high-risk factor; n = 259 (27.2%, admission rate=34.7%), 2; 189 (19.9%; 38.6%), 3; 106 (11.1%, 54.7%, 4; 62 (6.5%, 60.4%), 5; 48 (5.0%, 67.9%, 6+; 53 (5.6%, 67.9%). Furthermore, 660 (69.3%), 250 (26.3%), 34 (3.5%) and 8 (0.8%) participants had a low, medium, high, and very high CSRS respectively with respective admission rates of 31.4%, 56.0%, 76.5% and 75.0%. Admission rates (19.3-88.9%), use of an observation/decision unit (0-100%), and percentage high-risk (64.8-88.9%) varies widely between countries., Conclusion: This European prospective cohort study reported a 1% prevalence of syncope in the ED. 4 in 10 patients are admitted to hospital although there is wide variation between country in syncope management. Three-quarters of patients have ESC high-risk characteristics with admission percentage rising with increasing ESC high-risk factors., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Importance: Palpitation is one of the commonest presenting complaints to the emergency department (ED). Diagnosis depends on capturing an ECG during the episode. Unlike syncope, patients retain consciousness and therefore their ability to activate an ECG event recorder. The Investigation of Palpitation in the ED study demonstrated Food and Drug Administration approved AliveCor/Kardia device that links to a smartphone app was safe and effective. A Smartphone Palpitation and Pre-syncope Ambulatory Care Clinic was therefore established., Objectives: To review the first year of patients attending the service to determine the number and cost-effectiveness of cardiac dysrhythmias diagnoses., Design: Single-center cohort study., Settings and Participants: Royal Infirmary of Edinburgh, UK. All patients (over 16 years) presenting consecutively to ED with palpitation or pre-syncope, whose ECG was normal, had a compatible device and where an underlying cardiac dysrhythmia was possible were enrolled., Intervention: Ambulatory Care Clinic utilizing the AliveCor/Kardia device., Outcome Measures and Analysis: Number diagnosed with cardiac dysrhythmia and mean cost per diagnosis., Main Results: Between 24 July 2019 and 23 July 2020, 290 consecutive patients were referred of age 16-80 years (mean 43.3, SD 15.0). One hundred twenty (41.4%) were male. Two hundred thirty-seven (81.7%) were fitted with the device and 220 (75.9%) underwent full investigation. Seventeen of 237 (7.2%) patients had a cardiac diagnosis (12 atrial fibrillation/flutter, 5 supraventricular tachycardia and 1 atrial tachycardia)., Conclusions: There were 17 cardiac diagnoses (7.2%). The cost per symptomatic rhythm diagnosis was 358 GBP (~415 Euro) and the cost per cardiac dysrhythmia diagnosis was 4570 GBP (~5298 Euro). A smartphone-based event recorder clinic should be considered for ED palpitation patients., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To investigate echocardiography in life support (ELS) use in Emergency Department (ED) cardiac arrest patients before and after a training day., Methods: A prospective before and after cohort study. Data was collated over a 24-month period before and after an ELS training day from our ED ultrasound database [Registry of Emergency Based Ultrasound Scanning (REBUS)], ED electronic patient records and from stored digital ELS scans., Results: In the year before ELS training, eight of 187 cardiac arrest patients had ELS performed (4.3%). In the year after training, 46 of 232 cardiac arrest patients had ELS performed (19.8%; P<0.001). This increase has persisted with 40 of 129 (31%) patients undergoing ELS in the 6 months poststudy period. ELS aided management in six of eight pretraining cases and 32 of 46 post-training cases., Conclusion: Use of ELS significantly increased after the training day most commonly supporting a decision to stop resuscitation. This change in practice has been maintained.

Objectives: The aim of this study was to determine whether paramedics can be trained to perform and interpret focussed Echo in Life Support (ELS) for the assessment of cardiac movement and the recognition of reversible causes of cardiac arrest., Methods: This study is a prospective observational pilot study. Data were collected during a 1-day course training 11 paramedics to perform ELS scans on healthy volunteers. The students were assessed on image acquisition skills and theoretical knowledge (including interpretation). Level 1 ultrasound-trained emergency medicine physicians undertook the training and assessment., Results: All paramedics could obtain images in the parasternal and subxiphoid views. When performing scans in the 10-s pulse check window, 88% of attempts in both views were successful (subxiphoid mean image quality 3.8 out of 5, parasternal 4.0). Theoretical knowledge improved (mean precourse score 54%, postcourse score 89%; P<0.001). There was no apparent association between theoretical and practical performances. At 10 weeks, theoretical knowledge was nonsignificantly reduced (82%; P=0.13) but less when compared with practical performance (75% subxiphoid success, mean quality 3.0; 25% parasternal success, mean quality 4.0)., Conclusion: Paramedics can perform focused ELS, integrate attempts into simulated cardiac arrest scenarios and retain some of this knowledge. Further work is required to assess the feasibility of incorporating this into real-world cardiac arrest management.

Objectives: Does emergency ultrasound (EU) improve the speed of diagnosis of patients presenting to the emergency department (ED) with a ruptured abdominal aortic aneurysm (rAAA)?, Methods: This is a retrospective study of all patients presenting to the ED of the Royal Infirmary of Edinburgh (RIE) with an rAAA. The RIE surgical database and the RIE ED registry of emergency-based ultrasound scans were assessed and time to diagnose rAAA was compared for the periods before and after the introduction of EU, as well as for rAAA patients who underwent EU and those who did not. Patients with known AAA and those transferred from another hospital with known or suspected rAAA were excluded., Results: Between 27 December 2006 and 13 January 2009, before the establishment of our EU programme, 65 patients presented to the ED of RIE with an rAAA. The median time to diagnosis was 95 min [interquartile range (IQR) 41-195 min; n=30]. Between 14 January 2009 and 15 February 2012, after the establishment of our EU programme, 54 patients presented to the ED of RIE with an rAAA. The median time to diagnosis was 64 min (IQR 31-140 min; n=28; Z=0.95, P=0.3421). Eighteen out of the 28 patients with rAAA underwent EU; the median time to diagnosis was 60 min (IQR 27-115 min; n=18). Of the patients with rAAA, 35 did not undergo EU; the median time to diagnosis was 111 min (IQR 45-213 min; n=35; Z=-1.69, P=0.091). There was no improvement in survival between patients who underwent an ED EU and those who did not (P=0.40)., Conclusion: There was a nonsignificant trend towards a faster time to diagnosis (51 min) in rAAA patients who underwent EU on presenting to the ED compared with those who did not undergo an ED EU (111 min). There was no improvement in survival or length of ICU unit stay.

Objectives: The aim of this study was to describe baseline coagulation in patients presenting to the emergency department (ED) with a ruptured abdominal aortic aneurysm (rAAA) and its effect on survival., Methods: Retrospective study of ED, theatre and laboratory records of patients presenting with rAAA to the Royal Infirmary of Edinburgh ED. Patients with symptomatic aneurysms, those without an initial ED coagulation screen and those on warfarin were excluded. Major coagulopathy was defined as international normalized ratio or activated partial thromboplastin time (APTT) ratio of at least 1.5 or platelet count less than 50 × 10/l., Results: Between 1 July 2006 and 31 March 2011, 119 patients were enrolled. Mean (± SD) age was 76.5 ± 7.6 years and male to female ratio was 2.3 : 1. Ten patients died in the ED, 20 were considered not fit for surgery and 89 went to theatre. A total of 56 survived to hospital discharge. Seventeen (14.3%) patients had a major coagulopathy; an international normalized ratio or APTT ratio of at least 1.5. No patients had platelets less than 50 × 10/l, but eight patients had platelets less than 100 × 10/l. Neither ED prothrombin time (PT) nor ED APTT was associated with survival in either the operated [P=0.167 NS (PT) and P=0.353 NS (APTT); two-sided t-test] or entire cohort [P=0.254 NS (PT) and P=0.413 NS (APTT); two-sided t-test] groups., Conclusion: Although coagulopathy is often present in patients presenting with a rAAA, it does not seem to be associated with a poorer outcome. Our results seem to suggest that altering the current practice of minimal transfusion in the ED to include early transfusion of blood products, such as platelets or fresh frozen plasma, is therefore unlikely to improve outcome.

Objectives and Background: For the first time in the Emergency Department (ED), to assess the use of rotational thromboelastometry (ROTEM) in patients presenting with all-cause haemodynamic shock, specifically (a) to establish whether a 5- min (A5) or a 10-min result (A10) is accurate compared with a final maximum clot firmness (MCF) result; (b) to compare time to A10 and formal laboratory coagulation result; (c) to assess whether bleeding ED trauma, gastrointestinal and aortic aneurysm patients are coagulopathic according to ROTEM; and (d) to compare ROTEM results with formal laboratory coagulation parameters., Methods: Patients presenting to the ED in haemodynamic shock were recruited. A citrated coagulation sample was taken and once a ROTEM researcher arrived in the ED, was subjected to ROTEM analysis., Results: Between 28 September 2010 and 31 August 2011, 40 patients were recruited (15 gastrointestinal bleeds, 20 major trauma cases and five ruptured abdominal aortic aneurysms). A10 and MCF correlated well (κ=0.98); A5 and MCF correlated less well (κ=0.91). The mean time to result (SD) was 57 (28) min for the formal laboratory coagulation result and 50 (45) min for the ROTEM A10 result (including delay to start of analysis). Seven patients were coagulopathic on ROTEM., Conclusion: Eighteen percent of bleeding ED patients are coagulopathic using ROTEM including 25% of trauma patients. A 10-min ROTEM clot firmness (A10) is an excellent surrogate for MCF and allows a result to be obtained earlier than formal laboratory results and potentially within 10 min of the patient arriving in the ED.

Aim: To audit the management of nontraumatic hot swollen joints presenting to a large UK university teaching hospital and to design a simple emergency department (ED) algorithm to improve patient care based on existing guidelines and our experience., Methods: Prospective audit., Results: Between 2 February and 8 May 2009, 77 patients were enrolled. Median age was 58 years (range 19-89 years) and 57% were male patients. The most commonly affected joint was the knee (38%), with the knee, wrist, ankle, hip and elbow comprising 87% of affected joints. Thirty-three (43%) joints were aspirated; no organisms were found on microscopy or cultured in any aspirates; crystals were found in eight aspirates. Twenty-four patients were admitted. Gout was the most common final diagnosis in 14 (18%) patients, with cellulitis being the next most common diagnosis (n=9; 12%). Bursitis (n=7; 9%), nonspecific arthritis (n=7; 9%) and reactive arthritis (n=6; 8%) were also not uncommon. Four (5%) patients were treated for possible septic arthritis. It was noticed that many patients spent a long time in the ED waiting firstly for a decision to aspirate, and secondly for a senior clinician to perform this., Conclusion: Patients presenting with nontraumatic hot swollen joints are common and the knee, wrist, ankle, hip and elbow are commonly affected. Joint aspirate is required to rule out septic arthritis, should be considered early and appropriate personnel called, and can show the presence of gout or pseudogout. Septic arthritis should still be considered in patients with a negative aspirate in whom there is high clinical suspicion. Our simple ED algorithm may improve patient care.

The objective of this study was to assess whether the number of syncope attendances to the Emergency Department is related to daily temperature and humidity, or time of the day, day of the week, month or season of the year. All adult patients presenting with syncope over a 1-year period between 1 March 2007 and 29 February 2008 were enrolled. A circadian pattern of syncope attendances exists, peak attendance was between 10 : 00 and 16 : 00 h, especially in those aged above 65 years (P<0.001). There was no obvious relationship between attendances and mean daily temperature (r=0.16) and attendances and mean daily humidity (r=-0.14). There were 11% more attendances between December and May than between June and October (P=0.8, NS, chi). In conclusion, there is a circadian pattern of syncope attendances to the Emergency Department. The peak time for presentations is between 10 : 00 and 16 : 00 h. A trend was found towards more attendances between December and May. One hypothesis for this is differences between indoor and outdoor temperatures. Public health campaigns could be targeted towards elderly patients to ensure that they are aware of the increased risk of syncope on waking and also on transferring from cold to warm environments.

Aim: To establish whether D-dimer is an independent predictor of 1-month serious outcome and all-cause death in syncope patients presenting to the emergency department (ED)., Methods: This was a prospective cohort study of all adults presenting with syncope to an ED in the UK. Plasma D-dimer concentrations were determined in citrated plasma obtained at presentation. The primary endpoint was the combination of serious outcome and all-cause death at 1 month., Results: Of 237 patients enrolled, 205 patients had a suitable plasma sample and had complete follow-up. Seventeen patients had a serious outcome or death at 1 month including three patients with a pulmonary embolus and eight with a serious cardiovascular outcome. Nearly a half of all patients (n=94; 46%) had a plasma D-dimer concentration above the upper limit of normal, 10 of whom had a serious outcome or death at 1 month. Receiver-operator characteristic curve analysis showed no relationship between plasma D-dimer concentration and serious outcome or death at 1 month. An elevated plasma D-dimer concentration was found in all patients with a pulmonary embolus., Conclusion: Plasma D-dimer is frequently raised in patients presenting with syncope to the ED and consequently does not predict 1-month serious outcome or death. We conclude that there is no role for the routine measurement of D-dimer in the management of patients presenting to the ED with syncope.

Gamma hydroxybutyrate is increasingly being used recreationally in the United Kingdom. We present a case of gamma hydroxybutyrate overdose associated with paroxysmal sympathetic storm, a phenomenon usually confined to patients who have sustained traumatic brain injury.

Objective: To assess whether the 'LEMON' method, devised by the developers of the US National Emergency Airway Management Course, is an easily applied airway assessment tool in patients undergoing treatment in the emergency department resuscitation room., Methods: One hundred patients treated in the resuscitation room of a UK teaching hospital between June 2002 and January 2003 were assessed on criteria based on the 'LEMON' method., Results: All seven criteria of the 'Look' section of the method could be adequately assessed. Data for the 'Evaluate' section could not be obtained in 10 patients, with inter-incisor distance being the most problematical item. The 'Mallampatti' score was unavailable in 43 patients, and had to be assessed in the supine position in 32 of the remaining 57 patients. Assessment for airway 'Obstruction' and 'Neck mobility' could be performed in all patients., Conclusion: The 'Look', 'Obstruction' and 'Neck mobility' components of the 'LEMON' method are the easiest to assess in patients undergoing treatment in the emergency department resuscitation room. The 'Evaluate' and 'Mallampatti' components are less easily applied to the population that present to the resuscitation room, and assessment of these is more problematical and prone to inaccuracy. We suggest that the 'LEMON' airway assessment method may not be easily applied in its entirety to unselected resuscitation room patients, and that information on the 'Evaluate' and 'Mallampatti' parameters may not always be available.