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ObjectivesThe Manchester Acute Coronary Syndromes ECG (MACS-ECG) prediction model calculates a score based on objective ECG measurements to give the probability of a non-ST elevation myocardial infarction (NSTEMI). The model showed good performance in the emergency department (ED), but its accuracy in the pre-hospital setting is unknown. We aimed to externally validate MACS-ECG in the pre-hospital environment.MethodsWe undertook a secondary analysis from the Pre-hospital Evaluation of Sensitive Troponin (PRESTO) study, a multi-centre prospective study to validate decision aids in the pre-hospital setting (26 February 2019 to 23 March 2020). Patients with chest pain where the treating paramedic suspected acute coronary syndrome were included. Paramedics collected demographic and historical data and interpreted ECGs contemporaneously (as ‘normal’ or ‘abnormal’). After completing recruitment, we analysed ECGs to calculate the MACS-ECG score, using both a pre-defined threshold and a novel threshold that optimises sensitivity to differentiate AMI from non-AMI. This was compared with subjective ECG interpretation by paramedics. The diagnosis of AMI was adjudicated by two investigators based on serial troponin testing in hospital.ResultsOf 691 participants, 87 had type 1 AMI and 687 had complete data for paramedic ECG interpretation. The MACS-ECG model had a C-index of 0.68 (95% CI: 0.61 to 0.75). At the pre-determined cut-off, MACS-ECG had 2.3% (95% CI: 0.3% to 8.1%) sensitivity, 99.5% (95% CI: 98.6% to 99.9%) specificity, 40.0% (95% CI: 10.2% to 79.3%) positive predictive value (PPV) and 87.6% (87.3% to 88.0%) negative predictive value (NPV). At the optimal threshold for sensitivity, MACS-ECG had 50.6% sensitivity (39.6% to 61.5%), 83.1% specificity (79.9% to 86.0%), 30.1% PPV (24.7% to 36.2%) and 92.1% NPV (90.4% to 93.5%). In comparison, paramedics had a sensitivity of 71.3% (95% CI: 60.8% to 80.5%) with 53.8% (95% CI: 53.8% to 61.8%) specificity, 19.7% (17.2% to 22.45%) PPV and 93.3% (90.8% to 95.1%) NPV.ConclusionNeither MACS-ECG nor paramedic ECG interpretation had a sufficiently high PPV or NPV to ‘rule in’ or ‘rule out’ NSTEMI alone.

In 2021, there was a significant increase in the number of reported drink spiking incidents across the UK. The new phenomenon of spiking via injection also emerged, which gained significant media attention. Campaigns encouraged potential spiking victims to attend an ED for testing. However, there is limited published research on drink spiking and no published studies on injection spiking. One UK guideline for the management of spiking exists, advising testing ‘if clinically indicated’ and is likely underused. Therefore, patients are often managed without drug testing, psychological support or a clear onward referral pathway. This practice review will explore the background of spiking, discuss drug testing options and highlight the psychological sequelae of spiking. An example guideline for the management of spiking incidents is attached.

Background: Older people are at the greatest risk of poor outcomes after serious injury. Evidence is limited for the benefit of assessment by a geriatrician in trauma care. We aimed to determine the effect of geriatrician assessment on clinical outcomes for older people admitted to hospital with serious injury. Methods: In this multicentre observational study (FiTR 2), we extracted prospectively collected data on older people (aged ≥65 years) admitted to the 23 major trauma centres in England over a 2·5 year period from the Trauma Audit and Research Network (TARN) database. We examined the effect of a geriatrician assessment within 72 h of admission on the primary outcome of inpatient mortality in older people admitted to hospital with serious injury, with patients censored at discharge. We analysed data using a multi-level Cox regression model and estimated adjusted hazard ratios (aHRs). Findings: Between March 31, 2019, and Oct 31, 2021, 193 156 patients had records held by TARN, of whom 35 490 were included in these analyses. Median age was 81·4 years (IQR 74·1–87·6), 19 468 (54·9%) were female, and 16 022 (45·1%) were male. 28 208 (79·5%) patients had experienced a fall from less than 2 m. 16 504 (46·5%) people received a geriatrician assessment. 4419 (12·5%) patients died during hospital stay, with a median time from admission to death of 6 days (IQR 2–14). Of those who died, 1660 (37·6%) had received a geriatrician assessment and 2759 (62·4%) had not (aHR 0·43 [95% CI 0·40–0·46]; p

The perspective of patients is increasingly recognised as important to care improvement and innovation. Patient questionnaires such as patient-reported outcome measures may often require cross-cultural adaptation (CCA) to gather their intended information most effectively when used in cultures and languages different to those in which they were developed. The use of CCA could be seen as a practical step in addressing the known problems of inclusion, diversity and access in medical research.An example of the recent adaptation of a patient-reported outcome measure for use with ED patients is used to explore some key features of CCA, introduce the importance of CCA to emergency care practitioners and highlight the limitations of CCA.

IntroductionPatients presenting to EDs with chest pain of possible cardiac origin represent a substantial and challenging cohort to risk stratify. Scores such as HE-MACS (History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid) and HEAR (History, ECG, Age, Risk factors) have been developed to stratify risk without the need for troponin testing. Validation of these scores remains limited.MethodsWe performed a post hoc analysis of the Limit of Detection and ECG discharge strategy randomised-controlled trial dataset (n=629; June 2018 to March 2019; 8 UK hospitals) to calculate HEAR and HE-MACS scores. A ResultsMACE within 30 days occurred in 42/629 (7%) of the cohort. HE-MACS and HEAR scores identified 85/629 and 181/629 patients as ‘very low risk’, with MACE occurring in 0/85 and 1/181 patients, respectively. The sensitivities of each score for ruling out MACE were 100% (95% CI: 91.6% to 100%) for HE-MACS and 97.6% (95% CI: 87.7% to 99.9%) for HEAR. Presenting symptoms within these scores were poorly predictive, with only diaphoresis reaching statistical significance (OR: 4.99 (2.33 to 10.67)). Conventional cardiovascular risk factors and clinician suspicion were related to the presence of MACE at 30 days.ConclusionHEAR and HE-MACS show potential as rule out tools for acute myocardial infarction without the need for troponin testing. However, prospective studies are required to further validate these scores.

Introduction: The Trainee Emergency Research Network (TERN) was established in 2018 by the Royal College of Emergency Medicine (RCEM) to improve research engagement and demystify clinical research within emergency medicine (EM). The first studies involved over a hundred EDs across the UK and Ireland. These were selected through discussion and voting at early TERN meetings. Understanding the research priorities of trainees is important. The priorities perceived as important to clinicians reflect their daily working practice, and differ between junior and senior medical staff. Previous research prioritisation exercises have favoured senior input and there have been no previous trainee-specific research prioritisation exercises. It is important for research engagement that trainees are interested in projects they work on. A Delphi technique is often used to determine research priorities and was selected here. Methods A two-stage modified Delphi process surveyed UK and Ireland EM trainees using an online survey platform over a four-week period in November 2020. Stage 1 invited respondents to submit up to six research priorities they thought most important to their practice. These were refined by a panel of RCEM professors who provided an overview of ongoing trials and the wider research landscape. Duplicate entries, entries not from UK or Ireland trainees, previously answered questions or those outside the scope of EM were removed and refined to produce a shortlist for stage 2. In stage 2, a panel of EM trainees holding roles as TERN regional representatives participated in a five-round Delphi process to determine consensus between February 2021 – July 2021. The shortlisted priorities were rated on a five-point Likert scale asking trainees to rate their relative importance and comment upon these, suggesting amendments to be presented in the following round. Priorities reaching a predefined consensus (≥75%) after each round were included or excluded, with a predefined maximum of five rounds. After the five-round process, a collaborative online workshop between three clinicians, three patient and carer representatives and an independent facilitator was held to refine and rank the priorities which had attained consensus. Lay summaries explained each priority and the groups discussed, commented, amended, and ranked each priority, using a collaborative model of PPI to co-produce a list of research priorities. The methods are outlined in full (Supplementary Material 1).Results: For Stage 1, 60 responses with 162 entries were received. Shortlisting refined these to 64 questions which were amalgamated to produce 31 research priorities for Stage 2. Stage 2 involved a panel of 16 EM trainees. Each round had a response rate of 100%. 7 priorities were introduced during the five-round Delphi process which produced 12 priorities which attained consensus (Table 1), 12 priorities which were excluded and 14 priorities which did not attain consensus. The collaborative workshop refined these priorities. The full reported scores for each priority and items not attaining consensus are demonstrated in the supplementary material.Discussion: The research priorities attaining consensus reflect clinical dilemmas, life-threatening diagnoses, and the optimal delivery of care, reflecting priorities that trainees face daily. There were some limitations. The initial survey received submissions from 60 participants, fewer than other research prioritisation exercises. The usage of RCEM Professors to guide initial priority selection may have introduced bias toward their research interests. The decision not to hold a final meeting for the panellist group limited the ability to produce an ordinally-ranked list of trainee priorities, although the co-produced list incorporated the patient & carer voice into this process. The research priorities of EM trainees across the UK and Ireland have been identified and will help guide the direction of TERN and EM trainee research.

Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management.

ObjectiveTo quantify psychological distress experienced by emergency, anaesthetic and intensive care doctors during the acceleration phase of COVID-19 in the UK and Ireland.MethodsInitial cross-sectional electronic survey distributed during acceleration phase of the first pandemic wave of COVID-19 in the UK and Ireland (UK: 18 March 2020–26 March 2020 and Ireland: 25 March 2020–2 April 2020). Surveys were distributed via established specialty research networks, within a three-part longitudinal study. Participants were doctors working in emergency, anaesthetic and intensive medicine during the first pandemic wave of COVID-19 in acute hospitals across the UK and Ireland. Primary outcome measures were the General Health Questionnaire-12 (GHQ-12). Additional questions examined personal and professional characteristics, experiences of COVID-19 to date, risk to self and others and self-reported perceptions of health and well-being.Results5440 responses were obtained, 54.3% (n=2955) from emergency medicine and 36.9% (n=2005) from anaesthetics. All levels of doctor seniority were represented. For the primary outcome of GHQ-12 score, 44.2% (n=2405) of respondents scored >3, meeting the criteria for psychological distress. 57.3% (n=3045) had never previously provided clinical care during an infectious disease outbreak but over half of respondents felt somewhat prepared (48.6%, n=2653) or very prepared (7.6%, n=416) to provide clinical care to patients with COVID-19. However, 81.1% (n=4414) either agreed (31.1%, n=2709) or strongly agreed (31.1%, n=1705) that their personal health was at risk due to their clinical role.ConclusionsFindings indicate that during the acceleration phase of the COVID-19 pandemic, almost half of frontline doctors working in acute care reported psychological distress as measured by the GHQ-12. Findings from this study should inform strategies to optimise preparedness and explore modifiable factors associated with increased psychological distress in the short and long term.Trial registration numberISRCTN10666798.

Received 12th May 2021. Accepted 17th May 2021. Published online 28th May 2021. Issue published 1st August 2021.

This study aimed to gain an uncensored insight into the most difficult aspects of working as a frontline doctor across successive COVID-19 pandemic waves. Data collected by the parent study (CERA) was analysed using conventional content analysis. Participants comprised frontline doctors who worked in emergency, anaesthetic, and intensive care medicine in the UK and Ireland during the COVID-19 pandemic (n = 1379). All seniority levels were represented, 42.8% of the sample were male, and 69.2% were white. Four themes were identified with nine respective categories (in parentheses): (1) I’m not a COVID hero, I’m COVID cannon fodder (exposed and unprotected, “a kick in the teeth”); (2) the relentlessness and pervasiveness of COVID (“no respite”, “shifting sands”); (3) the ugly truths of the frontline (“inhumane” care, complex team dynamics); (4) an overwhelmed system exacerbated by COVID (overstretched and under-resourced, constant changes and uncertainty, the added hinderance of infection control measures). Findings reflect the multifaceted challenges faced after successive pandemic waves; basic wellbeing needs continue to be neglected and the emotional impact is further pronounced. Steps are necessary to mitigate the repeated trauma exposure of frontline doctors as COVID-19 becomes endemic and health services attempt to recover with inevitable long-term sequelae.

This study aimed to gain an uncensored insight into the most difficult aspects of working as a frontline doctor across successive COVID-19 pandemic waves. Data collected by the parent study (CERA) was analysed using conventional content analysis. Participants comprised frontline doctors who worked in emergency, anaesthetic, and intensive care medicine in the UK and Ireland during the COVID-19 pandemic (n = 1379). All seniority levels were represented, 42.8% of the sample were male, and 69.2% were white. Four themes were identified with nine respective categories (in parentheses): (1) I’m not a COVID hero, I’m COVID cannon fodder (exposed and unprotected, “a kick in the teeth”); (2) the relentlessness and pervasiveness of COVID (“no respite”, “shifting sands”); (3) the ugly truths of the frontline (“inhumane” care, complex team dynamics); (4) an overwhelmed system exacerbated by COVID (overstretched and under-resourced, constant changes and uncertainty, the added hinderance of infection control measures). Findings reflect the multifaceted challenges faced after successive pandemic waves; basic wellbeing needs continue to be neglected and the emotional impact is further pronounced. Steps are necessary to mitigate the repeated trauma exposure of frontline doctors as COVID-19 becomes endemic and health services attempt to recover with inevitable long-term sequelae.

This month’s update is by the Research in Emergency care, Avon Collaborative Hub. We used a multimodal search strategy, drawing on free open-access medical education resources and literature searches. We identified the five most interesting and relevant papers (decided by consensus) and highlight the main findings, key limitations and clinical bottom line for each paper. The papers are ranked as: ### Topic: critical care #### Rating: worth a peek There is known to be a U-shaped relationship between mortality and oxygen concentrations in critically ill patients.1 2 This multicentre randomised controlled trial (RCT) compared low-normal against high-normal arterial oxygen pressure (PaO2) in critically ill patients with systematic inflammatory response syndrome (SIRS). Four hundred adults with ≥2 SIRS criteria, admitted to the intensive care unit (ICU) with an expected stay of 48 hours or longer, were randomised to PaO2 targets of 8–12 kPa (low) or 14–18 kPa (high). The primary outcome was based on daily Sequential Organ Failure Assessment (SOFA) scores, summed over day 1–14, and ranked (SOFA-RANK). Participants were ranked from fastest organ failure improvement (lowest scores) to worsening organ failure or death (highest scores). The range of SOFA-RANK results was between minus scores (low) and positive scores (high). There was no significant difference in organ dysfunction at 14 days; median SOFA-RANK score was −35 (IQR −63 to 0) in the 8–12 kPa group vs −40 (IQR −76 to −4.5) in the 14–18 kPa group, median difference 10 (95% CI 0 to 21, p=0.06). There was no difference in secondary outcomes including 90-day mortality, duration of ventilation or length of ICU stay. There was no loss …

This study aimed to develop empirically grounded recommendations and a coherent model of psychological care derived from the experiences and psychological care needs of COVID-19 frontline doctors, using semi-structured interviews and thematic analysis. Participants were UK frontline doctors specialising in Emergency Medicine, Anaesthetics, or Intensive Care (n = 31) purposively sampled for maximum variation on gender, specialty, ethnicity, and trauma-related distress, most worked in ICU during the pandemic (71%). Four themes were derived: (1) ‘coping strategies’, participants used many, including exercise, mindfulness, and “wait until it gets really bad”, (2) ‘sources of support’, participants valued embedded psychological support, digital services, and informal conversations with colleagues or family, though there was little opportunity, (3) ‘organisational influences on wellbeing’, participants reported a love–hate relationship for concepts like ‘wellbeing’, seen as important but insulting when basic workplace needs were unmet, (4) ‘improving engagement with support’, analysis suggests we must reduce physical and psychological barriers to access and encourage leaders to model psychologically supportive behaviours. Doctors’ frontline COVID-19 working experiences shine a ‘spotlight’ on pre-existing problems such as lack of physical resources and access to psychological care. Empirically grounded recommendations and a model of incremental psychological care are presented for use in clinical services.

Trauma in the elderly (>65 years) is an increasingly common presentation to the ED. A fall from standing height is the most common mechanism after which such patients present, and rib fracture is the most common non-spinal fracture. Thoracic injury in patients aged over 65 is associated with significant morbidity and mortality. There are currently no universally applied guidelines for assessment, investigation and management of such patients. In this expert practice review, we discuss the evidence base and options for clinical management in this vulnerable patient group.

The Emergency Medicine Journal (EMJ) is introducing a new article format: Quality Improvement (QI) reports. In this editorial, we offer answers to the two critical questions any new article type poses: ‘why publish?’ and ‘why read?’. We also explain what is the difference between a QI report and a research paper and describe the requirements of these articles for potential authors. The origins of QI as a discipline are often traced to post-World War 2 Japanese manufacturing, with W. Edwards Deming as a founding father of both QI, and the ‘Japanese economic miracle’ of this period. Building on the work of fellow mathematician and statistician Walter Shewhart, Deming recognised he could understand and reduce variability through regular measurement, and as an engineer, he was able to improve design of both product and process. While it could be argued that attempts to improve quality in medicine can be traced back to Florence Nightingale, the focus on quality of care was given significant impetus in the decades of 1960–1980 when several articles identified deficits in care delivered at national levels.1 2 However, before it is assumed these deficiencies are behind us, in 2003, published data suggested that under 55% patients received recommended care in the USA.3 There are also several recent papers suggesting that internationally and across medical specialities this pattern continues.4 5 During the 1990s, there was an increase in the application of QI techniques and processes to healthcare settings, which has accelerated over the past two decades.1 Knowledge of QI is now an established part of many emergency medicine curricula and engagement in QI often a requirement of regulatory bodies. Batalden and Davidoff6 define QI as: ‘ The combined and unceasing efforts of everyone to make the changes that will lead to better patient outcomes (health), better …

Chest pain risk scores have become almost ubiquitous in their use in EDs internationally. Having internally and externally validated numerous risk scores, together with their use with high-sensitivity troponin (hs-cTn) assays (both T and I hs-cTn assays are available from a variety of manufacturers) over the past decade, I have turned against their use in the clinical environment, for now. Is this because I am disgruntled that not one centre, I am aware of, uses the modified Goldman risk score I spent 3 years of my life evaluating?1 Perhaps. My work evaluating the modified Goldman risk score was published over 5 years ago and at that time we found that this risk score when combined with a single hs-cTnT below the 99th percentile cut-off value taken at presentation to ED had a very high diagnostic accuracy for the rule-out of 30-day major adverse cardiac events (MACE), with a sensitivity of 98.8%. So why did it not take off? There are likely to be several reasons. The score itself is cumbersome, without a catchy acronym and these findings were from a single-centre study. However, one key finding from this earlier work was that an undetectable (below the limit of detection; LoD) hs-cTnT result in isolation, without the need for a cumbersome risk score, had an equally high diagnostic accuracy for the rule-out of 30-day MACE and allowed over 30% of patients with chest pain to be potentially discharged after a single hs-cTnT test. The premise that single hs-cTnT below the LoD, in combination with a non-ischaemic ECG, has since been evaluated in …

BackgroundWe aimed to estimate the diagnostic accuracy of the VitalScan magnetocardiograph (MCG) for suspected acute coronary syndrome (ACS).MethodsWe undertook a prospective cohort study evaluating the diagnostic accuracy of the MCG in adults with suspected ACS. The reference standard of ACS was determined by an independent adjudication committee based on 30-day investigations and events. The cohort was split into a training sample, to derive the MCG algorithm and an algorithm combining MCG with a modified Manchester Acute Coronary Syndrome (MACS) clinical probability score, and a validation sample, to estimate diagnostic accuracy.ResultsWe recruited 756 participants and analysed data from 680 (293 training, 387 validation), of whom 96 (14%) had ACS. In the training sample, the respective area under the receiver operating characteristic (AUROC) curves were the following: MCG 0.66 (95% CI 0.58 to 0.74), MACS 0.64 (95% CI 0.54 to 0.73) and MCG+MACS 0.70 (95% CI 0.63 to 0.77). MCG specificity was 0.16 (95% CI 0.12 to 0.21) at the threshold achieving acceptable sensitivity for rule-out (>0.98). In the validation sample (n=387), the respective AUROCs were the following: MCG 0.56 (95% CI 0.48 to 0.64), MACS 0.69 (95% CI 0.61 to 0.77) and MCG+MACS 0.64 (95% CI 0.56 to 0.72). MCG sensitivity was 0.89 (95% CI 0.77 to 0.95) and specificity 0.15 (95% CI 0.12 to 0.20) at the rule-out threshold. MCG+MACS sensitivity was 0.85 (95% CI 0.73 to 0.92) and specificity 0.30 (95% CI 0.25 to 0.35).ConclusionThe VitalScan MCG is currently unable to accurately rule out ACS and is not yet ready for use in clinical practice. Further developmental research is required.

Background: The psychological impact of the COVID-19 pandemic on doctors is a significant concern. Due to the emergence of a multiple pandemic waves, longitudinal data on the impact of COVID-19 is vital to ensure an adequate psychological response. The primary aim was to assess the prevalence and degree of psychological distress and trauma in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) doctors during the acceleration, peak and deceleration of the COVID-19 first wave. Personal and professional factors associated with psychological distress are also reported. Methods: A prospective online three-part longitudinal survey of frontline doctors across the UK and Ireland, administered at the acceleration, peak and deceleration of the COVID-19 first wave. Primary outcome measures were psychological distress and trauma, measured using the General Health Questionnaire-12 and the Impact of Events-Revised. Findings: Acceleration survey response rate was 15.9% (n=5440), of an estimated 34,188 doctors. Peak and deceleration response rates were 71·6% (n=3896) and 56·6% (n=3079) respectively. Prevalence of psychological distress was 44·7% (n=1334) during the acceleration, 36·9% (n=1098) at peak and 31·5% (n=918) at the deceleration phase. The prevalence of trauma was 23·7% (n=647) at peak and 17·7% (n=484) at deceleration. The prevalence of probable post-traumatic stress disorder was 12·6% (n=343) at peak and 10·1% (n=276) at deceleration. Worry of family infection due to clinical work was most strongly associated with both distress (R2 = 0·06) and trauma (R2 =0·10). Interpretation: Findings reflect a pattern of elevated distress at acceleration and peak, with some natural recovery. It is essential that policymakers seek to prevent future adverse effects through (a)provision of vital equipment to mitigate physical and psychological harm (b)increased awareness and recognition of signs of psychological distress and (c)the development of clear pathways to effective psychological care. Funding: Funding received from the Royal College of Emergency Medicine. Declaration of Interests: Many of the authors have been working as frontline clinicians during the COVID-19 pandemic. They have no competing interests to declare. Ethics Approval Statement: Ethical approval was obtained from the University of Bath (UK) and Children’s Health Ethics Committee (Ireland). Regulatory approval was obtained from the Health Regulation Authority (UK), Health and Care Research Wales. Participants provided electronic informed consent for each survey.

BackgroundRapid discharge strategies for patients with low-risk chest pain using high-sensitivity troponin assays have been extensively evaluated. The adherence to, and acceptability of such strategies, has largely been explored using quantitative data. The aims of this integrated qualitative study were to explore the acceptability of the limit of detection and ECG discharge strategy (LoDED) to patients and health professionals, and to refine a discharge information leaflet for patients with low-risk chest pain.MethodsPatients with low-risk chest pain who consented to a semi-structured interview were purposively sampled for maximum variation from four of the participating National Health Service sites between October 2018 and May 2019. Two focus groups with ED health professionals at two of the participating sites were completed in April and June 2019.ResultsA discharge strategy based on a single undetectable hs-cTn test (LoDED) was acceptable to patients. They trusted the health professionals who were treating them and felt reassured by other tests, (ECG) alongside blood test(s), even when the clinical assessment did not provide a firm diagnosis. In contrast, health professionals had reservations about the LoDED strategy, including concern about identifying low-risk patients and a shortened patient observation period. Findings from 11 patient interviews and 2 staff focus groups (with 20 clinicians) centred around three overarching themes: acceptability of the LoDED strategy, perceptions of symptom severity and uncertainty, and patient discharge information.ConclusionRapid discharge for low-risk chest pain is acceptable to patients, but clinicians reported some reticence in implementing the LoDED strategy. Further work is required to optimise discharge discussions and information provision for patients.

BackgroundTraumatic pneumothoraces are present in one-fifth of multiple trauma victims. Traditional teaching mandates the insertion of a chest drain in the majority of cases. However, recent observational evidence suggests a trend towards conservative management. The aim of this survey was to understand current emergency medicine (EM) practice in placing chest drains for the management of moderate to severe traumatic pneumothoraces.MethodologyThe survey was developed through expert consensus and sent electronically to senior EM doctors in 21 sites internationally. It described six clinical/imaging vignettes asking ‘how likely are you to insert an intercostal chest drain to manage the pneumothorax in ED?’. A five-point response was available from very unlikely to very likely. All pneumothoraces were >1 cm on imaging, but mechanism, physiology and need for ventilation varied.ResultsOf a potential 606 respondents, 222 responses were received (37% response rate). Respondents were from five different countries, with the majority qualified for more than 10 years (median; 18 years). Within each scenario, there was a large variation in responses with the exception of tension pneumothorax. For vignettes without tension pneumothorax, there was a range from 52% (non-compromised 1 cm pneumothorax in a ventilated patient) to 89% (open pneumothorax with minimal clinical compromise) in respondents reporting that they would be likely or very likely to insert a chest drain.ConclusionThere is considerable variation in clinical practice involving both conservative and invasive strategies in the treatment of moderate to severe traumatic pneumothoraces. This suggests clinical equipoise for interventional trials to determine the optimal management strategy for this patient group.

Suddenly, the world is facing a threat that was only previously depicted in science fiction books and movies, and in simulation exercises of events we thought we would never actually see in our lifetimes. The COVID-19 pandemic has, within a few months, affected everyone on the planet in one way or another. Despite talk of “preparedness,” we were not ready. Everyone feels underprepared and underprotected. Emergency Medicine’s role in this crisis is crucial. Each and every one of us has been called to contribute. We cannot deny we are frightened. Nevertheless, across the spectrum of emergency care, physicians, nurses, paramedics, advanced practitioners, administrative staff, technicians, transport and domestic support teams are all rising to the challenge. Wearing whatever personal protective equipment (PPE) we are told is the latest fashion, and fearing that we will catch the disease, or worse, spread it to our loved ones, we have assumed the front line for assessing, diagnosing, resuscitating and sorting the increasing number of equally frightened patients coming to us with what may or may not be COVID-19. In many institutions, it has been the ED that sounded the alarm that more space would be needed to manage these patients and keep those who are not infected separate from those who are. The combination of experiences and skills that emergency medicine professionals, many of who have voluntarily worked in disasters, limited income countries, the military and other challenging environments, as well as the more mundane but challenging work creating a safe and an orderly flow of care in crowded EDs, has served us well. Ever-changing directives about what to wear, who to test, how to clean do not bother us. We are used to a sudden surge in our volume due to a major car crash, terrorist attack or sporting event. We are …

There are certain events that resonate with all emergency clinicians, events that many of us hope we will never bear witness to and events that, unfortunately, some of us have. Mass casualty events are thankfully rare, with estimates in the USA of around 0.15% of all emergency service calls.1 However, in 2017 the NHS in the UK was faced with an unprecedented number of such events, including the Manchester Arena bombing. Each event poses new challenges in terms of environment, threats posed to staff and casualties and the injuries sustained.2 It is therefore important for ‘lessons learnt’ from mass casualty events to continue to be written up and published in a robust and scientific manner.3 However, at the centre of every mass casualty event are the patients themselves, those who may not survive, those who survive with life-changing injuries and those who are lucky to escape without physical injury but who suffer long-term psychological trauma as a result of events they witness. Authors of reports around mass casualty events therefore have a unique challenge when presenting events in a way that is scientific yet considers ethical publishing in terms of patient consent, potentially identifiable data, considerations of impact of publishing on communities and inevitable media reporting. Editors and journals too have a similar responsibility to patients who are involved in such events. It is therefore a great opportunity for the Emergency Medicine Journal (EMJ) not only to publish Dark et …

Aims/Objectives/BackgroundE-scooters have risen in popularity worldwide. However, e-scooter associated injuries have become a growing area of concern. In the UK, rental e-scooters became legalised in 2020, and have been rolled out in several UK cities. There is no published UK literature reporting e-scooter related injuries. This service evaluation aims to evaluate the impact of e-scooters on Emergency Departments (ED) within one UK city.Methods/DesignBetween May to June 2021, we conducted an approved (CE:74681) prospective observational service evaluation for a 4-week period across three EDs; one Adult Major Trauma centre (MTC), one city-centre Trauma Unit and one Paediatric MTC. All patients presenting to ED with an injury associated with an e-scooter (driver, passenger or bystander) were identified prospectively. Data collected included information on context of injury event and key clinical variables. Data was entered onto the online platform REDCap, and exported into Excel for analysis. Descriptive statistics are presented.Results/ConclusionsNinety patients with an e-scooter related injury presented to ED during the evaluation. Median age was 25 years (IQR, 20-33). Findings demonstrate head, upper limbs and lower limbs were commonly injured. Of the 19% who experienced a head injury, two patients sustained an intracranial haemorrhage and one a basal skull fracture. Fractures were diagnosed in 41% of patients. Only 7% of riders were helmeted and 28% were intoxicated with alcohol. In total 62 x-rays and 13 CTs were undertaken. Although the majority were discharged following minor injuries, 11% of patients required admission, including one major trauma.Whilst e-scooters are a convenient mode of transport, riders are vulnerable to traumatic injuries of varying severity. Notably, low rates of helmet use and high prevalence of alcohol intoxication, suggest a need for targeted public health interventions. Future large-scale research is required to better evidence injury patterns and severity, identify modifiable risk factors and inform policy.

Background: Risk stratification tools (RSTs) are used in healthcare settings to identify patients at risk of sepsis and subsequent adverse outcomes. In practice RSTs are used on admission and thereafter as ‘trigger’ tools prompting sepsis management. However, studies investigating their performance report scores at a single timepoint which varies in relation to admission. The aim of this meta-analysis was to determine if the predictive performance of RSTs is altered by the timing of their use. Methods: We conducted a systematic review and meta-regression analysis of studies published from inception to 31 October 2018, using EMBASE and PubMed databases. Any cohort studies investigating the ability of an RST to predict mortality in adult sepsis patients admitted to hospital, from which a 2x2 table was available or could be constructed, were included. The diagnostic performance of RSTs in predicting mortality was the primary outcome. Sensitivity, specificity, positive predictive value, negative predictive value and area under the receiver-operating curve (AUROC) were the primary measures, enabling further meta-regression analysis. Results: 47 studies were included, comprising 430,427 patients. Results of bivariate meta-regression analysis found tools using a first-recorded score were less sensitive than those using worst-recorded score (REML regression coefficient 0.57, 95% CI 0.07-1.08). Using worst-recorded score led to a large increase in sensitivity (summary sensitivity 0.76, 95% CI 0.67-0.83, for worst-recorded scores vs. 0.64 (0.57-0.71) for first-recorded scores). Scoring system type did not have a significant relationship with studies’ predictive ability. The most analysed RSTs were qSOFA (n=37) and EWS (n=14). Further analysis of these RSTs also found timing of their use to be associated with predictive performance. Conclusion: The timing of any RST is paramount to their predictive performance. This must be reflected in their use in practice, and lead to prospective studies in future.

BACKGROUND: Although calcific aortic valve disease (CAVD) is associated with coronary atherosclerosis, it is not known whether early CAVD is associated with coronary microcirculatory dysfunction (CMD). We sought to investigate the relationship between myocardial blood flow reserve (MBFR) - a measure of CMD, and early CAVD in the absence of obstructive epicardial coronary artery disease. We also determined whether this relationship was independent of coronary artery disease (CAD) and hs-CRP, a marker of systemic inflammation. METHODS: 183 patients with chest pain and unobstructed coronary arteries were studied. Aortic valve calcification score (AVCS), coronary total plaque length (TPL), and coronary calcium score were quantified from multislice CT. MBFR was assessed using vasodilator myocardial contrast echocardiography. Hs-CRP was measured from venous blood using a particle-enhanced immunoassay. RESULTS: Mean (±SD) participant age was 59.8 (9.6) years. Mean AVCS was 68 (258) AU, TPL was 15.6 (22.2) mm, and median coronary calcification score was 43.5AU. Mean MBFR was 2.20 (0.52). Mean hs-CRP was 2.52 (3.86) mg/l. Multivariable linear regression modelling incorporating demographics, coronary plaque characteristics, MBFR, and inflammatory markers, demonstrated that age (β=0.05, 95% CI: 0.02, 0.08, P=0.007), hs-CRP (β=0.09, CI: 0.02, 0.16, P=0.010) and diabetes (β=1.03, CI: 0.08, 1.98, P=0.033), were positively associated with AVCS. MBFR (β=-0.87, CI: -1.44, -0.30, P=0.003), BMI (β=-0.11, CI: -0.21, -0.01, P=0.033), and LDL (β=-0.32, CI: -0.61, -0.03, P=0.029) were negatively associated with AVCS. TPL and coronary calcium score were not independently associated with AVCS when included in the regression model. CONCLUSION: Coronary microvascular function as determined by measurement of myocardial blood flow reserve is independently associated with early CAVD. This effect is independent of the presence of coronary artery disease and also systemic inflammation.

A shortcut review was carried out to establish which inhaler with spacer technique provides the greatest improvement in symptoms in children with acute asthma. Four relevant papers were identified for inclusion using the reported search strategy. The author, date and country of publication; group studied; study type; relevant outcomes; results and study weaknesses of these papers are tabulated. It is concluded that a ‘tidal breathing’ technique, with a minimum of three breaths per inhaler activation, is likely equivalent in efficacy to a ‘single breath and hold technique’, and easier for a breathless child to perform.

Aims/Objectives/BackgroundTraumatic pneumothoraces are present in one-fifth of multiple trauma victims. Traditional teaching mandates the insertion of a chest drain in the majority of cases. However, recent retrospective observational evidence suggests a trend towards conservative management. The aim of this survey was to understand the current emergency medicine (EM) practice in placing chest drains for the management of moderate/severe traumatic pneumothoraces.Methods/DesignThis scoping survey was developed through expert consensus. To achieve face validity, clinical sensibility testing was performed using a pilot survey (with user feedback). There were 14 pilot-phase respondents. The survey was then modified to achieve content validity. The survey was sent electronically to senior EM doctors in 15 sites internationally, and involved six clinical/imaging vignettes asking ‘how likely are you to insert an intercostal chest drain to manage the pneumothorax in ED?’. A five-point response was available from very unlikely to very likely. All pneumothroraces were >1 cm on imaging, but mechanism, physiology and need for ventilation varied.Results/ConclusionsOf a potential 409 respondents, 141 responses were received (34% response rate). Respondents had a range of clinical experience, with the majority qualified more than 10 years (median; 19 years).For 5/6 cases chest drain insertion was likely or very likely in >50% of responses, ranging from 52% for a non-compromised 1 cm pneumothorax in a ventilated patient to 98% for a tension pneumothorax on chest x-ray. Chest drain insertion was unlikely or very unlikely (62% of responses) in one case; an 86-year-old female on rivaroxaban with moderate respiratory compromise (respiratory rate 30 min-1) and a 2 cm pneumothorax.There is a broad range of clinical practice involving both conservative and invasive strategies in the treatment of moderate/severe traumatic pneumothoraces. There is clinical equipoise for interventional trials to determine the optimal management strategy for this patient group.

IntroductionObservational data suggest a single high-sensitivity troponin blood test taken at emergency department (ED) presentation could be used to rule out major adverse cardiac events (MACE) in 10%–60% of ED patients with chest pain. This is done using an ‘undetectable’ cut-off (the Limit of Detection: LoD). We combined the LoD cut-off with ECG findings to create the LoDED strategy. We aim to establish whether the LoDED strategy works under real-life conditions, when compared with existing strategies, in a way that is cost-effective and acceptable to patients.Methods and analysisThis is a parallel-group pragmatic randomised controlled trial across UK EDs. Adults presenting to ED with suspected cardiac chest pain will be randomised 1:1. Existing rule-out strategies in current use across study centres, using serial high-sensitivity troponin testing, will be compared with the LoDED strategy. The primary outcome is successful early discharge (discharge from hospital within 4 hours of arrival) without MACE occurring within 30 days. Secondary outcomes include initial length of hospital stay; comparative costs; patient satisfaction and acceptability to patients. To detect a 9% difference between the early discharge rates (assuming an 8% rate in the standard care group) with 90% power, 594 patients need to be recruited, assuming a 95% follow-up rate.Ethics and disseminationThe study has been approved by the Frenchay Research Ethics Committee (reference 18/SW/0038). Results will be published in an international peer-reviewed journal. Lay summaries will be made available to patients.Trial registration numberISRCTN86184521; Pre-results.

Over the course of the past few decades, we have seen a major swing in the value placed on physician independent decision making. The independently minded physician, practising the art of medicine, using a combination of knowledge, experience and a little gestalt, is no longer the epitome of good practice; instead, researchers derive an increasing number of decision rules, and our societies and healthcare payers formulate guidance, which the good physician is expected to know and follow. For the most part, this is a good thing. Medicine has gotten increasingly complex, the knowledge base exceedingly large and the costs exploding; the individual physician would have trouble critically appraising all the literature in their field, and determining the most clinically effective and cost-effective way to proceed. However, as is the case with almost all medical remedies, there are side effects, even adverse reactions, to decision rules. Emergency medicine has plenty of decision rules: rules for head injury (in adults and children), c-spine injury, pulmonary embolism (PE), ankle and knee injuries and kidney stones, not to mention countless chest pain rules. The primary goal for all of these rules is to avoid missed diagnosis. When deriving decision rules, researchers often set out to achieve one overarching goal—a sensitivity approaching 100%, often at the cost of specificity. This means that a number of patients who do not need the tests will still get them. Therefore, when applying …

Objectives The Manchester Acute Coronary Syndromes (MACS) decision rule has been shown to be a powerful diagnostic tool in emergency department (ED) patients with suspected acute coronary syndromes (ACS). It has the potential to improve system efficiency by identifying patients suitable for discharge after a single blood draw for high-sensitivity troponin and heart-type fatty acid–binding protein (h-FABP) analysis at presentation to the ED. The objective was to externally validate the MACS decision rule and establish its diagnostic accuracy as a discharge tool in a new set of prospectively recruited ED patients. Methods In this preplanned analysis of a prospectively recruited single-center cohort, consecutive ED patients ≥18 years with suspected ACS were included. Testing for h-FABP and high-sensitivity troponin T was undertaken on serum drawn on arrival, and any clinical features required to calculate the MACS rule were recorded. The primary outcome was major adverse cardiac events (MACE) within 30 days (acute myocardial infarction [AMI], death, or revascularization). The secondary outcome was AMI alone, adjudicated using 6-hour troponin results. Results Of the 782 participants included, 78 (10.0%) developed MACE and 61 (7.8%) had an AMI. Of participants, 133 (17.0%) were identified as “very low risk” and therefore suitable for immediate discharge with a 0% incidence of MACE or AMI. Of remaining patients, 314 (40.2%) were “low risk,” 320 (40.9%) were “moderate risk,” and 15 (1.9%) were “high risk,” with incidences of MACE of 2.2, 19.7, and 53.3%, respectively. The sensitivity was 100% (95% confidence interval [CI] = 95.4% to 100%) for MACE at 30 days and 100% (95% CI = 94.1% to 100%) for AMI. The area under the receiver operating characteristic curve was 0.87 (95% CI = 0.83 to 0.91) for the MACS rule in the prediction of MACE. Conclusions In this prospectively recruited cohort of ED patients with suspected ACS, the MACS decision rule identifies a significant proportion of patients who are suitable for immediate discharge after a single blood draw at presentation, with a very low risk of MACE at 30 days. This study externally validates previous findings that the MACS rule is a powerful diagnostic tool in this setting. A randomized controlled trial to establish the utility of the rule in an everyday clinical setting is justified.

Hypoglycaemia is associated with increased cardiovascular and all-cause mortality in both subjects with and without coronary artery disease (CAD) [1]. Our group recently demonstrated that insulin-induced hypoglycaemia (IIH) is associated with a 14% reduction of myocardial blood flow reserve (MBFR) compared to baseline, in both healthy subjects and those with type 1 diabetes mellitus (T1DM) [2]. Cardiac troponin is a sensitive marker of myocardial injury and higher levels have been linked to adverse outcomes in patients with ACS [3]. A new ultrasensitive cardiac troponin I (us-cTnI) has been developed which has a limit of detection of at least one order of magnitude lower below that of current commercial assays. In comparison with current generation troponin assays, us-cTnI has been shown to be more sensitive in the detection of myocardial ischaemia. Furthermore, low but elevated levels of us-cTnI in patients presenting with suspected ACS, have been linked to adverse cardiovascular outcomes and death [4]. This study investigated whether 60 min duration of symptomatic IIH and reduction in MBFR, was associated with myocardial injury as determined by a change in serum levels of us-cTnI measured immediately following hypoglycaemia, in healthy and diabetic subjects without obstructive CAD.

Importance: High-sensitivity cardiac troponin I testing is widely used to evaluate patients with suspected acute coronary syndrome. A cardiac troponin concentration of less than 5 ng/L identifies patients at presentation as low risk, but the optimal threshold is uncertain.Objective: To evaluate the performance of a cardiac troponin I threshold of 5 ng/L at presentation as a risk stratification tool in patients with suspected acute coronary syndrome.Data Sources: Systematic search of MEDLINE, EMBASE, Cochrane, and Web of Science databases from January 1, 2006, to March 18, 2017.Study Selection: Prospective studies measuring high-sensitivity cardiac troponin I concentrations in patients with suspected acute coronary syndrome in which the diagnosis was adjudicated according to the universal definition of myocardial infarction.Data Extraction and Synthesis: The systematic review identified 19 cohorts. Individual patient-level data were obtained from the corresponding authors of 17 cohorts, with aggregate data from 2 cohorts. Meta-estimates for primary and secondary outcomes were derived using a binomial-normal random-effects model.Main Outcomes and Measures: The primary outcome was myocardial infarction or cardiac death at 30 days. Performance was evaluated in subgroups and across a range of troponin concentrations (2-16 ng/L) using individual patient data.Results: Of 11 845 articles identified, 104 underwent full-text review, and 19 cohorts from 9 countries were included. Among 22 457 patients included in the meta-analysis (mean age, 62 [SD, 15.5] years; n = 9329 women [41.5%]), the primary outcome occurred in 2786 (12.4%). Cardiac troponin I concentrations were less than 5 ng/L at presentation in 11 012 patients (49%), in whom there were 60 missed index or 30-day events (59 index myocardial infarctions, 1 myocardial infarction at 30 days, and no cardiac deaths at 30 days). This resulted in a negative predictive value of 99.5% (95% CI, 99.3%-99.6%) for the primary outcome. There were no cardiac deaths at 30 days and 7 (0.1%) at 1 year, with a negative predictive value of 99.9% (95% CI, 99.7%-99.9%) for cardiac death.Conclusions and Relevance: Among patients with suspected acute coronary syndrome, a high-sensitivity cardiac troponin I concentration of less than 5 ng/L identified those at low risk of myocardial infarction or cardiac death within 30 days. Further research is needed to understand the clinical utility and cost-effectiveness of this approach to risk stratification.

Objectives Early discharge of patients with presentations triggering assessment for possible acute coronary syndrome (ACS) is safe when clinical assessment indicates low risk, biomarkers are negative, and electrocardiograms (ECGs) are nonischemic. We hypothesized that the Emergency Department Assessment of Chest Pain Score (EDACS) combined with a single measurement of high-sensitivity cardiac troponin (hs-cTn) could allow early discharge of a clinically meaningful proportion of patients. Methods We pooled data from four patient cohorts from New Zealand and Australia presenting to an emergency department with symptoms suggestive of ACS. The primary outcome was major adverse cardiac events (MACE) within 30 days of presentation. In patients with a nonischemic ECG we evaluated the sensitivity for MACE and percentage low risk of every combination of high-sensitivity cardiac troponin T (hs-cTnT) concentration and high-sensitivity cardiac troponin I (hs-cTnI) concentration with EDACS. We used a standard smoothing technique on the probability density function for hs-cTn and EDACS and applied bootstrapping to determine the optimal threshold combinations, namely, the combination that maximized the percentage low risk with ≥98.5% sensitivity for MACE. Results From 2,536 patients, 2,258 presented without an ischemic ECG of whom 272 (12.1%) had a MACE within 30 days. The optimal threshold for hs-cTnI was 7 ng/L combined with an EDACS threshold of 16 (36.8% patients low risk). The optimal thresholds for hs-cTnT were 8 ng/L combined with an EDACS threshold of 15 (30.2% patients low risk). Conclusion Single measurements of both hs-cTnI and hs-cTnT at presentation combined with EDACS to identify over 30% of patients as low risk and therefore eligible for safe early discharge after only one blood draw.

Background: High-sensitivity assays for cardiac troponin T (hs-cTnT) are sometimes used to rapidly rule out acute myocardial infarction (AMI).Purpose: To estimate the ability of a single hs-cTnT concentration below the limit of detection (Data Sources: EMBASE and MEDLINE without language restrictions (1 January 2008 to 14 December 2016).Study Selection: Cohort studies involving adults presenting to the ED with possible acute coronary syndrome in whom an ECG and hs-cTnT measurements were obtained and AMI outcomes adjudicated during initial hospitalization.Data Extraction: Investigators of studies provided data on the number of low-risk patients (no new ischemia on ECG and hs-cTnT measurements Data Synthesis: Of 9241 patients in 11 cohort studies, 2825 (30.6%) were classified as low risk. Fourteen (0.5%) low-risk patients had AMI. Sensitivity of the risk classification for AMI ranged from 87.5% to 100% in individual studies. Pooled estimated sensitivity was 98.7% (95% CI, 96.6% to 99.5%). Sensitivity for 30-day MACEs ranged from 87.9% to 100%; pooled sensitivity was 98.0% (CI, 94.7% to 99.3%). No low-risk patients died.Limitation: Few studies, variation in timing and methods of reference standard troponin tests, and heterogeneity of risk and prevalence of AMI across studies.Conclusion: A single hs-cTnT concentration below the limit of detection in combination with a nonischemic ECG may successfully rule out AMI in patients presenting to EDs with possible emergency acute coronary syndrome.Primary Funding Source: Emergency Care Foundation.

Cardiac troponin (cTn) is a highly specific biomarker of myocardial injury and is central to the diagnosis of acute myocardial infarction (AMI). By itself, however, cTn cannot identify the cause of myocardial injury. ‘Troponinitis’ is the condition that leads clinicians to falsely assign a diagnosis of AMI based only on the fact that a patient has an elevated cTn concentration. There are many causes of myocardial injury other than AMI. Clinicians are required to differentiate myocardial injury caused by AMI from other causes.In part 1 of this series on cTn, we provide a structured overview to help practising clinicians to interpret ‘positive’ cTn results appropriately. There are three core principles. First, when reviewing a cTn result, clinicians must carefully consider the clinical context. Only this can distinguish primary (termed type 1) AMI caused by coronary artery disease from secondary (termed type 2) AMI caused by another condition with an imbalance in the supply and demand of oxygen to the myocardium. Second, clinicians must consider the patient’s baseline condition in order to determine the presence or absence of factors that may predict a chronic cTn elevation. Third, clinicians should routinely use serial sampling to detect a change of cTn that is expected in patients with acute (rather than chronic) myocardial injury. Using these simple principles, clinicians can avoid underdiagnosis and overdiagnosis of AMI.