Emergency Care and Medicine

Background/Objectives: This study aims to compare the safety of tenecteplase versus alteplase for acute ischemic stroke. Methods: This was a multicenter, retrospective cohort study including 11 Memorial Hermann Health System hospitals in Houston from 7 December 2022 to 7 June 2023. Adults presenting with an acute ischemic stroke who received alteplase or tenecteplase were included in this study. The primary outcome was the incidence of hemorrhagic conversion after 24 h of thrombolytic administration. Secondary outcomes included door-to-needle time, incidence of a major or minor bleed, length of hospital stay, incidence of any adverse effect, modified Rankin score at discharge, patient discharge disposition, medication cost, and mortality. Results: A total of 173 patients were reviewed, with 87 patients in the tenecteplase group and 86 patients in the alteplase group. Gender, actual body weight, and use of aspirin or dual antiplatelet therapy within 24 h of thrombolytic administration were statistically disproportionate between both groups. Hemorrhagic conversion occurred in seven patients in the tenecteplase group and eight patients in the alteplase group (p = 0.79). Medication cost was statistically significant between both groups. All other secondary outcomes were similar between tenecteplase and alteplase. Conclusions: In this underpowered study, we did not observe a statistically significant difference in the rate of 24 h hemorrhagic conversion between the tenecteplase and alteplase groups. Further studies with a large sample size are warranted to assess safety outcomes. Full article

Objectives: This study evaluates the efficacy of existing and new aerosol mitigation methods during nebulization (Neb) in combination with high-flow nasal cannula (HFNC) oxygen supplementation and non-invasive ventilation (NIV). Methods: We recorded fugitive aerosol particle concentrations over time and assessed the peak (P) and area (A) efficacy of active and passive mitigation methods, comparing them to a no-mitigation condition. Peak efficacy was measured by the reduction in maximum aerosol concentration, while area efficacy was quantified by the reduction of the area under the aerosol concentration–time curve. Results: For HFNC with Neb, we found that active mitigation using a mask with a biofilter and a fan (referred to as the aerosol barrier mask) significantly outperformed passive mitigation with a face mask. The peak and area efficacy for aerosol reduction were 99.0% and 96.4% for active mitigation and 35.9% and 7.6% for passive mitigation, respectively. For NIV with Neb, the active mitigation method, using a box with a biofilter and fan, also outperformed passive mitigation using only the box. The peak and area efficacy for aerosol reduction were 92.1% and 85.5% for active mitigation and 53.7.0% and 25.4% for passive mitigation, respectively. Conclusion: We concluded that active mitigation set up systems advantageous for effective reduction of airborne aerosols during aerosol generated procedures. Full article

Background/Objectives: Traumatic brain injury (TBI) is a global public health concern, affecting over 60 million people annually. It is associated with high rates of mortality and disability, particularly among young and economically active individuals, and remains the leading cause of death in people under 40 years of age. Although computed tomography (CT) is the standard method for excluding intracranial bleeding (ICB), it is frequently unavailable in resource-limited settings where the burden of TBI is greatest. The InfraScanner 2000 is a near-infrared spectroscopy (NIRS) device designed to detect ICB and may serve as a triage tool in environments without access to CT imaging. This study aimed to evaluate the diagnostic performance of the InfraScanner 2000 for detecting ICB in the emergency department (ED) of a trauma center in a cohort of Colombian patients with TBI. Methods: This prospective study was conducted in Cali, Colombia, between December 2019 and February 2021. Adult patients presenting to the ED with blunt TBI were enrolled. InfraScanner assessments were performed according to a standardized protocol, and all participants underwent head CT within 6 h of injury. Results: A total of 140 patients were included. Of these, 66% were male and 34% were female. Most patients (63.57%) were between 18 and 39 years old, with a median age of 39 years (IQR: 18–86). The InfraScanner demonstrated a sensitivity of 60.0% (95% CI: 32.5–84.8), specificity of 78.4% (95% CI: 71.2–85.6), positive predictive value (PPV) of 25.0%, and negative predictive value (NPV) of 94.2% for detecting ICB. Conclusions: The InfraScanner 2000 showed good specificity and high NPV in identifying ICB among Colombian patients with TBI. These findings suggest it could serve as a useful triage tool to support decision-making in emergency settings with limited access to CT imaging. Full article

Background: Several studies have suggested that laparoscopic peritoneal lavage for the treatment of diverticulitis might be associated with an increased event rate. The WSES (World Society of Emergency Surgery) guidelines recommend performing laparoscopic peritoneal lavage only in highly selected patients; however, selection criteria remain poorly described. This study, based on a single-center retrospective cohort of patients presenting with acute diverticulitis and undergoing surgery, aimed to assess the complication and long-term outcomes of the lavage group and to report our experience with the treatment of acute diverticulitis. Methods: Operative management of acute sigmoid diverticulitis was involved, in particular, laparoscopic peritoneal lavage, primary resection, and the Hartmann procedure. Results: Six-month follow-ups showed the occurrence of Clavien–Dindo complications in ≥2 in 21.9% of patients in the sigmoidectomy group versus 61.1% of patients in the lavage group (p = 0.0028). Among the 11 patients with complications after laparoscopic lavage, 9 required a second surgery. After a comparison between the patients with complications and those without who were managed with laparoscopic lavage, descriptive differences were found regarding the BMI (95% CI, 21.7–24.3 vs. 95% CI, 24.7–31.3, p = 0.0419). In analysis, a BMI of ≥27 kg/m² (OR, 16 p = 0.049) was associated with short- and long-term complications in the lavage group. There was no evidence for an association between complications and a BMI of ≥27 kg/m² in the primary resection (OR, 1.61 p = 1) or the Hartmann procedure group (OR, 4.25 p = 0.1438). Perforated colonic diverticulitis treated with laparoscopic peritoneal lavage was associated with a high morbidity rate. Conclusions: The choice of surgical strategy for acute diverticular pathology is complex, influenced by various conditions. BMI could be a prognostic factor for long-term outcomes, including recurrent diverticulitis and the occurrence of abscesses. Full article

Background/Objectives: A 2-year-old male presented to the emergency department (ED) with vomiting and abdominal discomfort following ingestion of multiple magnets from a sibling’s bracelet. This case highlights the risks associated with magnet ingestion and the need for coordinated multidisciplinary care and public health intervention. Methods: Radiographs revealed magnets in the oropharynx, stomach, and small bowel. Emergency physicians coordinated care with otolaryngology, gastroenterology, and general surgery. Results: Laryngoscopy successfully removed two magnets from the uvula, and endoscopy retrieved 30 magnets from the stomach. General surgery performed a diagnostic laparoscopy, identifying residual magnets in the colon. Gastroenterology attempted a colonoscopy but was unable to retrieve magnets due to formed stool, leading to bowel preparation and serial imaging. The patient eventually passed 12 magnets per rectum without surgical intervention. Conclusions: This case emphasizes the importance of multidisciplinary collaboration in managing magnet ingestion, a preventable cause of serious gastrointestinal injury. Recent studies highlight the increasing incidence and severity of such cases due to accessibility and inadequate regulation. These findings underscore the need for public awareness and adherence to management protocols to mitigate morbidity and mortality in pediatric patients. Full article

Background/Objectives: The goal of educators is to leave no learner behind. Ultrasounds require dexterity and 3D image interpretation. They are technologically complex, and current medical residency programs lack a reliable means of assessing this ability among their trainees. This prompts consideration as to whether background characteristics or certain pre-existing skills can serve as indicators of learning aptitude for ultrasounds. The objective of this study was to determine whether these characteristics and skills are indicative of learning aptitude for ultrasounds. Methods: This prospective study was conducted with third-year medical students rotating in emergency medicine at the New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA. First, students were given a pre-test survey to assess their background characteristics. Subsequently, a psychomotor task (Purdue Pegboard) and visual–spatial task (Revised Purdue Spatial Visualization Tests) were administered to the students. Lastly, an ultrasound task was given to identify the subxiphoid cardiac view. A rubric assessed ability, and proficiency was determined as a 75% or higher score in the ultrasound task. Results: In total, 97 students were tested. An analysis of variance (ANOVA) was used to ascertain if any background characteristics from the pre-test survey was associated with the ultrasound task score. The student’s use of cadavers to learn anatomy had the most correlation (p-value of 0.02). Assessing the psychomotor and visual–spatial tasks, linear regressions were used against the ultrasound task scores. Correspondingly, the p-values were 0.007 and 0.008. Conclusions: Ultrasound ability is based on hand–eye coordination and spatial relationships. Increased aptitude in these abilities may forecast future success in this skill. Those who may need more assistance can have their training tailored to them and further support offered. Full article

Background: Hip fractures are a major cause of morbidity and mortality, particularly in the elderly, and the incidence is expected to rise significantly in the coming years. One of the key challenges in managing hip fracture patients is perioperative blood loss, which often necessitates allogeneic blood transfusion. Tranexamic acid (TXA), a synthetic antifibrinolytic agent, has been shown to reduce blood loss in various surgical settings, including elective orthopaedics. However, unlike elective surgery where bleeding begins intraoperatively, bleeding in hip fracture patients starts at the time of injury. This scoping review aimed to evaluate the existing literature on the use of early TXA administration, specifically at the point of admission, in patients with hip fractures. Methods: A comprehensive search of EMBASE and PubMed was conducted up to March 2025, and eight studies were identified that met the inclusion criteria, including three randomised controlled trials (RCTs). Six of these studies compared patients receiving TXA on admission to controls who received no TXA, involving a total of 840 patients. Most studies focused on extracapsular fractures in elderly, predominantly female patients. Results: Findings were mixed: four of the six studies found no statistically significant differences in haemoglobin levels or transfusion rates, while two RCTs demonstrated significantly reduced transfusion needs in the TXA group. Trends across studies suggested reduced blood loss and transfusion risk with TXA administered on admission. Importantly, no increase in complications, including venous thromboembolism, were observed. Conclusion: Early TXA administration in hip fracture patients appeared to be safe and may reduce transfusion requirements. Further high-quality research is warranted to determine the optimal timing and dosing strategy for TXA in this setting and to confirm the efficacy in reducing perioperative blood loss and transfusion risk. Full article

Background/Objectives: The objective of this review is to map nurses’ responsibilities in addressing individuals who are victims of violence, specifically in the preservation of forensic evidence in both intra- and extra-hospital contexts. The research question is as follows: What are a nurse’s responsibilities regarding the care of victims of violence for the preservation of forensic evidence in in-hospital and out-of-hospital emergencies? Methods: The mnemonic PCC (P-Population, C-Concept, and C-Context) method was followed according to the recommendations of the Joanna Brigs Institute (2024). The population is defined as “individuals who are victims of violence”, the concept (phenomenon of interest) as “nursing interventions determining responsibilities in forensic evidence preservation”, and the context as “intra- and extra-hospital emergencies”. A search was conducted in the following databases: CINAHL Complete via EBSCO Host, Medline Complete via EBSCO Host, PubMed, Web of Science, and RCAAP via B-ON. From the total articles retrieved, 18 were selected for analysis. Results: The 18 articles emphasized the critical role of nurses in preserving forensic evidence in both intra- and extra-hospital contexts. These findings were grouped into six domains to clarify the topic: (1) knowledge and training of nurses on forensic evidence preservation and the implementation of standardized protocols; (2) collection of biological and non-biological samples to preserve evidence on the victim’s body; (3) collection of biological and non-biological samples to preserve evidence on the victim’s objects and belongings; (4) documentation of forensic traces and evidence; (5) maintenance of the chain of custody; and (6) ongoing interprofessional collaboration between nurses, law enforcement, and judicial authorities. Conclusions: Intra- and extra-hospital emergencies, teams must be proficient in recognizing victims of violence and in conducting appropriate evidence preservation to ensure their legal admissibility. Full article

Severe burns are among the most traumatic injuries, characterized by tissue damage, systemic inflammation, significant fluid shifts, and a high risk of complications such as infections, organ failure, anemia, malnutrition, and psychological trauma. This article reviews recent literature from the PubMed and Google Scholar databases to outline critical components of burn care, from initial resuscitation and stabilization through rehabilitation. Key topics include early airway management to prevent respiratory compromise, meticulous fluid resuscitation to maintain tissue perfusion while avoiding complications like fluid overload, and optimal pain management. It also discusses nutritional support tailored to the burn patient’s hypermetabolic state and surgical techniques like early debridement and skin grafting. Beyond physical recovery, the review emphasizes the importance of addressing the psychological impact of burn injuries, including depression, anxiety, and post-traumatic stress, which can significantly affect long-term outcomes. By integrating the expertise of a multidisciplinary team with a personalized approach and practical recommendations, this review aims to provide clinicians with a comprehensive framework for managing severe burns, from the initial emergency response to the challenges of inpatient care and, finally, rehabilitation. Full article

Background: Concussion education for athletes can improve long-term outcomes in injury prevention. As a contact sport, Quadball has seen tremendous growth in its player population over the past decade. However, there is a paucity of understanding of sports injury epidemiology in these sports compared to other contact sports in the world. The aim of this study is to describe the attitude, knowledge, and awareness of concussions among Quadball players in the United States. Methods: This study implemented a cross-sectional methodology. Specifically, a modified version of the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS) was introduced to Quadball participants to address the primary aim of this study. Results: A total of 237 Quadball players participated in this study. In this cohort, 57.8% of participants reported having some form of prior concussion training or education. A cumulative 77.0% accuracy of concussion knowledge index questions was found among participants. Conclusions: The findings of this study indicate that the knowledge of sports concussions in Quadball may be greater than or comparable to that of other contact sports in the United States. Full article

Pneumothoraces are a common and potentially severe condition in the emergency setting. Various pathophysiological mechanisms (spontaneous and traumatic) could be involved, consequently defining the diagnostic–therapeutic pathway. Understanding these underlying etiologies is essential for advancing diagnostic strategies and guiding therapeutic measures. Recent insights into diagnostic and therapeutic strategies focus on the role of ultrasound and the effectiveness of small-bore chest tubes in managing all types of pneumothoraces with a reduced risk of complications. Moreover, observation is emerging as a possible conservative approach in hemodynamically stable patients regardless of the etiology of the pneumothorax. This review aims to provide a valuable resource to improve diagnostic and therapeutic management, comparing traditional methods and promising, less invasive therapeutic interventions. Full article

Background: Musculoskeletal (MSK) discomfort is a significant occupational hazard for eye care professionals, including ophthalmologists, who report high rates of MSK discomfort. This systematic review investigated the impact of various interventions, such as regular exercise, posture-correcting aids, and surgical heads-up displays, on reducing MSK pain in the operating room. Methods: This review was reported following PRISMA guidelines and was prospectively registered in the PROSPERO database (CRD42024559189). A systematic literature search was conducted of Embase, MEDLINE, and Web of Science from inception to 2024. Included studies were categorized as exercise modifications, equipment modifications, or training aids. All MSK pain-related outcomes from any time point were extracted. Risk of bias was assessed using the Murad tool, the Cochrane risk-of-bias tool for randomized trials (RoB 2), and the Risk Of Bias In Non-Randomized Studies-of Interventions (ROBINS-I) tool. Results: The systematic search strategy identified 2276 studies, of which 53 qualified for full-text screening with 13 resultant studies including 712 eyecare specialists. Physical activity was found unanimously to reduce MSK pain, with favourable evidence for the utilization of posture-correcting aids. There was mixed—but mostly favourable—evidence for the use of surgical heads-up displays. Conclusions: Exercise modifications, such as yoga and regular exercise; equipment modification with heads-up displays during surgery; and training aids for posture correction were shown to be beneficial for MSK-related pain among ophthalmologists. Future studies should strive to improve the certainty of evidence on ergonomics-related interventions for ophthalmologists, which will better support practice and guideline development. Full article

Background/Objectives: This study examines trends in appendectomy utilization in US emergency departments (EDs) from 2012 to 2021 using National Emergency Department Sample (NEDS) data. The objective is to explore appendectomy frequency, appendicitis management, disease progression, and resource distribution in EDs. A predictive model was developed to forecast trends from 2022 to 2032, aiming to improve patient outcomes and support operational planning in EDs. Methods: A cross-sectional analysis was conducted using NEDS data from 2012 to 2021. Appendectomy trends were assessed in four ways: first, comparing the total number of appendectomies with total ED visits to determine relative frequencies; second, comparing trends in Complicated Appendicitis (CA) and Uncomplicated Appendicitis (UA) patients; third, categorizing each appendicitis type based on clinical complications and comorbidities; and finally, using a linear regression model to predict trends through 2032. Results: During the study period, the overall appendectomy rate decreased, while the proportion of patients with Complicated Appendicitis rose. Appendectomies in patients without complications or comorbidities showed a decline, while those in patients with complications or comorbidities increased. Predictive modeling suggests that trends in all subgroups will continue to rise until 2032. Conclusions: This study highlights evolving appendicitis management trends in EDs. The results advocate for fast-track appendectomy pathways and better resource allocation to enhance efficiency, reduce complications, and improve patient care. These findings assist healthcare systems in preparing for ED throughput challenges and refining surgical management strategies. Full article

Objectives: Stroke is a leading cause of disability worldwide, requiring timely intervention with intravenous thrombolysis (IVT) or endovascular thrombectomy (EVT). This study evaluates real-world stroke management in a regional stroke unit, focusing on IVT administration and EVT transfer logistics. Design: A sub-analysis was performed using prospectively collected data from an observational study. Setting: This study took place at a regional, non-university stroke unit in Germany, serving approximately 253,000 inhabitants. Participants: A total of 2436 patients were admitted for suspected stroke between May 2019 and June 2021. Outcome Measures: Outcome measures included IVT administration rates, reasons for IVT non-administration, and EVT transfer logistics for acute ischemic stroke (AIS) patients. Results: Of 952 stroke cases, 14.8% received IVT, with a mean door-to-needle time (DNT) of 41 ± 36 min. The most common reasons for IVT non-administration were unclear or elapsed symptom onset (51.8%), anticoagulation (7.9%), resolving symptoms (18.4%), and intracranial hemorrhage (7.1%). EVT transfers occurred in 6.7% of AIS patients, with a mean door-in-door-out (DIDO) time of 81 ± 36 min. Conclusions: This study highlights the low IVT rate, primarily due to delayed hospital presentation, and the limited number of EVT transfers. The prolonged DIDO times emphasize the urgent need for streamlined transfer protocols to optimize stroke care delivery. Full article

Background: Gastrointestinal bleeding (GIB) is a frequent emergency department (ED) presentation with rare but life-threatening causes, including arterio-enteric fistulas (AEF), which account for less than 1% of GIB cases. Ilio-enteric fistulas are even more rare but have similar morbidity and mortality. Methods: This case report describes a 51-year-old male with a history of type 2 diabetes mellitus, diabetic retinopathy, and pancreas–kidney transplantation who presented to the ED with a massive hemorrhage from an ilio-enteric fistula. Despite initial stability, the patient became hypotensive and deteriorated to pulseless electrical activity (PEA) arrest. Despite multiple arrests, he survived and was discharged to a rehabilitation facility. Results: AEFs, particularly iliac-enteric fistulas, are diagnostically challenging and often present with nonspecific symptoms. Diagnostic imaging, especially CT angiography, is crucial, although initial non-contrast CT may miss the diagnosis. Early consultation with vascular surgery is essential for managing these patients. Conclusions: This case underscores the need to consider AEF in the differential diagnosis of GIB, particularly in post-transplant patients, and highlights the importance of prompt intervention. Full article

Background/Objectives: Among the factors contributing to medical errors and misdiagnosis, patient handoffs play a significant role. The negative impact of handoffs includes miscommunications, omissions, and information loss. Patient handoffs are inherent to emergency department (ED) patient care and are recognized as high-risk events. The aim of this study was to use a mixed-methods approach, incorporating a retrospective chart review and qualitative analysis, to understand emergency physicians’ perceptions of handoffs, including their impact on patient safety, patient flow, and patient satisfaction, as well as the strategies employed to manage handoffs and their perceived efficacy. Methods: A seven-question online survey was distributed to 120 attending ED physicians employed across a large academic health system comprising six hospitals. Additionally, a 3-year retrospective chart review provided insights into avoidable handoffs in the ED. Results: The survey responses showed that 69% of physicians believed that handoffs reduced patient safety, 55% felt that they reduced patient satisfaction, and 66% perceived them as contributing to longer patient stays. Additionally, 86% of physicians preferred to hand off no more than two patients, while 79% preferred to receive no more than two. Thematic content analysis identified key factors influencing physician preferences, including ownership, patient safety, patient flow, cooperation and colleagueship, and the challenges of continuing workups. To minimize handoffs, ED physicians primarily reported strategies such as staying late after shifts, restricting patient signups, and planning patient disposition toward the end of their shifts. Lastly, retrospective data analysis suggested that implementing one-hour overlapping shifts and restricting patient signups could reduce ED handoffs by 30%. Conclusions: ED physicians perceive handoffs as affecting patient safety, patient satisfaction, and patient flow negatively and prefer fewer handoffs. Overlapping shifts and selective patient signup strategies may reduce handoffs. Full article