Emergency Care and Medicine

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

Background/Objectives: The COVID-19 pandemic overwhelmed many health care facilities with patients, leading to an increased risk of potential transmission. Though the disease process was identical, the triaging system was unique at different sites, without a unified system for emergency department triaging globally. Proper implementation of pre-screening and triaging is of paramount importance in tertiary care settings to prevent nosocomial spread of infection. Methods: Each country has its own triage guidelines and Infection, Prevention, and Control policies developed by its health ministry and may face significant challenges in implementing them. Triage guidelines followed by two tertiary care hospitals in Detroit, United States of America and Manipal, India are compared during the early phases of the COVID-19 pandemic. Results: This paper offers a unique perspective of the challenges experienced with the hospital triage practices and provides solutions to address them. The future trajectory of COVID-19 epidemiology in both countries will be determined by the adherence to best practices in Infection Prevention and Control and triage protocols. The healthcare facility triage algorithm is constantly evolving in both settings as new evidence is being added to hospital epidemiology and infection prevention practices. Conclusions: Training healthcare workers on new triage protocols is required. It is critical for infectious disease doctors, clinical microbiologists, hospital epidemiologists, and Infection Prevention and Control (IPC) staff to collaborate with clinicians, nurses, and other ancillary staff in order to successfully implement the triage protocols. Developing and modifying guidelines for cleaning hospital triage areas and providing high throughput for patient care are also important lessons learned. Usage of face shields and the quality of Personal Protective Equipment (PPE) should be ensured for all healthcare workers (HCWs). Resilient staff and resilient hospital infrastructure are crucial for a sustainable response to future pandemics. Full article

Background: ST-elevation myocardial infarction (STEMI) is a life-threatening emergency. Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy, provided it is performed promptly (within 120 min of the ECG-based diagnosis). However, the failure rate of PPCI remains high, particularly in patients with more severe conditions, potentially leading to serious complications. Objective: Through this case, we want to introduce coronary fibrinolysis as a rescue therapy after failing with primary PPCI. Methods: Case report. Results: We reported a clinical case of a STEMI patient who underwent coronary fibrinolysis as a rescue therapy after PPCI failure. The patient was a 62-year-old male patient who was a 40-pack-year smoker. He was diagnosed with STEMI and immediately received PPCI, but the aspiration process and angioplasty were unsuccessful. Subsequently, we decided to use coronary fibrinolysis and the follow-up coronary angiography showed coronary revascularization, and chest pain was resolved. Conclusions: This case highlighted a potential therapeutic approach of coronary fibrinolysis for patients experiencing PPCI failure. Full article

Background: “Do Not Resuscitate” (DNR) status has been implicated as an independent risk factor for mortality in patients admitted to the ICU. The implications of DNR status in older, critically ill patients for whom these conversations are often most relevant are less known. Objective: To determine the relationship between code status and mortality in a subset of critically ill, older ICU patients. Methods: Retrospective cohort study of critically ill older adults as defined by an APACHE II score ≥20 and age ≥70, admitted to the ICU at a large community hospital in Ontario from 1 January 2013 to 31 December 2018. Results: Of 613 patients admitted to the ICU, 163 met the inclusion criteria. Of these, 64 (39.3%) had a DNR order, while the remaining 99 (60.7%) did not and were considered full code. We found a strong association between DNR status and mortality (OR 2.61; 95% CI 1.33 to 5.09). Patients with a DNR order stayed fewer days in the ICU (7.7 days (±3.6) vs. 9.9 days (±8.3)) and used fewer resources than similarly ill patients who were full code with no difference in discharge morbidity. Patients with a DNR order had lower average costs of hospital and ICU admissions in comparison to patients who were full code (CAD 49,589.10/pt. vs. CAD 59,704.70/pt. (Canadian dollars)). Conclusions: Among critically ill, older ICU patients, DNR status is strongly associated with in-hospital mortality. Those in the full code group used more resources, resulting in higher costs of hospitalization without any difference in discharge morbidity. Full article

Objective: Sudden Death (SD) is a high-mortality emergency event that typically occurs within one hour of symptom onset. Accurate risk prediction is essential for optimizing post-resuscitation care. This study aims to enhance the survival rate of patients experiencing sudden death by developing and validating a risk prediction model for in-hospital mortality following successful resuscitation. Method: This study is a retrospective analysis of data that were collected prospectively from a standardized clinical database. All data were recorded at the time of patient admission using a predefined protocol to ensure consistency and accuracy. We retrospectively analyzed the data collected from 295 patients who experienced sudden death and achieved successful resuscitation at Wuhan Central Hospital from January 2017 to June 2024. The patients were assigned to groups using a randomization process into training and validation sets using k-fold cross-validation and further categorized within these sets based on in-hospital mortality as the outcome. A prediction model was constructed, and its efficacy was validated using logistic regression analysis, which was visualized with nomograms. Results: The results of this regression analysis of the training set demonstrated the actual length of hospital stay, in-hospital norepinephrine dosage, post-resuscitation respiratory rate, and sinus rhythm after resuscitation as independent influencing factors (p < 0.05), which formed the basis of the prediction model. The analysis of the training set exhibited high discriminative ability, with an area under the ROC curve (AUC) of 0.860, which exceeds the commonly accepted threshold for good classification performance, and the calibration, applicability, and reasonableness were all favorable. When the model was applied to the validation set, the AUC was 0.758, and the discrimination, calibration, applicability, and reasonableness of the validation set were also satisfactory. Conclusions: the main conclusion is that a risk prediction model for in-hospital mortality following resuscitation from sudden death was successfully developed and internally validated, offering a significant advancement in clinical decision-making support. Full article

Background: Somatic symptom disorder (SSD) involves physical symptoms that cannot entirely be explained by an organic medical cause, accompanied by persistent thoughts, feelings and behaviours relating to one’s health. SSD is common yet underdiagnosed in emergency departments (EDs). This study aimed to assess emergency physician (EP) readiness, attitudes and perceptions toward diagnosing SSD and explore demographic trends. Methods: In total, 1339 Canadian EPs were invited to respond to a survey collecting demographic information and assessing attitudes toward SSD in four domains: perceptions of SSD, attitudes toward patients, diagnostic confidence, and physician–patient communication. Data were analyzed using t-tests and ANOVA to determine associations with demographic information. Results: Of the 96 survey respondents, 75 met the eligibility criteria. In total, 44% estimated that emotional stress was the primary cause of symptoms in 11–20% of their patients. Most felt that SSD was underdiagnosed and that effective therapies exist. Concerns included medico-legal implications, managing patients’ emotions, and potential negative reactions to non-organic diagnoses. Most respondents felt prepared and confident broaching the diagnosis. More experienced EPs felt that there was time to broach the topic of SSD, while rural EPs were less concerned about patient offence than urban counterparts. Conclusions: EPs recognize SSD as common and underdiagnosed, acknowledging its diagnosis as part of their role. Challenges identified include managing patients’ emotions, time constraints, and reliance on only diagnosing SSD once an organic etiology is excluded. Training pathway, experience, and practice setting impact perceptions and attitudes around SSD. The findings suggest opportunities for improving SSD care through targeted interventions, communication training, and enhanced diagnostic education. Full article

Background: Spontaneous rupture of the liver capsule secondary to the progression of hepatocellular carcinoma is a rare complication with high mortality. Case Description: This article presents the case of a 73-year-old male with no prior HCC diagnosis who presents acute abdominal pain and hemodynamic instability. Computed tomography reveals a heterogeneous liver lesion with capsular rupture and hemoperitoneum. Discussion: Management strategies focus on hemodynamic stabilization and bleeding control through transcatheter arterial embolization (TAE), surgical hemostasis or liver resection, the treatment selection is based on disease severity and patient condition. Conclusions: This case highlights the importance of considering HCC rupture in patients with acute abdominal pain and risk factors for liver disease, as early recognition and appropriate intervention significantly impact survival outcomes. Full article

Background: Femoral shaft fractures are very common in the pediatric population; however, information is scarce. Methods: A total of 189 pediatric patient records were reviewed to identify the characteristics of diaphyseal fractures, including origin, type, pattern, surgical technique, and complications. Descriptive statistics were used to calculate frequencies and percentages. Meanwhile, continuous and categorical variables were analyzed using logistic regression to compare the different types of fractures in the population. Results: The proportion of males was higher compared to females (2:1). The highest prevalence was observed in the 10–14-year-old age group (n = 71; 37.5%). The primary mechanism of injury was traffic accidents (n = 93; 49.2%). Left femoral shaft fractures (n = 101; 53.4%) were the most prevalent. Transverse patterns predominated among the identified fractures (n = 105; 55.6%), most of which were closed fractures. Among the complications, non-union was the most frequent (n = 13; 6.9%), followed by wound infections (n = 3; 1.5%). Obesity (p < 0.001) and overweight (p < 0.001) were statistically significant in the left-sided femoral shaft fracture group. Conclusions: Non-union was the main complication identified in our study population. Obesity and overweight were identified as predictive variables for left-sided femoral shaft fractures. Meanwhile, none of the injury mechanisms showed statistical significance. Diaphyseal fractures in the pediatric population are underestimated, as well as the predictors causing them. Therefore, it is necessary to establish better management strategies for this type of fracture in pediatric patients. Full article

Background/Objectives: This study aimed to explore the feasibility of predicting short stays among urgent admissions to an acute hospital in Singapore. With an increase in the average length of stay (LOS) in hospitals in recent years, accurately predicting short stays could enable hospitals to better manage inpatient demand and reduce emergency department (ED) overcrowding. Methods: This was a retrospective study of urgent admissions to Changi General Hospital, Singapore, from 1 January 2016 to 30 June 2022. To identify potential short stayers, a total of 25 features comprising demographic characteristics, admission and clinical characteristics, and healthcare utilization history were analyzed for each admitted patient at the point when the ED physician decided to admit the patient. The dataset was further split into a development dataset and an external validation dataset based on the year of admission. A CatBoost classifier was trained using 75% of the development dataset. Apart from reporting the model’s prediction accuracy, we conducted various analyses and simulations to study the effects of the features crucial to the prediction output. Results: The prediction accuracy of the model was evaluated on both the development test dataset (25%) and the external validation dataset. On the former, the area under the receiver operating characteristic (AUROC) and the area under the precision-recall curve (AUPRC) were 0.803 (95% CI: 0.799, 0.808) and 0.755 (95% CI: 0.749, 0.762), respectively, with the precision = 0.700 (95% CI: 0.694, 0.707) and recall = 0.692 (95% CI: 0.685, 0.699). On the external validation dataset, the performance was similar. The ED diagnosis and whether the admission required a surgical procedure were the most important features for making the prediction. Conclusions: The LOS prediction model could help providers to identify short stayers early in the course of their inpatient journeys so they could make interventions to better manage the overall utilization of hospital beds. Full article

Introduction: Sedative and antipsychotic (SAP) agents are amongst the most common overdoses seen clinically, with few available antidotes. The proposed “lipid shuttle” mechanism of action for intravenous lipid emulsion (ILE) could augment the redistribution of SAP agents from the central nervous system in overdoses. We reviewed randomised controlled clinical trials to evaluate the effect of intravenous lipid emulsion when the indication for use was a reduction in the level of consciousness in SAP overdoses. Methods: We searched for human randomized controlled trials comparing the use of ILE to placebos in SAP drug overdoses. Animal and non-randomised human studies were excluded. Relevant databases were searched with two independent reviewers assessing studies for inclusion and risk of bias using the ROB 2 tool. Results: Five identified studies enrolled 270 patients in total, of whom 226 had isolated tramadol or clozapine toxicity. One study was assessed as having serious concerns for bias, and the other four as having some potential for bias. In all studies, there was a statistically significant increase in the Glasgow Coma Scale (GCS), favouring the ILE groups. This effect does not appear to have been due to changes in haemodynamics. Secondary outcomes on length of stay and QT interval were also positive. No patient died in any study. Conclusions: In the five reported randomised human trials of the effect of ILE on level of consciousness post-SAP overdose, patients receiving ILE had a greater increase in GCS over time. The potential for bias existed in all studies, and trial results may be true but specific to the intoxicants and situations studied, which prevents the generalisability of findings. More research is both feasible and necessary in this area. Full article

Self-awareness among nurses involved in inter-hospital transport is crucial, as recognizing their limitations helps them improve their skills and make better use of tools that support inter-hospital transport, ultimately resulting in more efficient care. Objectives: To evaluate nurses’ self-perceived competences in an emergency department in Portugal regarding the inter-hospital transport of critically ill patients, implement interventions to facilitate the development of nurses’ competences, and evaluate the interventions carried out. Methods: A quality improvement project was conducted in three phases. The first phase involved a diagnostic study, the second phase focused on implementing interventions to improve nurses’ performance, and the third phase consisted of a descriptive study to evaluate the interventions implemented. Results: A total of 40 nurses participated in the study, with an average age of 39 (39.10 ± 11.83) years old, an average of 16 (16.09 ± 11.06) years of professional nursing experience, and an average of 11 (10.94 ± 10.91) years of experience in inter-hospital transport of critically ill patients. The nursing records during inter-hospital transport received the lowest self-perception rating, prompting the implementation of an intervention in the form of a nursing records checklist. Conclusions: The interventions implemented led to a change in self-perceptions of competence. Nurses’ self-awareness of their competences and limitations is crucial to deliver safe and quality nursing care. Providing opportunities for reflection on skills is therefore crucial to improving care delivery and encouraging the development of professional skills, attitudes, and behaviors. Full article

Background/Objectives: During the early phase of the coronavirus disease 2019 (COVID-19) pandemic, people were advised to stay at home and the American College of Surgeons suggested the nonoperative management (NOM) of uncomplicated appendicitis. We hypothesized that patients presented with more cases of complicated appendicitis during the early phase of COVID-19 compared with the previous year; we further hypothesized that more patients had NOM. Methods: Adults diagnosed with appendicitis were retrospectively reviewed from electronic medical records throughout a single county-wide hospital system. The pre-pandemic period (3 January 2019–30 June 2019, PRE) was compared with the pandemic period (3 January 2020–30 June 2020, POST). The primary outcome was AAST grade of appendicitis. Results: There were 278 cases of appendicitis in PRE and 269 in POST. The rate of complicated appendicitis (grades II–V) was higher in POST (39% vs. 30%, p = 0.0375), most prominently in the northern hospitals in the county (41% vs. 27%, p = 0.004), with non-operative management in six (3.2%) cases. Grades III–V, consistent with perforation, were seen in 33% of POST vs. 27% of PRE cases (p = 0.098). Grade I appendicitis was managed non-operatively in only six (1.6%) patients. There were fewer readmissions in POST (4% vs. 8%, p = 0.0427) and no mortalities during the study period. Conclusions: There was a significant increase in presentation with complicated appendicitis during the early phase of the COVID-19 pandemic in the northern hospitals in the county. There was no increase in NOM of uncomplicated appendicitis and no change in hospital LOS but there were fewer readmissions during COVID-19. Full article

Background: Overcrowding in emergency services (ESs) is an escalating issue in many countries worldwide, and it is also evident in the paediatric context. Specifically, in paediatric emergency departments (PEDs) in Europe, there has been a noticeable upward trend in demand for care over the past decade, peaking at 9.1 million visits in 2020. Objectives: To identify interventions aimed at reducing non-urgent presentations (NUPs) and attendance rate PEDs. Methods: A systematic review of the last five years was conducted using various databases (Web of Science, PubMed, Scopus, and CINAHL) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: A total of 15 articles were included in the final review, detailing five types of interventions: (1) telemedicine-based interventions, (2) the continuity of care interventions, (3) health literacy-based interventions, (4) interventions focused on establishing a point of access prior to emergency care, and (5) multidisciplinary interventions. Conclusions: The results of this review suggest the implementation of telemedicine-based interventions, the promotion of continuity of care, and the enhancement of parental health literacy as strategies to address the issue of overcrowding in PEDs. Full article

Post-COVID-19, significant triage modifications were made in emergency hospital medical care. Previous scoping reviews investigated triage changes during COVID-19. This scoping review uniquely considers post-pandemic effects. It searches the parameters “COVID-19, triage, hospital, emergency medical care” in four primary databases, one register, and a supplementary database to determine the range of emergency hospital triage changes. Following PRISMA guidelines, studies included are post-2023 publications, those in English, and research studies. Excluded were duplicates, reviews, books, and reports lacking research studies or including irrelevant information on COVID-19, triage, hospital, or emergency medical care. Identified are 1071 records: OVID (n = 20), PubMed (n = 2), Scopus (n = 46), Web of Science (n = 20), Cochrane COVID-19 Register (n = 18), and Google Scholar (n = 965). Six studies are included from the Web of Science (n = 1) and Google Scholar (n = 5). One study includes reports from six different countries; thus, there are 11 reports. The modification of triage was concerning four ways, with each country focusing on a specific triage change. Adaptive changes were proactive rather than reactive. Triage-related future research suggestions include the four triage aspects, international comparisons, and longitudinal change. The recommendation is for research assessing Google Scholar. Full article

Background: Abnormalities in the canal of the Nuck are rare clinical entities with presentation in the early adulthood of females. Given their rarity, they can be misdiagnosed with a strangulated inguinal hernia. Methods: Herein, we report a young female with painful swelling of the right inguinal hernia and its surgical approach. Results: A 37-year-old female presented to the emergency department with pain in the right lower abdominal quadrant and an edematous inguinal mass. Physical examination showed a palpable inguinal mass, setting the suspicion for possible incarcerated inguinal hernia. Laboratory exams were within normal ranges. The patient was subsequently treated surgically. During the operation, a cystic well-rounded mass was identified and completely excised. The mesh and plug technique was the chosen technique for the restoration of the inguinal canal. The hospitalization length was one day, and the post-operative course was uneventful. Conclusions: Although a Nuck cyst is a rare entity, it should be taken into consideration in female adults who present with an inguinal mass. Full article

Intensive Care Unit-Acquired Weakness (ICU-AW) is a common and severe complication in critically ill patients, characterized by profound and often prolonged muscle weakness. The complexity of its diagnosis and management requires a multidimensional approach that integrates clinical, electrophysiological, and imaging tools. This review focuses on the challenges in diagnosing ICU-AW, emphasizing the limitations of traditional methods such as manual muscle testing and electrophysiological studies, and highlights the emerging role of neuromuscular ultrasound (NMUS) as a promising, non-invasive diagnostic aid. Despite its utility, no gold standard exists for NMUS, making it an evolving area of research. The pathophysiological basis of ICU-AW involves multiple mechanisms, including critical illness polyneuropathy (CIP), critical illness myopathy (CIM), and muscle atrophy due to disuse. Understanding these underlying mechanisms is crucial for advancing diagnostic strategies and informing therapeutic interventions. Recent insights into the molecular and cellular pathways involved, such as the role of oxidative stress, mitochondrial dysfunction, and the ubiquitin-proteasome system, have opened new avenues for targeted therapies. Management of ICU-AW remains challenging as no specific treatment has been proven fully effective. Current strategies focus on early mobilization, minimizing sedation, and optimizing nutritional support. Emerging therapies targeting molecular pathways involved in muscle degradation are under investigation, highlighting the potential to translate pathophysiological understanding into therapeutic innovations. This review underscores the need for ongoing research to establish standardized diagnostic protocols and develop targeted treatments for ICU-AW. Full article