Emergency medicine journal : EMJ
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Since 'legal highs' emerged as drugs of abuse in the UK, Emergency Physicians have battled to keep up with the latest drug craze. Whilst many of these drugs present with recognisable toxidromes, the effect of new compounds or medications cannot be readily predicted. In Belfast, we have witnessed a recent increase in the number of patients presenting after recreational abuse of Pregabalin (Lyrica). Patients, state that the medication induces a state similar to drunkenness, hence the street name 'Budweiser's'. To our knowledge this is the first case series detailing the recreational abuse of Pregabalin, a drug which has become popular in primary care. ⋯ Emergency Physicians should be aware of the current use of Pregabalin as a recreational drug. Patients are either taking tablets whole or cutting and snorting them. 60% of patients in this case series presented to the ED with seizures and 20% required ICU admission. We recommend that patients who present with potential Lyrica toxicity should be admitted for observation with the treating physician being mindful of the potential for seizure activity.
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Admissions to the Emergency Department with chest pain constitute a significant proportion of the work-load. In England it represents 6% of all Emergency Department (ED) attendances. These attendances translate to accounting for approximately 25% of acute medical admissions. One method of excluding myocardial infarction is the use of a rapid point of care Triple Cardiac Marker test. This allows testing at time point 0 and 90 minutes and negates the need for a delayed troponin. One of the markers, myoglobin, has a high sensitivity but low specificity. If there is a 25% rise in myoglobin between two tests then it is considered a positive result. The patient then requires a 12-hour troponin. Locally, there was concern over the value of including myoglobin in the triple test as it was felt that it lead to inappropriate admissions. ⋯ The use of myoglobin in the triple test does appear to be appropriate for the local population. There is a significant short-coming in the application of the triple test that is putting patients at risk of an adverse outcome. The current chest pain proforma as it stands does not appear to prevent inappropriate discharges.
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International guidance has recently recommended serial proximal compression ultrasound (CUS) as first line imaging for suspected deep vein thrombosis (DVT). Limitations with this strategy include attrition, lack of a clear diagnosis, and increased costs associated with serial resource use / clinical review. Single whole-leg CUS is a routine alternative diagnostic strategy that can reduce repeat attendance and identify alternative pathology. We sought to assess the performance characteristics of an established emergency department ambulatory protocol incorporating whole-leg CUS by non-physicians for exclusion of DVT. ⋯ Patients who have anticoagulation withheld following a negative or inconclusive whole leg CUS for suspected DVT have a low rate of adverse events at 3 months. Including the calf in ultrasound examination aided and clarified diagnosis in approximately one third of patients. Technical failure remains an issue: several factors were significantly associated with inconclusive results in our cohort and may warrant an alternative diagnostic approach Abstract 008 Table 1Measuring ED crowding Measure Operational DefinitionAbility of ambulances to offload patients.An ED is crowded when the 90th percentile time between ambulance arrival and offload is greater than 15 minutesPatients who leave without being seen or treated (LWBS)An ED is crowded when the number of patients who LWBS is greater than or equal to 5%.Time until TriageAn ED is crowded when there is a delay greater than 5 minutes from patient arrival to begin their initial triage.ED occupancy rate.An ED is crowded when the occupancy rate is greater than 100%.Patients' total length of stay in the EDAn ED is crowded when the 90th percentile patient's, total length of stay is greater than 4 hours.Time until a physician first sees the patientAn ED is crowded when an emergent (1 or 2) patient waits longer than 30 minutes to be seen by a physicianED boarding timeAn ED is crowded when less than 90% of patients have left the ED 2 hour after the admission decision.Number of patients boarding in the ED.Boarders are defined as admitted patients waiting to be placed in an inpatient bed. An ED is crowded when there is greater than 10% occupancy of boarders in the ED ED; Emergency Department Abstract 008 Table 2Performance of the ICMED against clinician perception of crowding Sensitivity (95% CI)Specificity (95% CI)Ambulance Offload55.9 (45.3-66.5)90.0 (83.6-96.4)Nurse Triage70.6 (60.8-80.3)76.0 (66.9-85.1)Occupancy55.9 (45.3-66.5)78.0 (69.1-86.9)Total stay55.9 (45.3-66.5)100.0 (88.8-100)ED Boarding Time55.9 (45.3-66.5)100.0 (88.8-100)Time to see a Physician32.4 (22.4-42.4)84.0 (76.2-91.8)Patients Boarding85.3 (77.7-92.9)70.0 (60.2-79.8)One Violation100.0 (89.7-100)38.0 (27.6-48.4)Two Violations100.0 (89.7-100)60.0 (49.5-70.5)Three Violations91.2 (85.1-97.2)100.0 (92.9-100)Four Violations50.0 (39.3-60.7)100.0 (88.8-100)Five Violations26.5 (17.0-35.9)100.0 (88.8-100)Six Violations23.5 (14.5-32.6)100.0 (88.8-100)Seven Violations8.8 (2.8-14.9)100.0 (88.8-100).
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The Emergency Department (ED) is a fertile ground for medical error. In numerous other areas checklists (and the associated cultural changes) have been brought in to reduce error. Following the National Audit Project into airway complications in 2011, guidelines were produced recommending the use of a checklist prior to rapid sequence induction (RSI) along with capnography in the ED. Similarly, College of Emergency Medicine (CEM) guidelines recommended 'checks' prior to sedation and capnography use. The project objectives were firstly to review the national use of checklists (and capnography). Secondly, within one trust which has already implemented the checklists, to ascertain if they were used in reality. Finally, the study looked into attitudes and how barriers to implementation could be overcome. ⋯ The use of checklists within Emergency Medicine remains limited. Their uptake within a trust that has implemented them has been slow. Cultural resistance within the workplace remains a barrier that needs to be overcome.
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Paediatric trauma team leaders (TTL) may be trained in different clinical sub specialties. The purpose of this study was to compare TTL trained in adult and paediatric emergency medicine in ordering pan CT scans in a similar category of trauma patient. Radiation doses received are often extremely high and carry with them a significantly increased risk for the child of developing cancer in the future. ⋯ Trauma team leaders from paediatric and adult emergency background have a similar propensity to order CT pan scans in trauma. Regardless of who the TTL was, the overall yield of the CT pan scans was only 50%, so the need for weighing up the risks/benefits is imperative in this group.