Emergency medicine journal : EMJ
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Review
BET 2: Sharing decisions for patients with suspected cardiac chest pain in the emergency department.
A short-cut review was carried out to establish whether shared decision making used alongside a decision aid can lead to greater patient satisfaction, lower healthcare resource use and non-inferior clinical outcomes in patients with suspected acute coronary syndromes. Four studies were directly relevant to the question. ⋯ The clinical bottom line is that the use of shared decision-making tools in the ED for management of patients with low-risk chest pain appears to be beneficial to the patient and the physician. Use of these shared decision-making tools appears to increase patient knowledge and satisfaction, while decreasing decision conflict and resource use, without causing additional negative outcomes for the patient.
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A short-cut review was carried out to establish whether the Manchester Acute Coronary Syndromes (MACS) and Troponin-only MACS (T-MACS) decision aids can safely rule out acute coronary syndromes in patients presenting to the ED with suspected cardiac chest pain. Six studies were directly relevant to the question. ⋯ The clinical bottom line is that both rules have high sensitivity for acute coronary syndromes, including the detection of major adverse cardiac events at 30 days. The original MACS algorithm may have marginally greater sensitivity than T-MACS but has inferior specificity and requires the use of a biomarker assay (for heart-type fatty acid binding protein) that is not currently widely used in practice.
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There is a lack of clarity regarding the use of prophylactic antibiotics for patients presenting with penetrating injuries. A structured literature review and review of penetrating injury records in an MTC was undertaken with a view to help guide clinical practice. ⋯ Strong evidence exists for the use of prophylactic antibiotics for chest wounds requiring tube thoracostomy. The Cochrane review concluded that there is no evidence base for prophylactic antibiotic use for penetrating abdominal trauma, with EAST recommendations based on weaker evidence.Drawing conclusions about infectious outcomes from TARN data is difficult due to low total numbers, differences in record-keeping for secondary transfers and a high proportion of patients with another requirement for antibiotics.For penetrating thoracic injury requiring chest drain there is evidence of benefit for prophylactic antibiotics, in other patients with penetrating injury due to the current lack of evidence, clinical judgement based on the circumstances of penetrating injury is recommended.
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Multicenter Study
Perceived support at work after critical incidents and its relation to psychological distress: a survey among prehospital providers.
Prehospital providers are at increased risk for psychological distress. Support at work after critical incidents is believed to be important for providers, but current guidelines are in need of more scientific evidence. This study aimed to investigate: (1) to what extent prehospital providers experience support at work; (2) whether support at work is directly associated with lower distress and (3) whether availability of a formal peer support system is related to lower distress via perceived colleague support. ⋯ Prehospital providers at risk of psychological distress may benefit from support from colleagues and management and from having time to recover after critical incidents. Formal peer support may assist providers by increasing their sense of support from colleagues. These findings need to be verified in a longitudinal design.
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Recent events involving a significant number of casualties have emphasised the importance of appropriate preparation for receiving hospitals, especially Emergency Departments, during the initial response phase of a major incident. Development of a mass casualty resilience and response framework in the Northern Trauma Network included a review of existing planning assumptions in order to ensure effective resource allocation, both in local receiving hospitals and system-wide.Existing planning assumptions regarding categorisation by triage level are generally stated as a ratio for P1:P2:P3 of 25%:25%:50% of the total number of injured survivors. This may significantly over-, or underestimate, the number in each level of severity in the case of a large-scale incident. ⋯ Despite the heterogeneity of data and range of incident type there is sufficient evidence to suggest that current planning assumptions are incorrect and a more refined model is required. An important finding is the variation in proportion of critical cases depending upon the mechanism. For example, a greater than expected proportion results from incidents involving a building fire whereas the existing model may over-estimate critical caseload in more 'conventional' incidents such as a transportation accident or even in terrorism-related incidents.A new model suggesting the proportions of casualties expected by severity categorisation and incident type is shown in table 2. A more detailed investigation is planned to further refine and develop this model.emermed;34/12/A865-a/T1F1T1Table 1emermed;34/12/A865-a/T2F2T2Table 2.