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issn:1471-227
1.  Trauma exposure, posttraumatic stress disorder and the effect of explanatory variables in paramedic trainees 
Background
Emergency healthcare workers, including trainees and individuals in related occupations are at heightened risk of developing posttraumatic stress disorder (PTSD) and depression owing to work-related stressors.
We aimed to investigate the type, frequency, and severity of direct trauma exposure, posttraumatic stress symptoms and other psychopathology amongst paramedic trainees. In order to create a risk profile for individuals who are at higher occupational risk of developing PTSD, we examined risk and resilience factors that possibly contributed to the presence and severity of posttraumatic symptomatology.
Methods
Paramedic trainees (n = 131) were recruited from a local university. A logistic regression analysis was conducted using the explanatory variables age, gender, population group, trauma exposure, depression, alcohol abuse, alcohol dependence, resilience and social support.
Results
94% of paramedic trainees had directly experienced trauma, with 16% meeting PTSD criteria. A high rate of depression (28%), alcohol abuse (23%) and chronic perceived stress (7%) and low levels of social support was found. The number of previous trauma exposures, depression, resilience and social support significantly predicted PTSD status and depression had a mediating effect.
Conclusion
There is a need for efficient, ongoing screening of depressive and PTSD symptomatology in trauma exposed high risk groups so that early psychological supportive interventions can be offered.
doi:10.1186/1471-227X-14-11
PMCID: PMC4004503  PMID: 24755358
Trauma; Posttraumatic stress disorder; Paramedic trainees; Emergency medical workers
2.  What decides the suspicion of acute coronary syndrome in acute chest pain patients? 
Background
Physicians assessing chest pain patients in the emergency department (ED) base the likelihood of acute coronary syndrome (ACS) mainly on ECG, symptom history and blood markers of myocardial injury. Among these, the ECG has been stated to be the most important diagnostic tool. We aimed to analyze the relative contributions of these three diagnostic modalities to the ED physicians’ evaluation of ACS likelihood in clinical practice.
Methods
1151 consecutive ED chest pain patients were prospectively included. The ED physician’s subjective assessment of the patient’s likelihood of ACS (obvious ACS, strong, vague or no suspicion of ACS), the symptoms and the ECG were recorded on a special form. The ED TnT value was retrieved from the medical records. Frequency tables and logistic regression models were used to evaluate the contributions of the diagnostic tests to the level of ACS suspicion.
Results
Symptoms determined whether the physician had any suspicion of ACS (odds ratio, OR 526 for symptoms typical compared to not suspicious of ACS) since neither ECG nor TnT contributed significantly (ORs not significantly different from 1) to this assessment. ACS was suspected in only one in ten patients with symptoms not suspicious of ACS. Symptoms were also more important (OR 620 for typical symptoms) than ECG (OR 31 for ischemic ECG) and TnT (OR 3.4 for a positive TnT) for the assessment of obvious ACS/strong suspicion versus vague/no suspicion. Of the patients with ST-elevation on ECG, 71% were considered to have an obvious ACS, as opposed to only 6% of those with symptoms typical of ACS and 10% of those with a positive TnT.
Conclusion
The ED physicians used symptoms as the most important assessment tool and applied primarily the symptoms to determine the level of ACS suspicion and to rule out ACS. The ECG was primarily used to rule in ACS. The TnT level played a minor role for the assessment of ACS likelihood. Further studies regarding ACS prediction based on symptoms may help improve decision-making in ED patients with possible ACS.
doi:10.1186/1471-227X-14-9
PMCID: PMC4005623  PMID: 24742353
3.  Risk stratification of adult emergency department syncope patients to predict short-term serious outcomes after discharge (RiSEDS) study 
Background
While Canadian ED physicians discharge most syncope patients with no specific further follow-up, approximately 5% will suffer serious outcomes after ED discharge. The goal of this study is to prospectively identify risk factors and to derive a clinical decision tool to accurately predict those at risk for serious outcomes after ED discharge within 30 days.
Methods/Design
We will conduct a prospective cohort study at 6 Canadian EDs to include adults with syncope and exclude patients with loss of consciousness > 5 minutes, mental status changes from baseline, obvious witnessed seizure, or head trauma prior to syncope. Emergency physicians will collect standardized clinical variables including historical features, physical findings, and results of immediately available tests (blood, ECG, and ED cardiac monitoring) prior to ED discharge/hospital admission. A second emergency physician will evaluate approximately 10% of study patients for interobserver agreement calculation of predictor variables. The primary outcome will be a composite serious outcome occurring within 30 days of ED discharge and includes three distinct categories: serious adverse events (death, arrhythmia); identification of serious underlying disease (structural heart disease, aortic dissection, pulmonary embolism, severe pulmonary hypertension, subarachnoid hemorrhage, significant hemorrhage, myocardial infarction); or procedures to treat the cause of syncope. The secondary outcome will be any of the above serious outcomes either suspected or those occurring in the ED. A blinded Adjudication Committee will confirm all serious outcomes. Univariate analysis will be performed to compare the predictor variables in patients with and without primary outcome. Variables with p-values <0.2 and kappa values ≥0.60 will be selected for stepwise logistic regression to identify the risk factors and to develop the clinical decision tool. We will enroll 5,000 patients (with 125 positive for primary outcome) for robust identification of risk factors and clinical decision tool development.
Discussion
Once successfully developed, this tool will accurately risk-stratify adult syncope patients; however, validation and implementation will still be required. This program of research should lead to standardized care of syncope patients, and improve patient safety.
doi:10.1186/1471-227X-14-8
PMCID: PMC4003802  PMID: 24629180
Syncope; Serious outcomes; Prognosis; Arrhythmia; Emergency department; Management
4.  Thoraco- abdominal impalement injury: a case report 
Background
Impalement injury is an uncommon presentation in the emergency department (ED), and penetrating thoraco-abdominal injuries demand immediate life-saving measures and prompt care. Massive penetrating trauma by impalement in a pediatric case represents a particularly challenging presentation for emergency providers in non-trauma center settings.
Case presentation
We report a case of 10 year old male who presented in our ED with an alleged history of fall from an approximately 15 foot tall coconut tree, landing over an upright bamboo stake approximately 50 centimeter long, resulting in a trans-abdomino, trans-thoracic injury. In addition to prompt resuscitation and hospital transfer, assessment of damage to vital structures in conjunction with surgical specialty consultation was an immediate goal.
Conclusion
This article describes a case study of an impalement injury, relevant review of the available literature, and highlights the peculiar strategies required in the setting of a resource limited ED.
doi:10.1186/1471-227X-14-7
PMCID: PMC3984728  PMID: 24592862
Nepal; Trauma; Emergency medicine; Trauma surgery; Rural emergency medicine
5.  Use of prehospital ultrasound in North America: a survey of emergency medical services medical directors 
Background
Advances in ultrasound imaging technology have made it more accessible to prehospital providers. Little is known about how ultrasound is being used in the prehospital environment and we suspect that it is not widely used in North America at this time. We believe that EMS system characteristics such as provider training, system size, population served, and type of transport will be associated with use or non-use of ultrasound. Our study objective was to describe the current use of prehospital ultrasound in North America.
Methods
This study was a cross-sectional survey distributed to EMS directors on the National Association of EMS Physicians (NAEMSP) mailing list. Respondents had the option to complete a paper or electronic survey.
Results
Of the 755 deliverable surveys we received 255 responses from across Canada and the United states for an overall response rate of 30%. Of respondents, 4.1% of EMS systems (95% CI 1.9, 6.3) reported currently using ultrasound and an additional 21.7% (95% CI 17, 26.4) are considering implementing ultrasound. EMS services using ultrasound have a higher proportion of physicians (p < 0.001) as their highest trained prehospital providers when compared to the survey group as a whole. The most commonly cited current and projected applications are Focused Abdominal Sonography for Trauma (FAST) and assessment of pulseless electrical activity (PEA) arrest. The cost of equipment and training are the most significant barriers to implementation of ultrasound. Most medical directors want evidence that prehospital ultrasound improves patient outcomes prior to implementation.
Conclusions
Prehospital ultrasound is infrequently used in North America and there are a number of barriers to its implementation, including costs of equipment and training and limited evidence demonstrating improved outcomes. A research agenda for prehospital ultrasound should focus on patient-important outcomes such as morbidity and mortality. Two commonly used indications that could be a focus of standardized training programs are the FAST exam, and assessment of PEA arrest.
doi:10.1186/1471-227X-14-6
PMCID: PMC3941255  PMID: 24580744
Ultrasonography; Emergency medical services
6.  Consensus on items and quantities of clinical equipment required to deal with a mass casualties big bang incident: a national Delphi study 
Background
Major short-notice or sudden impact incidents, which result in a large number of casualties, are rare events. However health services must be prepared to respond to such events appropriately. In the United Kingdom (UK), a mass casualties incident is when the normal response of several National Health Service organizations to a major incident, has to be supported with extraordinary measures. Having the right type and quantity of clinical equipment is essential, but planning for such emergencies is challenging. To date, the equipment stored for such events has been selected on the basis of local clinical judgment and has evolved without an explicit evidence-base. This has resulted in considerable variations in the types and quantities of clinical equipment being stored in different locations. This study aimed to develop an expert consensus opinion of the essential items and minimum quantities of clinical equipment that is required to treat 100 people at the scene of a big bang mass casualties event.
Methods
A three round modified Delphi study was conducted with 32 experts using a specifically developed web-based platform. Individuals were invited to participate if they had personal clinical experience of providing a pre-hospital emergency medical response to a mass casualties incident, or had responsibility in health emergency planning for mass casualties incidents and were in a position of authority within the sphere of emergency health planning. Each item’s importance was measured on a 5-point Likert scale. The quantity of items required was measured numerically. Data were analyzed using nonparametric statistics.
Results
Experts achieved consensus on a total of 134 items (54%) on completion of the study. Experts did not reach consensus on 114 (46%) items. Median quantities and interquartile ranges of the items, and their recommended quantities were identified and are presented.
Conclusions
This study is the first to produce an expert consensus on the items and quantities of clinical equipment that are required to treat 100 people at the scene of a big bang mass casualties event. The findings can be used, both in the UK and internationally, to support decision makers in the planning of equipment for such incidents.
doi:10.1186/1471-227X-14-5
PMCID: PMC3936839  PMID: 24559111
Mass casualties; Major incident; Ambulance; Delphi method; Internet; Paramedic; Big bang; Clinical equipment
7.  BMC Emergency Medicine reviewer acknowledgement, 2013 
Contributing reviewers
The editors of BMC Emergency Medicine would like to thank all our reviewers who have contributed to the journal in Volume 13 (2013).
doi:10.1186/1471-227X-14-4
PMCID: PMC3922280
8.  Predictors for delayed encephalopathy following acute carbon monoxide poisoning 
Background
In Japan, many carbon monoxide (CO) poisoning cases are transported to emergency settings, making treatment and prognostic assessment an urgent task. However, there is currently no reliable means to predict whether “delayed neuropsychiatric sequelae (DNS)” will develop after acute CO poisoning. This study is intended to find out risk factors for the development of DNS and to characterize the clinical course following the development of DNS in acute CO poisoning cases.
Methods
This is a retrospective cohort study of 79 consecutive patients treated at a single institution for CO poisoning. This study included 79 cases of acute CO poisoning admitted to our emergency department after attempted suicide, who were divided into two groups consisting of 13 cases who developed DNS and 66 cases who did not. The two groups were compared and analyzed in terms of clinical symptoms, laboratory findings, etc.
Results
Predictors for the development of DNS following acute CO poisoning included: serious consciousness disturbance at emergency admission; head CT findings indicating hypoxic encephalopathy; hematology findings including high creatine kinase, creatine kinase-MB and lactate dehydrogenase levels; and low Global Assessment Scale scores. The clinical course of the DNS-developing cases was characterized by prolonged hospital stay and a larger number of hyperbaric oxygen (HBO) therapy sessions.
Conclusion
In patients with the characteristics identified in this study, administration of HBO therapy should be proactively considered after informing their family, at initial stage, of the risk of developing DNS, and at least 5 weeks’ follow-up to watch for the development of DNS is considered necessary.
doi:10.1186/1471-227X-14-3
PMCID: PMC3909505  PMID: 24484081
Delayed encephalopathy; Carbon monoxide poisoning; Delayed neuropsychiatric sequelae; Suicide attempt; Psychiatric emergency
9.  Quality of emergency medical care in Gondar University Referral Hospital, Northwest Ethiopia: a survey of patients’ perspectives 
Background
Ethiopia has fairly good coverage but very low utilization of health care services. Emergency medical care services require fast, correct and curious services to clients as they present with acute problems. In Ethiopia and Gondar in particular, the quality of emergency medical care has not been studied. The main aim of this study was to assess the disease profile and patients’ satisfaction in Gondar University Referral Hospital (GURH).
Methods
A facility based cross-sectional study was conducted among patients visiting GURH for emergency care. Ethical clearance was obtained from the Institutional Review Board of University of Gondar. Patients were selected by systematic random sampling, using patient flow list in the day and night emergency services. Data were collected using a standard Press Ganey questionnaire by BSc health science graduates. Data were entered in to Epi Info 3.5.3 software and exported to SPSS version 20.0 for windows for analysis.
Results
A total of 963 patients (response rate = 96.8%) were studied. The mean (+ s.d.) age of patients was 28.4 (+17.9) years. The overall satisfaction using the mean score indicates that 498 (51.7%) 95%CI: (48.4% - 54.9%) were satisfied with the service, the providers and the facility suitability whereas 465(48.3%) 95%CI: (45.1%- 51.6%) were not satisfied. Seven hundred and six (73.3%) 95%CI: 70.4%-76.1%, patients reported that they have been discriminated or treated badly during the service provision in the hospital. OPD site visited (p < 0.0001), visiting days of the week (P < 0.049), medical condition on arrival (P < 0.0001), degree of confidence in the hospital (AOR = 1.9, 95%CI: 1.1, 3.1), reported discrimination/bad treatment of patients with service (AOR = 0.4, 95%CI: 0.2, 0.7), were significantly associated determinants of patient satisfaction.
Conclusions
Non-communicable disease emergencies like injuries and cardiovascular diseases are common. There is a low level of patient satisfaction related to lack of confidence in the hospital for treatment, discrimination towards patient care, and under and delayed treatment of patients who were not in serious medical conditions. Hospitals shall prepare themselves to address the increasing challenge of non-communicable disease emergencies. It is important to revise the service delivery in the emergency department to improve staff courtesy and politeness, commitment, reduce discrimination and bad treatment and proper triage of emergencies at all points of care to increase patient satisfaction giving emphasis to earlier working days.
doi:10.1186/1471-227X-14-2
PMCID: PMC3902003  PMID: 24456203
Emergency care; Quality; Patient satisfaction; Gondar; Northwest Ethiopia
10.  Cut throat injuries at a university teaching hospital in northwestern Tanzania: a review of 98 cases 
Background
Cut throat injuries though rarely reported in literature pose a great therapeutic challenge because multiple vital structures are vulnerable to injuries in the small, confined unprotected area. A sudden increase in the number of cut throat patients in our centre in recent years prompted the authors to analyze this problem. This study was conducted in our local setting to describe the etiology, patterns and treatment outcome of these injuries.
Methods
This was a combined retrospective and prospective study of cut throat injury patients who were managed at Bugando Medical Centre between February 2009 and January 2013. Statistical data analysis was done using SPSS software version 17.0.
Results
A total of 98 patients with cut throat injuries were studied. Males outnumbered females by a ratio of 2.4: 1. The median age of patients was 26 years (range 8 to 78 years). Majority of patients (79.6%) had no employment and most of them (65.3%) came from rural community. Homicide was the commonest (55.1%) cause, followed by suicidal attempts (34.7%) and accidental (10.2%) injuries. Interpersonal conflict (24.4%) was the most common motivating factor for homicidal injury whereas psychiatric illness (16.2%) and road traffic accidents (9.2%) were the most frequent motivating factors of suicidal attempt and accidental injuries respectively. The majority of injuries were in Zone II accounting for 65.3% of cases and most of them had laryngeal (57.1%) injury. Surgical debridement, laryngeal/hypopharynx repair and tracheostomy were the most common surgical procedures performed in 93.9%, 73.5% and 70.4% of patients respectively. Postoperative complication rate was 57.1%, the commonest being surgical site infections in 28.1% of patients and it was significantly associated with late presentation and anatomical zones (P < 0.001). The overall median duration of hospitalization was 12 days. Patients who had postoperative complications stayed longer in the hospital and this was statistically significant (p = 0.011). Mortality rate was 11.2% and was significantly associated with co-morbidities, delayed presentation and presence of complications (p < 0.001). The follow up of patients was poor.
Conclusions
Cut throat injuries are a major cause of morbidity and mortality among young adult males in our setting. Addressing the root causes of violence such as poverty, unemployment, and substance abuse will reduce the incidence of these injuries in our environment.
doi:10.1186/1471-227X-14-1
PMCID: PMC3893495  PMID: 24423426
Cut throat injuries; Etiology; Patterns; Treatment outcome; Tanzania
11.  All purulence is local – epidemiology and management of skin and soft tissue infections in three urban emergency departments 
Background
Skin and soft tissue infection (SSTIs) are commonly treated in emergency departments (EDs). While the precise role of antibiotics in treating SSTIs remains unclear, most SSTI patients receive empiric antibiotics, often targeted toward methicillin-resistant Staphylococcus aureus (MRSA). The goal of this study was to assess the efficiency with which ED clinicians targeted empiric therapy against MRSA, and to identify factors that may allow ED clinicians to safely target antibiotic use.
Methods
We performed a retrospective analysis of patient visits for community-acquired SSTIs to three urban, academic EDs in one northeastern US city during the first quarter of 2010. We examined microbiologic patterns among cultured SSTIs, and relationships between clinical and demographic factors and management of SSTIs.
Results
Antibiotics were prescribed to 86.1% of all patients. Though S. aureus (60% MRSA) was the most common pathogen cultured, antibiotic susceptibility differed between adult and pediatric patients. Susceptibility of S. aureus from ED SSTIs differed from published local antibiograms, with greater trimethoprim resistance and less fluoroquinolone resistance than seen in S. aureus from all hospital sources. Empiric antibiotics covered the resultant pathogen in 85.3% of cases, though coverage was frequently broader than necessary.
Conclusions
Though S. aureus remained the predominant pathogen in community-acquired SSTIs, ED clinicians did not accurately target therapy toward the causative pathogen. Incomplete local epidemiologic data may contribute to this degree of discordance. Future efforts should seek to identify when antibiotic use can be narrowed or withheld. Local, disease-specific antibiotic resistance patterns should be publicized with the goal of improving antibiotic stewardship.
doi:10.1186/1471-227X-13-26
PMCID: PMC3878171  PMID: 24359038
Skin and soft tissue infections; Antibiotic resistance; Antimicrobial stewardship
12.  An association between systolic blood pressure and stroke among patients with impaired consciousness in out-of-hospital emergency settings 
Background
Stroke is difficult to diagnose when consciousness is disturbed. However few reports have discussed the clinical predictors of stroke in out-of-hospital emergency settings. This study aims to evaluate the association between initial systolic blood pressure (SBP) value measured by emergency medical service (EMS) and diagnosis of stroke among impaired consciousness patients.
Methods
We included all patients aged 18 years or older who were treated and transported by EMS, and had impaired consciousness (Japan Coma Scale ≧ 1) in Osaka City (2.7 million), Japan from January 1, 1998 through December 31, 2007. Data were prospectively collected by EMS personnel using a study-specific case report form. Multiple logistic regressions assessed the relationship between initial SBP and stroke and its subtypes adjusted for possible confounding factors.
Results
During these 10 years, a total of 1,840,784 emergency patients who were treated and transported by EMS were documented during the study period in Osaka City. Out of 128,678 with impaired consciousness, 106,706 who had prehospital SBP measurements in the field were eligible for our analyses. The proportion of patients with severe impaired consciousness significantly increased from 14.5% in the <100 mmHg SBP group to 27.6% in the > =200 mmHg SBP group (P for trend <0.001). The occurrence of stroke significantly increased with increasing SBP (adjusted odd ratio [AOR] 1.34, 95% confidence interval [CI] 1.33 to 1.35), and the AOR of the SBP > =200 mmHg group versus the SBP 101-120 mmHg group was 5.26 (95% CI 4.93 to 5.60). The AOR of the SBP > =200 mmHg group versus the SBP 101-120 mmHg group was 9.76 in subarachnoid hemorrhage (SAH), 16.16 in intracranial hemorrhage (ICH), and 1.52 in ischemic stroke (IS), and the AOR of SAH and ICH was greater than that of IS.
Conclusions
Elevated SBP among emergency patients with impaired consciousness in the field was associated with increased diagnosis of stroke.
doi:10.1186/1471-227X-13-24
PMCID: PMC3878578  PMID: 24341562
Systolic blood pressure; Prehospital; Impaired consciousness
13.  Continuous professional competence (CPC) for emergency medical technicians in Ireland: educational needs assessment 
Background
As in other countries, the Irish Regulator for Pre-Hospital practitioners, the Pre-Hospital Emergency Care Council (PHECC), will introduce a Continuous Professional Competence (CPC) framework for all Emergency Medical Technicians (EMTs), Paramedics and Advanced Paramedics (APs). This framework involves EMTs participating in regular and structured training to maintain professional competence and enable continuous professional developments. To inform the development of this framework, this study aimed to identify what EMTs consider the optimum educational outcomes and activity and their attitude towards CPC.
Methods
All EMTs registered in Ireland (n = 925) were invited via email to complete an anonymous online survey. Survey questions were designed based on Continuous Professional Development (CPD) questionnaires used by other healthcare professions. Quantitative and qualitative analyses were performed.
Results
Response rate was 43% (n = 399). 84% of participants had been registered in Ireland for less than 24 months, while 59% had been registered EMTs for more than one year. Outcomes were: evidence of CPC should be a condition for EMT registration in Ireland (95%), 78% believed that EMTs who do not maintain CPC should be denied the option to re-register. Although not required to do so at the time of survey, 69% maintained a professional portfolio and 24% had completed up to 20 hours of CPC activities in the prior 12 months. From a list of 22 proposed CPC activities, 97% stated that practical scenario-based exercises were most relevant to their role. E-learning curricula without practical components were considered irrelevant (32%), but the majority of participants (91%) welcomed access to e-learning when supplemented by related practical modules.
Conclusion
EMTs are supportive of CPC as a key part of their professional development and registration. Blended learning, which involves clinical and practical skills and e-learning, is the optimum approach.
doi:10.1186/1471-227X-13-25
PMCID: PMC3898252  PMID: 24345064
Emergency medical technicians; Continuous professional development; CPD; Blended learning; E-learning; Educational; Ambulance
14.  Methodology for developing quality indicators for the care of older people in the Emergency Department 
Background
Compared with younger people, older people have a higher risk of adverse health outcomes when presenting to emergency departments. As the population ages, older people will make up an increasing proportion of the emergency department population. Therefore it is timely that consideration be given to the quality of care received by older persons in emergency departments, and to consideration of those older people with special needs. Particular attention will be focused on important groups of older people, such as patients with cognitive impairment, residents of long term care and patients with palliative care needs. This project will develop a suite of quality indicators focused on the care of older persons in the emergency department.
Methods/design
Following input from an expert panel, an initial set of structural, process, and outcome indicators will be developed based on thorough systematic search in the scientific literature. All initial indicators will be tested in eight emergency departments for their validity and feasibility. Results of the data from the field studies will be presented to the expert panel at a second meeting. A suite of Quality Indicators for the older emergency department population will be finalised following a formal voting process.
Discussion
The predicted burgeoning in the number of older persons presenting to emergency departments combined with the recognised quality deficiencies in emergency department care delivery to this population, highlight the need for a quality framework for the care of older persons in emergency departments. Additionally, high quality of care is associated with improved survival & health outcomes of elderly patients. The development of well-selected, validated and economical quality indicators will allow appropriate targeting of resources (financial, education or quality management) to improve quality in areas with maximum potential for improvement.
doi:10.1186/1471-227X-13-23
PMCID: PMC4029470  PMID: 24314126
Emergency service; Hospital; Quality indicators; Health care; Geriatrics; Health services for the aged; Dementia; Cognitive impairment; Residential facilities; Protocol
15.  Emergency department utilization among recently released prisoners: a retrospective cohort study 
Background
The population of ex-prisoners returning to their communities is large. Morbidity and mortality is increased during the period following release. Understanding utilization of emergency services by this population may inform interventions to reduce adverse outcomes. We examined Emergency Department utilization among a cohort of recently released prisoners.
Methods
We linked Rhode Island Department of Corrections records with electronic health record data from a large hospital system from 2007 to 2009 to analyze emergency department utilization for mental health disorders, substance use disorders and ambulatory care sensitive conditions by ex-prisoners in the year after release from prison in comparison to the general population, controlling for patient- and community-level factors.
Results
There were 333,369 total ED visits with 5,145 visits by a cohort of 1,434 ex-prisoners. In this group, 455 ex-prisoners had 3 or more visits within 1 year of release and 354 had a first ED visit within 1 month of release. ED visits by ex-prisoners were more likely to be made by men (85% vs. 48%, p < 0.001) and by blacks (26% vs. 16%, p < 0.001) compared to the Rhode Island general population. Ex-prisoners were more likely to have an ED visit for a mental health disorder (6% vs. 4%, p < 0.001) or substance use disorder (16%vs. 4%, p < 0.001). After controlling for patient- and community-level factors, ex-prisoner visits were significantly more likely to be for mental health disorders (OR 1.43; 95% CI 1.27-1.61), substance use disorders (OR 1.93; 95% CI 1.77-2.11) and ambulatory care sensitive conditions (OR 1.09; 95% CI 1.00-1.18).
Conclusions
ED visits by ex-prisoners were significantly more likely due to three conditions optimally managed in outpatient settings. Future work should determine whether greater access to outpatient services after release from prison reduces ex-prisoners’ utilization of emergency services.
doi:10.1186/1471-227X-13-16
PMCID: PMC3818565  PMID: 24188513
Vulnerable populations; Mental health; Substance abuse; Emergency department
16.  Appendicitis: What does really make the difference between private and public hospitals? 
Background
Appendicitis is one of the most common surgical emergencies and is also a time-sensitive condition. Delays in treatment increase the risk of appendiceal perforation (AP), and thus AP rates have been used as a proxy to measure access to surgical care. It is very well known that in Brazil there are big differences between the public and private healthcare systems. Those differences can reflect in the treatment of what are considered simple cases, like appendicitis. As far as we know, it has no known links to behavioral or social risk factors, and has only one treatment option – appendectomy. The purpose of this study was to compare treatment received by Brazilian people, both by those who depend on the public and private healthcare system, and how it affects their outcome.
Methods
Data was collected from the records of all patients submitted to appendectomy, in a public and in a private Sao Paulo city’s hospitals, during January to April of 2010.
Results
Patients admitted by the public hospital present symptoms for a longer period of time than those treated by the private one. It took a significantly higher amount of time for the patients from the public hospital undergo surgery, and their length of stay is also significantly higher.
Conclusions
Appendicitis in a public scenario is associated with increased time from onset of symptoms to operative intervention and the main reason is the delayed presentation. Clinical polices for abdominal pain should be instituted by the public healthcare system, based on population education, healthcare professionals training and establishment of strategies that can speed the diagnosis process up.
doi:10.1186/1471-227X-13-15
PMCID: PMC3728156  PMID: 23890214
Appendectomy; Socioeconomic condition; Ultrasound; CT scan
17.  Factors affecting pediatric isotonic fluid resuscitation efficiency: a randomized controlled trial evaluating the impact of syringe size 
Background
Goal-directed therapy guidelines for pediatric septic shock resuscitation recommend fluid delivery at speeds in excess of that possible through use of regular fluid infusion pumps. In our experience, syringes are commonly used by health care providers (HCPs) to achieve rapid fluid resuscitation in a pediatric fluid resuscitation scenario. At present, it is unclear which syringe size health care providers should use when performing fluid resuscitation to achieve maximal fluid resuscitation efficiency. The objective of this study was therefore to determine if an optimal syringe size exists for conducting manual pediatric fluid resuscitation.
Methods
This 48-participant parallel group randomized controlled trial included 4 study arms (10, 20, 30, 60 mL syringe size groups). Eligible participants were HCPs from McMaster Children’s Hospital, Hamilton, Canada blinded to the purpose of the trial. Consenting participants were randomized using a third party technique. Following a standardization procedure, participants administered 900 mL (60 mL/kg) of isotonic saline to a simulated 15 kg child using prefilled provided syringes of the allocated size in rapid sequence. Primary outcome was total time to administer the 900 mL and this data was collected through video review by two blinded outcome assessors. Sample size was predetermined based upon a primary outcome analysis using one-way ANOVA.
Results
12 participants were randomized to each group (n=48) and all completed trial protocol to analysis. Analysis was conducted according to intention to treat principles. A significant difference in fluid resuscitation time (in seconds) was found between syringe size group means: 10 mL, 563s [95% CI 521; 606]; 20 mL, 506s [95% CI 64; 548]; 30 mL, 454s [95% CI 412; 596]; 60 mL, 455s [95% CI 413; 497] (p<0.001).
Conclusions
The syringe size used when performing manual pediatric fluid resuscitation has a significant impact on fluid resuscitation speed, in a setting where fluid filled syringes are continuously available. Greatest efficiency was achieved with 30 or 60 mL syringes.
Trial registration
ClinicalTrials.gov, NCT01494116
doi:10.1186/1471-227X-13-14
PMCID: PMC3729679  PMID: 23883424
Fluid therapy; Resuscitation; Shock; Pediatrics
18.  Evidence-based paramedic models of care to reduce unnecessary emergency department attendance – feasibility and safety 
Background
As demand for Emergency Department (ED) services continues to exceed increases explained by population growth, strategies to reduce ED presentations are being explored. The concept of ambulance paramedics providing an alternative model of care to the current default ‘see and transport to ED’ has intuitive appeal and has been implemented in several locations around the world. The premise is that for certain non-critically ill patients, the Extended Care Paramedic (ECP) can either ‘see and treat’ or ‘see and refer’ to another primary or community care practitioner, rather than transport to hospital. However, there has been little rigorous investigation of which types of patients can be safely identified and managed in the community, or the impact of ECPs on ED attendance.
Methods/Design
St John Ambulance Western Australia paramedics will indicate on the electronic patient care record (e-PCR) of patients attended in the Perth metropolitan area if they consider them to be suitable to be managed in the community. ‘Follow-up’ will examine these patients using ED data to determine the patient’s disposition from the ED. A clinical panel will then develop a protocol to identify those patients who can be safely managed in the community. Paramedics will then assess patients against the derived ECP protocols and identify those deemed suitable to ‘see and treat’ or ‘see and refer’. The ED disposition (and other clinical outcomes) of these ‘ECP protocol identified’ patients will enable us to assess whether it would have been appropriate to manage these patients in the community. We will also ‘track’ re-presentations to EDs within seven days of the initial presentation. This is a ‘virtual experiment’ with no direct involvement of patients or changes in clinical practice. A systems modelling approach will be used to assess the likely impact on ED crowding.
Discussion
To date the efficacy, cost-effectiveness and safety of alternative community-based models of emergency care have not been rigorously investigated. This study will inform the development of ECP protocols through the identification of types of patient presentation that can be considered both safe and appropriate for paramedics to manage in the community.
doi:10.1186/1471-227X-13-13
PMCID: PMC3724748  PMID: 23855265
Pre-hospital; Extended care paramedics; Ambulance; Emergency department demand; Community care; Patient safety; Economic evaluation
19.  The ultra-early protective effect of ulinastatin on rabbit acute lung injury induced by paraquat 
BMC Emergency Medicine  2013;13(Suppl 1):S7.
Objective
To study ultra-early pathophysiological changes of rabbit acute lung injury (ALI) caused by paraquat (PQ) and discuss the ultra-early protective effect of ulinastatin on rabbit ALI due to PQ.
Methods
30 New Zealand white rabbits were randomly divided into a control group, a paraquat group and an ulinastatin intervention group with 10 rabbits in each group. For paraquat group and intervention group a single dose of paraquat (35mg/kg) was injected intraperitoneally to establish rabbit models of ALI. The control group was injected an equal volume of saline. The intervention group was treated with 100Ku/kg ulinastatin immediately after the establishment of the ALI model. The respective experimental groups underwent 320-slice CT perfusion scan of pleural at 2h, 4h and 6h time point after modeling to get CTP (CT Perfusion) images and related parameters. 2mL blood was collected in the marginal ear vein to determine the mass concentration of the vascular endothelial growth factor (VEGF). The animals were killed by air embolism after 6h and lung tissue was taken for pathology observation.
Results
The reginal blood flow (rBF) and reginal blood volume (rBV) of paraquat group at 2,4,6 h time point were significantly (P <0.05) lower than those of control group. The intervention group rBF and rBV at 2, 4 and 6 h time points were significantly higher (P <0.05) compared to paraquat group. The permeability surface (rPS) and VEGF mass concentration of paraquat group at 2,4,6 h time point were significantly higher than the control group (P <0.05), and the intervention group rPS and VEGF mass concentrations at 2,4,6h time point were significantly lower (P <0.05) than those of paraquat group. Pathological detection indicators of paraquat group (congestive capillary percentage, the number of red blood cells outside of capillaries, percentage of capillaries with basement membrane damage) were significantly higher (P <0.05) at 6h time point compared with the control group, while significantly lower (P <0.05) in intervention group than in paraquat groups. Pathological observation under light microscope showed in paraquat group obvious inflammatory cell infiltration, alveolar epithelial cell hyperplasia, widened alveolar septum, visible focal hemorrhage, visible acute and chronic inflammatory cell infiltration in bronchioles cavity; under electron microscopy alveolar epithelial cell degeneration and necrosis, vascular welling of the endothelial cells, basement membrane rupture, a lot of exudates in alveolar space. In the intervention group, the above the symptoms were mitigated.
Conclusion
In the ultra-early stage of rabbit ALI induced by PQ, pulmonary vascular endothelial cell is damaged and serum VEGF mass concentration and pulmonary vascular permeability increase. Early ulinastatin intervention can reduce serum VEGF level and PQ-induced vascular permeability amplitude, indicating that ulinastatin has a protective effect on pulmonary vascular endothelial cells.
doi:10.1186/1471-227X-13-S1-S7
PMCID: PMC3701465  PMID: 23902632
20.  Functions of standard CPR training on performance qualities of medical volunteers for Mt. Taishan International Mounting Festival 
BMC Emergency Medicine  2013;13(Suppl 1):S3.
Background
Cardiopulmonary resuscitation (CPR) is a sudden emergency procedure that requires a rapid and efficient response, and personnel training in lifesaving procedures. Regular practice and training are necessary to improve resuscitation skills and reduce anxiety among the staff. As one of the most important skills mastered by medical volunteers serving for Mt. Taishan International Mounting Festival, we randomly selected some of them to evaluate the quality of CPR operation and compared the result with that of the untrained doctors and nurses. In order to evaluate the functions of repeating standard CPR training on performance qualities of medical volunteers for Mt. Taishan International Mounting Festival, their performance qualities of CPR were compared with those of the untrained medical workers working in emergency departments of hospitals in Taian.
Methods
The CPR performance qualities of 52 medical volunteers (Standard Training Group), who had continually taken part in standard CPR technical training for six months, were tested at random and were compared with those of 68 medical workers (Compared Group) working in emergency departments of hospitals in Taian who hadn’t attended CPR training within a year. The QCPR 3535 monitor (provided by Philips Company) was used to measure the standard degree of single simulated CPR performance, including the chest compression depth, frequency, released pressure between compressions and performance time of compression and ventilation, the results of which were recorded in the table and the number of practical compression per minute was calculated. The data were analyzed by x2 Test and t Test. The factors which would influence CPR performance, including gender, age, placement, hand skill, posture of compression and frequency of training, were classified and given parameters, and were put to Logistic repression analysis.
Results
The CPR performance qualities of volunteers were much higher than those of the compared group. The overall pass rates were respectively 86.4% and 31.9%; the pass rates of medical volunteers in terms of the chest compression depth, frequency, released pressure between compressions were higher than those of the compared group, which were 89.6%, 94.2%, 95.8% vs 50.3%, 53.0%, 83.1%, P<0.01; there were few differences in overall performance time, which were (118.4±13.5s) vs (116.0±10.4s), P>0.05; the duration time of ventilation in each performance section was much shorter than that in the compared group, which were (6.38±1.2) vs (7.47±1.7), P<0.01; there were few differences in the number of practical compression per minute, which were (78.2±3.5) vs (78.8±12.2), P>0.05); the time proportion of compression and ventilation was 2.6:1 vs 2.1:1. The Logistic repression analysis showed that CPR performance qualities were clearly related to hand skill, posture of compression and repeating standard training, which were respectively OR 13.12 and 95%CI (2.35~73.2); OR 30.89, 95%CI (3.62~263.5); OR 4.07,95%CI (1.16~14.2).
Conclusion
The CPR performance qualities of volunteers who had had repeating standard training were much higher than those of untrained medical workers, which proved that standard training helped improve CPR performance qualities.
doi:10.1186/1471-227X-13-S1-S3
PMCID: PMC3701466  PMID: 23902568
21.  Emergency treatment on facial laceration of dog bite wounds with immediate primary closure: a prospective randomized trial study 
BMC Emergency Medicine  2013;13(Suppl 1):S2.
Background
To investigate the emergency treatment on facial laceration of dog bite wounds and identify whether immediate primary closure is feasible.
Methods
Six hundred cases with facial laceration attacked by dog were divided into two groups randomly and evenly. After thorough debridement, the facial lacerations of group A were left open, while the lacerations of group B were undertaken immediate primary closure. Antibiotics use was administrated only after wound infected, not prophylactically given. The infection rate, infection time and healing time were analyzed.
Results
The infection rate of group A and B was 8.3% and 6.3% respectively (P>0.05); the infection time was 26.3±11.6h and 24.9±13.8h respectively (P>0.05), the healing time was 9.12±1.30d and 6.57±0.49d respectively (P<0.05) in taintless cases, 14.24±2.63d and 10.65±1.69d respectively (P<0.05) in infected cases.
Compared with group A, there was no evident tendency in increasing infection rate (8.3% in group A and 6.3% in group B respectively) and infection period (26.3±11.6h in group A and 24.9±13.8h in group B respectively) in group B. Meanwhile, in group B, the wound healing time was shorter than group A statistically in both taintless cases (9.12±1.30d in group A and 6.57±0.49d in group B respectively) and infected cases (14.24±2.63d in group A and 10.65±1.69d in group B respectively).
Conclusion
The facial laceration of dog bite wounds should be primary closed immediately after formal and thoroughly debridement. And the primary closure would shorten the healing time of the dog bite wounds without increasing the rate and period of infection. There is no potentiality of increasing infection incidence and infection speed, compared immediate primary closure with the wounds left open. On the contrary, primary closure the wounds can promote its primary healing. Prophylactic antibiotics administration was not recommended. and the important facial organ or tissue injuries should be secondary reconditioned.
doi:10.1186/1471-227X-13-S1-S2
PMCID: PMC3701467  PMID: 23902527
22.  Combined treatment with bone marrow mesenchymal stem cells and methylprednisolone in paraquat-induced acute lung injury 
BMC Emergency Medicine  2013;13(Suppl 1):S5.
Background
To evaluate the efficacy of combined treatment with bone marrow mesenchymal stem cell (BMSC) transplantation and methylprednisolone (MP) to treat paraquat (PQ)-induced acute lung injury.
Materials and methods
A total of 102 female rats were randomly divided into five groups: PQ, BMSC, MP, BMSC + MP and normal control. After 14 days of PQ poisoning, the survival of rats, wet/dry weight ratio of lung tissue, serum levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-10, malondialdehyde (MDA) and superoxidase dismutase (SOD), and the expression of nuclear factor (NF)-кB p65 in lung tissue were determined.
Results
Rats in BMSC and BMSC + MP groups survived. BMSC transplantation significantly decreased the wet/dry weight ratio of lung tissue, down-regulated NF-кB p65 expression in lung tissue, lowered serum levels of TNF-α, IL-1β, IL-6 and MDA, and increased serum levels of IL-10 and SOD. These changes were particularly significant on days 7–14 after PQ poisoning. The above changes were more significant in the MP group on days 1–3 after PQ poisoning, compared with those of the BMSC group. However, the BMSC + MP group showed more significant changes on days 1–14 after PQ poisoning than those of both BMSC and MP groups.
Conclusions
MP inhibits the inflammatory response, reduces the products of lipid peroxidation and promotes survival of transplanted BMSC, thus improving the intermediate and longer term efficacy of BMSC transplantation for treatment of PQ-induced lung injury.
doi:10.1186/1471-227X-13-S1-S5
PMCID: PMC3701473  PMID: 23902576
23.  Explore the influence of BMI in the optimal time of weaning from sequential mechanical ventilation for severity chronic obstructive pulmonary disease 
BMC Emergency Medicine  2013;13(Suppl 1):S1.
Objective
To study the clinical effect of body mass index (BMI) in the optimal time of weaning from sequential invasive-noninvasive mechanical ventilation (MV) by treating severity chronic obstructive pulmonary disease (COPD) patients.
Methods
94 patients with severity COPD were divided into the control group (BMI<21) and the study group (BMI>21). These two groups were treated by similar symptomatic therapies such as mechanical ventilation, antibacterial, antispasmodic, relieving asthma, antitussive, expectorant, correction of electrolyte imbalance and acid-base balance disorders, strengthen nutritional support, etc.
Results
Compared with the control group, the study group had shorter duration of invasive mechanical ventilation, non-invasive mechanical ventilation time, total mechanical ventilation time, total hospital stay (P<0.01). There are significant differences between these two groups in re-intubation rate, VAP occurred in the number of case, hospital mortality rate in 28 days (P<0.05).
Conclusions
It is difficult to wean successfully from sequential mechanical ventilation for severity COPD patients (BMI<21), so BMI as one of important reference index can be used to estimate the optimal time for weaning from sequential mechanical ventilation for severity COPD patients.
doi:10.1186/1471-227X-13-S1-S1
PMCID: PMC3701485  PMID: 23902470
24.  Acute fatal chest pain: optimized procedure in emergency department 
BMC Emergency Medicine  2013;13(Suppl 1):S4.
Objective
To explore the diagnostic procedure of acute fatal chest pain in emergency department (ED) in order to decrease the misdiagnosis rate and shorten the definite time to diagnosis. The ultimate aim is to rescue the patients timely and effectively.
Methods
Three hundreds and two patients (56.9±11.8 Years, 72% men) complained with acute chest pain and chest distress presenting to our ED were recruited. They were divided into two groups according to visiting time (Group I: from October 2010 to March 2011, Group II: from October 2011 to March 2012). The misdiagnosis rate, definite time for diagnosis and medical expense were analyzed. Patients of Group I were diagnosed by initial doctors who made their diagnosis according to personal experience in outpatient service or rescue room in ED. While patients of Group II were all admitted to rescue room and were diagnosed and rescued according to the acute chest pain screening flow-process diagram. Differences inter-group was compared.
Results
The misdiagnosis rate of fatal chest pain in Group I and Group II was 6.8% and 0% respectively, and there was statistic difference (P=0.000). The definite time to diagnosis was 65.3 min and 40.1 min in control and Group II respectively, the difference had statistic significance (P=0.000). And the mean cost for treatment was 787.5/124.5 ¥/$ and 905.5/143.2 ¥/$ respectively, and there was statistic difference too (P=0.012).
Conclusion
Treating emergency patients with acute chest pain according to the acute chest pain screening flow-process diagram in rescue room will decrease misdiagnosis apparently, and it can also shorten the definite time to correct diagnosis. It has a remarkable positive role in rescuing patients with acute chest pain timely and effectively.
doi:10.1186/1471-227X-13-S1-S4
PMCID: PMC3701502  PMID: 23902535
25.  The outcomes of 1120 severe multiple trauma patients with hemorrhagic shock in an emergency department: a retrospective study 
BMC Emergency Medicine  2013;13(Suppl 1):S6.
Objective
Uncontrolled hemorrhagic shock is a significant factor in death of severe multiple trauma patients. The acute management of injured bleeding in emergency department (ED) may improve patient outcomes. The medical records of severe multiple trauma patients with hemorrhagic shock in our ED were reviewed to summarize an evidence-based approach to the management of critically injured bleeding trauma patients.
Methods
A retrospective study was carried out from January 2002 to December 2011 in a Chinese tertiary hospital. Clinical data from major trauma patients with hemorrhagic shock admitted to ED were evaluated. The patients were stratified based on the characteristics of traumatic condition and resuscitation strategies. The medical treatments and the outcomes of these severe multiple trauma patients were described.
Results
A total of 1120 major trauma patients, consisting of 832 males and 288 females, were enrolled. 906 of the patients (80.9%) were injured in traffic accidents, 104 (9.3%) from falling, and 100 from other reasons. The number of injured sites varied from 2 to 6, 616(55.0%) more than 3. 902 (80.5%) trauma patients have recovered and been discharged from hospital.
Conclusions
Uncontrolled hemorrhagic shock is a main reason of trauma patients’ death. The resuscitation strategy should center upon permissive hypotension and early hemostatic resuscitation combined identified and corrects coagulopathy. The current approach to the management of critically injured bleeding trauma patients is able to improve patient outcomes.
doi:10.1186/1471-227X-13-S1-S6
PMCID: PMC3701514  PMID: 23902600

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