Recommendations for blood sampling in emergency departments from the European Society for Emergency Medicine (EUSEM), European Society for Emergency Nursing (EuSEN), and European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase. Executive summary.

AIM: Blood Sampling Guidelines have been developed to target European emergency medicine-related professionals involved in the blood sampling process (e.g. physicians, nurses, phlebotomists working in the ED), as well as laboratory physicians and other related professionals. The guidelines population focus on adult patients. The development of these blood sampling guidelines for the ED setting is based on the collaboration of three European scientific societies that have a role to play in the preanalytical phase process: EuSEN, EFLM, and EUSEM. The elaboration of the questions was done using the PICO procedure, literature search and appraisal was based on the GRADE methodology. The final recommendations were reviewed by an international multidisciplinary external review group. RESULTS: The document includes the elaborated recommendations for the selected sixteen questions. Three in pre-sampling, eight regarding sampling, three post-sampling, and two focus on quality assurance. In general, the quality of the evidence is very low, and the strength of the recommendation in all the questions has been rated as weak. The working group in four questions elaborate the recommendations, based mainly on group experience, rating as good practice. CONCLUSIONS: The multidisciplinary working group was considered one of the major contributors to this guideline. The lack of quality information highlights the need for research in this area of the patient care process. The peculiarities of the emergency medical areas need specific considerations to minimise the possibility of errors in the preanalytical phase.

Influence of the embedded participant on learners' performance during high-fidelity simulation sessions in healthcare.

BACKGROUND: The embedded participant (EP) plays a key role during a full scale/high-fidelity simulation (HFS) session. He/she is expected to guide the learner towards the achievement of the educational objectives of the scenario. However, his/her influence on learners' performance stands undetermined and this effect remains briefly addressed in the literature. This study primarily aims to assess whether the EP could have an influence on the performance of the learner during a HFS scenario. The secondary aim was to establish an inventory of the EP practices in France. METHODS: This retrospective study was conducted in Lyon Claude Bernard University Health Simulation Centre (France). Anaesthesia and critical care residents in postgraduate years 1 to 5 who were scheduled for their HFS sessions during the 2016 to 2021 academic years were included. Two investigators independently evaluated the resident performance regarding both technical and non-technical skills from video recordings. In addition, a nationwide survey was sent out by email through the networks of the Francophone Healthcare Simulation Society (SoFraSimS, Société Francophone de Simulation en Santé) to collect information on EP practices in French-speaking Simulation centres. RESULTS: From a total of 344 HFS videos analysed, a cohort of 19 experienced EPs was identified. The EPs had an influence on the technical and non-technical performances of the learners. The 147 responses to the survey showed that predefined rules of EP good practice existed in only 36% of the simulation centres and 65% of respondents believed that specific EP training would be justified. CONCLUSION: The EP can exert an influence on the performance of the learners during HFS. For acting as an EP, a great variability of practices and a lack of training are reported by professionals working in simulation centres. These results suggest that more attention must be paid to EP training and attitudes during simulation, especially if summative simulations are extensively developed.

Role of ultrasonography in upper airway assessment: A comparison with computerized tomography measurements.

INTRODUCTION: This study aimed to compare ultrasonography (US) measurements of the upper airway to computerized tomography (CT) measurements. Our study's primary outcome is to research the accuracy of US measurements in the evaluation of upper airway diameters when CT is taken as the gold standard; the secondary outcome is to determine the time required to obtain US measurements. METHODS: This prospective study included patients ≥18 years old that had undergone thoracic or neck CT due to current clinical necessity. The US measurement for each patient was performed by two researchers with different levels of experience, both of whom were blinded to each other and the CT measurements. Measurements were obtained from the vocal cords and subglottic region. The duration of the US performance was also recorded. RESULTS: The US and CT measurements were obtained from 94 patients. Concordance between US and CT measurements was found in the Bland-Altman analysis, with a mean -0.05 mm difference for vocal cord diameter and -1.2 mm for subglottic diameter. The intra-class correlation coefficients (ICC) between the CT and US measurements were 0.993, and 0.609 for vocal cord and subglottic diameter measurements, respectively. The ICC between US performers was 0.992 for vocal cord diameter and 0.959 for subglottic diameter. The US's mean time for vocal cord diameter measurement was 38 ± 23 s, and the mean time for subglottic diameter measurement was 49 ± 30 s. CONCLUSION: The concordance between US and CT measurements is high and the measurements of different practitioners with different experience levels are compatible with each other.

Comparison of the effects PRICE and POLICE treatment protocols on ankle function in patients with ankle sprain.

BACKGROUND: Ankle sprain is a frequent reason for presentation to the emergency department. Current treatment modalities include Protection, Optimal Loading, Ice, Compression, and Elevation (POLICE) and Protection, Rest, Ice, Compression, and Elevation (PRICE). This study aimed to compare the effects of PRICE and POLICE treatment protocols. METHODS: This randomized controlled study was conducted between October 15, 2020, and October 15, 2021, at Ankara University's Department of Emergency Medicine. Double-blind randomization was used to assign patients to either the POLICE or PRICE treatment groups. RESULTS: In total, 109 patients were included. In the POLICE group, the median difference between the American Orthopedic Foot and Ankle Scores on admission and the 14th day following the injury was 34.5 (IQR: 27.25-41.75), while that of the PRICE group was 24 (IQR: 15.5-35). In the POLICE group, the median value of the difference in the Foot and Ankle Disability Index scores on admission and the 14th day following the injury was 42 (IQR: 35.25-50), while that of the PRICE group was 31 (IQR: 22-41.5). CONCLUSION: The POLICE treatment protocol provided more effective and faster recovery than the PRICE treatment protocol.

Rectus Sheath Hematoma in a Patient with Dual-Antiplatelet Therapy Including Ticagrelor: A Case Report.

Rectus sheath hematoma (RSH) is an uncommon cause of abdominal pain associated with several risk factors including trauma, asthma, chronic obstructive pulmonary disease, pregnancy, and anticoagulation as it can be iatrogenic. Dual-antiplatelet therapy (DAPT), combined usage of a P2Y12 receptor inhibitor and aspirin, is a cornerstone treatment for patients with acute coronary syndromes. Ticagrelor is a P2Y12 receptor inhibitor with several adverse hemorrhagic complications. An 86-year-old male patient was admitted to the emergency department with abdominal pain and a palpable abdominal mass at the left upper quadrant of the abdomen. His medical history revealed coronary artery disease with medications including acetylsalicylic acid and ticagrelor. Contrast-enhanced abdominal computed tomography revealed RSH. The patient was treated conservatively with bed rest and analgesia. DAPT is an essential component of the management of acute coronary syndromes to prevent recurrent cardiac thrombotic events. However, hemorrhagic complications such as RSH may be encountered with DAPT. Emergency medicine physicians and cardiologists should keep in mind RSH in patients presenting with abdominal pain and using DAPT with ticagrelor.

Evaluation of the Validity and Reliability of ANKUTRIAGE, a New Decision Support System in Pediatric Emergency Triage.

BACKGROUND: The intensity of emergency services is an increasing health problem all over the world, necessitating an effective triage system. The aim of this study was to evaluate the validity and reliability of the "ANKUTRIAGE" in children. METHODS: This prospective, longitudinal study was carried out at a pediatric emergency department. ANKUTRIAGE, a 5-level computer-aided triage decision support system, was developed. Patients younger than 18 years who do not need emergency intervention, who had complete vital sign measurements, who gave consent for the study, and who were admitted to the emergency service during working hours with trained personnel were included. For validity, agreement between the urgency levels determined by ANKUTRIAGE and the reference triage systems: Pediatric Canadian Triage and Acuity Scale and Emergency Severity Index, was evaluated. In addition, the association of urgency levels with clinical outcomes was studied. To assess reliability, patients were evaluated by 2 blinded healthcare professionals using ANKUTRIAGE and a quadratic weighted κ was estimated. RESULTS: A total of 1232 children with a median age of 4.00 years were included. ANKUTRIAGE acuity levels significantly correlated with the number of resources used, the number of patients undergoing life-saving procedures, pediatric intensive care unit, and overall hospitalization rates, respectively ( P < 0.001, P < 0.001, P < 0.001, P < 0.001). The agreement of ANKUTRIAGE with Pediatric Canadian Triage and Acuity Scale was found to be 0.94 (95% confidence interval [CI], 0.93-0.94), with an Emergency Severity Index of 0.75 (95% CI, 0.70-0.80). The interrater agreement between 2 evaluators who used ANKUTRIAGE reflected as excellent consistency 0.92 (95% CI, 0.89-0.95; κ > 0.8). CONCLUSIONS: ANKUTRIAGE demonstrated high agreement with clinical outcomes and with proven triage systems and reflected high reliability between users. ANKUTRIAGE will enable a more standardized and practical triage, especially in crowded pediatric emergency departments and in situations where triage is performed by health professionals with different experience and professions.

Pelvic Compression Device (Binder) Application Training in Medical Students: A Manikin Study.

BACKGROUND: Correct application of external pelvic compression devices (binders) is crucial in managing multitrauma patients with suspected pelvic fractures to control hemorrhage. Yet, there is a lack of practical training standards for pelvic compression device application in medical school education. OBJECTIVE: This study aimed to evaluate simulation training of pelvic compression device application by medical students to determine the number of applications required to meet proficiency measured by correct application and timeliness. METHODS: This is an observational cross-sectional measurement study of a convenience sample of 132 volunteer senior medical students who participated in a 30-min theoretical and simulation training session on the application of pelvic compression devices. The study was conducted between January 1, 2020, and March 1, 2020. Two weeks after the training, the students performed 10 consecutive pelvic compression device applications, each followed by a 5-min feedback session break. Application step accuracy and timing were observed and recorded. The percentage of correct applications was compared by χ2 test. RESULTS: The correct application rate for the first application was 42.4%, with an average of 92 s, 95% confidence interval (CI): 91.00-93.72. The highest correct application rate occurred in the eighth application (97%, p < .001), with an average application time of 87 s, 95% CI: 85.62-87.72. CONCLUSION: We found that at least eight pelvic compression device manikin applications were required to achieve proficiency.

Validation of the Turkish version of the second victim experience and Support Tool (T-SVEST).

Objectives: Second victim experience defines the healthcare professionals involved in unexpected adverse patient events. The Second Victim Experience and Support Tool (SVEST) is a tool used to measure the second victim experience and the desired support resources. This study aims to carry out a cross-cultural adaptation of the SVEST and to evaluate the psychometric properties of the Turkish version (T-SVEST). Methods: The T-SVEST was translated and adapted according to World Health Organization guidelines. 221 healthcare professionals including physicians, residents and nurses working at the emergency department, completed the survey. â€‹Cronbach's â€‹α â€‹values were assessed for reliability, and construct validity was assessed through confirmatory factor analysis in order to evaluate model fit. Results: The global Cronbach's α score of the T-SVEST was 0.90. The final version of the TSVEST including 24 items was consistent with values between 0.83 and 0.89. The most consistent dimension was turnover intentions with a Cronbach's value of 0.89, it was followed by institutional support (Cronbach α = 0.88). After applying modifications suggested by â€‹confirmatory factor analysis, a final model including 9 factor-structure (7 dimensions and 2 outcome variables) and 24 items was significantly improved with acceptable â€‹comparative fit index, â€‹Tucker-Lewis index â€‹and â€‹root mean square error of approximation. Conclusion: The Turkish version of the SVEST is a reliable and valid instrument that can be used to identify second victims and help implement support resources.

The acute motor axonal neuropathy variant of Guillain-Barré Syndrome diagnosed after ankle trauma.

A case of Guillain-Barré syndrome (GBS) was diagnosed in a patient admitted to the emergency department (ED) after ankle trauma was presented. GBS is generally defined as immune-mediated peripheral neuropathy that develops after an infection. Our patient presented to ED with ankle trauma that developed after fatigue. Lateral, medial, and posterior malleolar fractures were detected in the ankle. The patient with loss of motor strength in the distal muscles was diagnosed with acute motor axonal neuropathy variant of GBS. After GBS treatment, the patient's loss of muscle strength regressed, and then surgical treatment was performed. We aimed to present this case report, which emphasizes the systematic approach of the emergency physician without having a large differential diagnosis list.

Reliability and Validity of a New Computer-Based Triage Decision Support Tool: ANKUTRIAGE.

OBJECTIVE: Triage is a tool used to determine patients' severity of illness or injury within minutes of arrival. This study aims to assess the reliability and validity of a new computer-based triage decision support tool, ANKUTRIAGE, prospectively. METHODS: ANKUTRIAGE, a 5-level triage tool was established considering 2 major factors, patient's vital signs and characteristics of the admission complaint. Adult patients admitted to the ED between July and October, 2019 were consecutively and independently double triaged by 2 assessors using ANKUTRIAGE system. To measure inter-rater reliability, quadratic-weighted kappa coefficients (Kw) were calculated. For the validity, associations among urgency levels, resource use, and clinical outcomes were evaluated. RESULTS: The inter-rater reliability between users of ANKUTRIAGE was excellent with an agreement coefficient (Kw) greater than 0.8 in all compared groups. In the validity phase, hospitalization rate, intensive care unit admission and mortality rate decreased from level 1 to 5. Likewise, according to the urgency levels, resource use decreased significantly as the triage level decreased (P < 0.05). CONCLUSIONS: ANKUTRIAGE proved to be a valid and reliable tool in the emergency department. The results showed that displaying the key discriminator for each complaint to assist decision leads to a high inter-rater agreement with good correlation between urgency levels and clinical outcomes, as well as between urgency levels and resource consumptions.

Population structure and pattern of geographic differentiation of Colorado potato beetle, Leptinotarsa decemlineata (Coleoptera: Chrysomelidae) in Turkey.

BACKGROUND: The Colorado potato beetle (CPB) is the most harmful pest of potato in potato cultivation regions globally. Although it is an economically important agricultural pest, the population structure and colonization route of this species in Turkey are uncertain. We used microsatellite and mitochondrial DNA (mtDNA) markers to obtain information about the population source, structure and bio-invasion route of CPB populations in Turkey. RESULTS: The common single mtDNA haplotype in European CPB populations was obtained in all Turkish CPB populations based on mtDNA data analysis. However, microsatellites revealed a low level of genetic variation in CPB populations. The results of microsatellite analysis [factorial correspondence analysis (FCA), Bayesian analysis of genetic population structure (BAPS), unweighted pair group method with arithmetic mean (UPGMA) dendrogram, F-statistics and Nei's distances] indicated three groups for invasive CPB: Thrace-Marmara and Aegean; Black Sea, Central Anatolia and Mediterranean; Northeastern Anatolia. Region-specific alleles have been identified in regions, where commercial potato cultivation and insecticide use are intensive. CONCLUSION: The detection of a single fixed European haplotype in all Turkish populations has proved that CPB in Turkey originated from Europe as a result of a founder event occurred in European populations. Low genetic variation was due to the short time period since the spread of CPB from America to Europe. The highest number of private alleles were found in the top commercial potato cultivation region-Central Anatolia from where the CPB populations spread to other parts of Turkey. © 2021 Society of Chemical Industry.

An unusual course of SARS-CoV-2 infection: Challenging diagnosis of Guillain-Barré Syndrome.

COVID-19, caused by severe acute respiratory syndrome coronavirus-2, typically presents with respiratory symptoms and fever, but still a variety of clinical presentations have been reported. In this study, it was aimed to report a case of COVID-19 with an atypical presentation and an atypical course. As well, the recovery phase was complicated with GBS and consequently cytomegalovirus infection. It should be kept in mind that patients with COVID-19 severe disease need to be followed for neurological and other complications which may arise during the course of critical illness.

Therapeutic Applications of Stem Cells and Extracellular Vesicles in Emergency Care: Futuristic Perspectives.

Regenerative medicine (RM) is an interdisciplinary field that aims to repair, replace or regenerate damaged or missing tissue or organs to function as close as possible to its physiological architecture and functions. Stem cells, which are undifferentiated cells retaining self-renewal potential, excessive proliferation and differentiation capacity into offspring or daughter cells that form different lineage cells of an organism, are considered as an important part of the RM approaches. They have been widely investigated in preclinical and clinical studies for therapeutic purposes. Extracellular vesicles (EVs) are the vital mediators that regulate the therapeutic effects of stem cells. Besides, they carry various types of cargo between cells which make them a significant contributor of intercellular communication. Given their role in physiological and pathological conditions in living cells, EVs are considered as a new therapeutic alternative solution for a variety of diseases in which there is a high unmet clinical need. This review aims to summarize and identify therapeutic potential of stem cells and EVs in diseases requiring acute emergency care such as trauma, heart diseases, stroke, acute respiratory distress syndrome and burn injury. Diseases that affect militaries or societies including acute radiation syndrome, sepsis and viral pandemics such as novel coronavirus disease 2019 are also discussed. Additionally, featuring and problematic issues that hamper clinical translation of stem cells and EVs are debated in a comparative manner with a futuristic perspective. Graphical Abstract.

Diaphragm dysfunction detected with ultrasound to predict noninvasive mechanical ventilation failure: A prospective cohort study.

OBJECTIVE: This study aimed to examine the use of point-of-care ultrasonography (POCUS) in detecting diaphragmatic dysfunction (DD) and evaluate its ability to predict noninvasive mechanical ventilation (NIV) failure in patients presented to the emergency department with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). METHODS: In this prospective cohort study, the diaphragm was examined using POCUS in patients with AECOPD. DD was defined as a diaphragm thickening fraction of less than 20% during spontaneous breathing. NIV failure was the primary outcome of the study, and duration of hospital stay and in-hospital mortality were the secondary outcomes. Specificity, sensitivity, positive predictive value, and negative predictive value were estimated for predicting NIV failure in DD and evaluating the diagnostic performance of POCUS. RESULTS: 60 patients were enrolled the study. NIV failure was found in 11 (73.3%) of 15 patients with DD and in 2 (4.4%) of 45 patients without DD. In predicting NIV failure, DD had a sensitivity of 84.6% (95% confidence interval [CI]:54.6-98.1), specificity of 91.5% (95% CI:79.6-97.6), positive predictive value of 73.3% (95% CI:51.2-87.8), and negative predictive value of 95.6% (95% CI:85.7-98.7). The duration of hospital stay was not different between groups (p = .065). No in-hospital mortality was seen in patients without DD. CONCLUSIONS: DD has high sensitivity and specificity in predicting NIV failure in patients admitted to the emergency department with AECOPD. DD can be assessed by an experienced clinician noninvasively using POCUS in emergency departments.

Independent factors for prediction of poor outcomes in patients with febrile neutropenia.

BACKGROUND: Febrile neutropenia (FN) is a life-threatening condition that requires urgent management in the emergency department (ED). Recent progress in the treatment of neutropenic fever has underscored the importance of risk stratification. In this study, we aimed to determine independent factors for prediction of poor outcomes in patients with FN. MATERIAL AND METHODS: We retrospectively evaluated 200 chemotherapy-induced febrile neutropenic patients who visited the ED. Upon arrival at the ED, clinical data, including sex, age, vital signs, underlying systemic diseases, laboratory test results, estimated GFR, blood cultures, CRP, radiologic examinations, and Multinational Association of Supportive Care in Cancer (MASCC) score of all febrile neutropenic patients were obtained. Outcomes were categorized as "poor" if serious complications during hospitalization, including death, occurred. RESULTS: The platelet count <50 000 cells/mm3 (OR 3.90, 95% CI 1.62-9.43), pulmonary infiltration (OR 3.45, 95% CI 1.48-8.07), hypoproteinemia <6 g/dl (OR 3.30, 95% CI 1.27-8.56), respiratory rate >24/min (OR 8.75, 95% CI 2.18-35.13), and MASCC score <21 (OR 9.20, 95% CI 3.98-21.26) were determined as independent risk factors for the prediction of death. The platelet count <50 000 cells/mm3 (OR 3.93, 95% CI 1.42-10.92), serum CRP >50 mg/dl (OR 3.80, 95% CI 1.68-8.61), hypoproteinemia (OR 7.81, 95% CI 3.43-17.78), eGFR ≤90 ML/min/1.73 m2 (OR 3.06, 95% CI 1.13-8.26), and MASCC score <21 (OR 3.45, 95% CI 1.53-7.79) were determined as independent risk factors for the prediction of poor clinical outcomes of FN patients. Platelet count, protein level, respiratory rate, pulmonary infiltration, CRP, MASCC score, and eGFR were shown to have a significant association with outcome. CONCLUSIONS: The results of our study may help emergency medicine physicians to prevent serious complications with proper use of simple independent risk factors besides MASCC score.

The accuracy of ultrasound evaluation in foot and ankle trauma.

OBJECTIVES: Foot and ankle injuries that result in sprains or fractures are commonly encountered at the emergency department. The purpose of the present study is to find out the accuracy of ultrasound (US) scanning in injuries in the aforementioned areas. METHODS: Ottawa Ankle Rules-positive patients older than 16 years who presented to the emergency department with foot or ankle injuries were eligible. For all patients, US evaluation of the whole foot and ankle was performed by an emergency physician before radiographic imaging. All radiographic images were evaluated by an orthopedic specialist and compared with the interpretations of the US. RESULTS: One hundred thirty-one patients were included in the study. Radiographic evaluation enabled the determination of fractures in 20 patients, and all of these were identified with US imaging. Moreover, US evaluation radiographically detected a silent ankle fracture in 1 patient. The sensitivity of US scanning in detecting fractures was 100% (95% confidence interval [CI], 83.8-100), the specificity was 99.1% (95% CI, 95-99.8), the positive predictive value was 95.2% (95% CI, 89.6-98), and the negative predictive value was 100% (95% CI, 96.4-100), respectively. The most common fractures were detected at the lateral malleolus and at the basis of the fifth metatarsal. CONCLUSIONS: Ultrasound imaging permits the evaluation of foot and ankle fractures. Because it is a highly sensitive technique, US can be performed in the emergency department with confidence.