Emergency Medicine: Clinical Advances and Challenges in Diagnosis and Treatment, 2nd Edition

A special issue of Journal of Personalized Medicine (ISSN 2075-4426). This special issue belongs to the section "Personalized Critical Care".

Deadline for manuscript submissions: 25 July 2024 | Viewed by 5944

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Guest Editor
Department of Surgery, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania
Interests: emergency medicine; airway management; difficult airway; sepsis; biomarkers; COVID-19; immunological dysfunction
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Special Issue Information

Dear Colleagues,

I am pleased to announce that, due to the success of the first edition of the Special Issue “Emergency Medicine: Clinical Advances and Challenges in Diagnosis and Treatment”, we have launched a second edition in 2024 for high-quality submissions in the Personalized Critical Care Section. We are also confident that the next Special Issue will have at least the same interest from the authors (https://www.mdpi.com/journal/jpm/special_issues/O3R11NE3X4). Of similar importance to updated and improved emergency medicine is medical education.

The emergency medicine specialty exhibits dynamic growth in clinical and research perspectives and is characterized by continuous advances in research, practices, and technologies. Essentially, “optimizing early diagnosis and treatment” is emerging as an influential component in the development of this field of medicine, where the development of emergency medical professionals is a valuable resource. Improving the clinical skills of emergency care, including rapid response, efficiency, and service attitude, as well as the skills of medical professionals in the emergency department, are significant.

The next generation of doctors in the emergency field requires the most innovative, technological, and based on simulation training to acquire the proper practical experience and further multidisciplinary clinical thinking, and because of this, one of the objectives is to expose studies whose principal aim is medical education.

The main objective of this edition is to acquire the most valuable information regarding the newest approaches in the diagnosis and treatment of emergency care patients that will create new perspectives on patient management through various case reports. At the same time, we keep our attention on the technologies and innovations that facilitate and improve the quality of the treatments received by patients in the emergency department.

This second edition aims to collect and welcome articles from adjacent areas of acute care, such as intensive care, pre-hospital care, acute stroke care, health services research, and implementation research. Our goal is to improve the quality of care by publishing high-quality research for emergency medicine and related specialties, focusing on original research, reviews, and case reports to bring valuable educational information related to emergency medicine practice, teaching, and research.

Prof. Dr. Ovidiu Alexandru Mederle
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Personalized Medicine is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • shock and resuscitation
  • sepsis
  • learning
  • critical patient approach
  • medical education
  • challenging diagnosis
  • treatment advances
  • use of simulation in medical training
  • emergency department digitalization
  • interesting cases in emergency medicine
  • diagnostic and therapeutic protocols in emergency medicine

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Published Papers (7 papers)

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Research

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14 pages, 1591 KiB  
Article
Code Stroke Alert: Focus on Emergency Department Time Targets and Impact on Door-to-Needle Time across Day and Night Shifts
by Florina Buleu, Daian Popa, Carmen Williams, Anca Tudor, Dumitru Sutoi, Cosmin Trebuian, Covasala Constantin Ioan, Aida Iancu, Gabriel Cozma, Ana-Maria Marin, Ana-Maria Pah, Ion Petre and Ovidiu Alexandru Mederle
J. Pers. Med. 2024, 14(6), 596; https://doi.org/10.3390/jpm14060596 - 2 Jun 2024
Viewed by 204
Abstract
Background and objectives: To minimize stroke-related deaths and maximize the likelihood of cerebral reperfusion, medical professionals developed the “code stroke” emergency protocol, which allows for the prompt evaluation of patients with acute ischemic stroke symptoms in pre-hospital care and the emergency department (ED). [...] Read more.
Background and objectives: To minimize stroke-related deaths and maximize the likelihood of cerebral reperfusion, medical professionals developed the “code stroke” emergency protocol, which allows for the prompt evaluation of patients with acute ischemic stroke symptoms in pre-hospital care and the emergency department (ED). This research will outline our experience in implementing the stroke code protocol for acute ischemic stroke patients and its impact on door-to-needle time (DTN) in the ED. Methods: Our study included patients with a “code stroke alert” upon arrival at the emergency department. The final sample of this study consisted of 258 patients eligible for intravenous (IV) thrombolysis with an onset-to-door time < 4.5 h. ED admissions were categorized into two distinct groups: “day shift” (from 8 a.m. to 8 p.m.) (n = 178) and “night shift” (from 8 p.m. to 8 a.m.) (n = 80) groups. Results: An analysis of ED time targets showed an increased median during the day shift for onset-to-ED door time of 310 min (IQR, 190–340 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3–9 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3–9 min), and for door-to-physician (neurologist) time of 7 min (IQR, 5–10 min), also during the day shift. During the night shift, an increased median was found for door-to-CT time of 21 min (IQR, 16.75–23 min), for door-to-CT results of 40 min (IQR, 38–43 min), and for door-to-needle time of 57.5 min (IQR, 46.25–60 min). Astonishingly, only 17.83% (n = 46) of these patients received intravenous thrombolysis, and the proportion of patients with thrombolysis was significantly higher during the night shift (p = 0.044). A logistic regression analysis considering the door-to-needle time (minutes) as the dependent variable demonstrated that onset-to-ED time (p < 0.001) and door-to-physician (emergency medicine physicians) time (p = 0.021) are predictors for performing thrombolysis in our study. Conclusions: This study identified higher door-to-CT and door-to-emergency medicine physician times associated with an increased DTN, highlighting further opportunities to improve acute stroke care in the emergency department. Further, door-to-CT and door-to-CT results showed statistically significant increases during the night shift. Full article
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11 pages, 1344 KiB  
Article
Multi-Marker Approach in Patients with Acute Chest Pain in the Emergency Department
by Andrea Piccioni, Silvia Baroni, Federica Manca, Francesca Sarlo, Gabriele Savioli, Marcello Candelli, Alessandra Bronzino, Marcello Covino, Antonio Gasbarrini and Francesco Franceschi
J. Pers. Med. 2024, 14(6), 564; https://doi.org/10.3390/jpm14060564 - 25 May 2024
Viewed by 403
Abstract
Background: Chest pain is a prevalent reason for emergency room referrals and presents diagnostic challenges. The physician must carefully differentiate between cardiac and noncardiac causes, including various vascular and extracardiovascular conditions. However, it is crucial not to overlook serious conditions such as acute [...] Read more.
Background: Chest pain is a prevalent reason for emergency room referrals and presents diagnostic challenges. The physician must carefully differentiate between cardiac and noncardiac causes, including various vascular and extracardiovascular conditions. However, it is crucial not to overlook serious conditions such as acute coronary syndrome (ACS). Diagnosis of acute myocardial infarction (AMI) and early discharge management become difficult when traditional clinical criteria, ECG, and troponin values are insufficient. Recently, the focus has shifted to a “multi-marker” approach to improve diagnostic accuracy and prognosis in patients with chest pain. Methods: This observational, prospective, single-center study involved, with informed consent, 360 patients presenting to the emergency department with typical chest pain and included a control group of 120 healthy subjects. In addition to routine examinations, including tests for hsTnI (Siemens TNIH kit), according to the 0–1 h algorithm, biochemical markers sST2 (tumorigenicity suppression-2) and suPAR (soluble urokinase plasminogen activator receptor) were also evaluated for each patient. A 12-month follow-up was conducted to monitor outcomes and adverse events. Results: We identified two groups of patients: a positive one (112 patients) with high levels of hsTnI, sST2 > 24.19 ng/mL, and suPAR > 2.9 ng/mL, diagnosed with ACS; and a negative one (136 patients) with low levels of hsTnI, suPAR < 2.9 ng/mL, and sST2 < 24.19 ng/mL. During the 12-month follow-up, no adverse events were observed in the negative group. In the intermediate group, patients with hsTnI between 6 ng/L and the ischemic limit, sST2 > 29.1 ng/mL and suPAR > 2.9 ng/mL, showed the highest probability of adverse events during follow-up, while those with sST2 < 24.19 ng/mL and suPAR < 2.9 ng/mL had a better outcome with no adverse events at 12 months. Conclusion: Our data suggest that sST2 and suPAR, together with hsTnI, may be useful in the prognosis of cardiovascular patients with ACS, providing additional information on endothelial damage. These biomarkers could guide the clinical decision on further diagnostic investigations. In addition, suPAR and sST2 emerge as promising for event prediction in patients with chest pain. Their integration into the standard approach in PS could facilitate more efficient patient management, allowing safe release or timely admission based on individual risk. Full article
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17 pages, 3058 KiB  
Article
Better Performance of Modified Scoring Systems to Predict the Clinical Outcomes of Vibrio Bacteremia in the Emergency Department: An Observational Study
by Chia-Ming Hsieh, Sung-Yuan Hu, Ming-Shun Hsieh, Shih-Che Huang, Chia-Hui Shen and Yi-Chun Tsai
J. Pers. Med. 2024, 14(4), 385; https://doi.org/10.3390/jpm14040385 - 3 Apr 2024
Viewed by 700
Abstract
Background: Vibrio is a genus of Gram-negative bacteria found in various aquatic environments, including saltwater and freshwater. Vibrio bacteremia can lead to sepsis, a potentially life-threatening condition in which the immune system enters overdrive in response to the disease, causing widespread inflammation and [...] Read more.
Background: Vibrio is a genus of Gram-negative bacteria found in various aquatic environments, including saltwater and freshwater. Vibrio bacteremia can lead to sepsis, a potentially life-threatening condition in which the immune system enters overdrive in response to the disease, causing widespread inflammation and damage to tissues and organs. V. vulnificus had the highest case fatality rate (39%) of all reported foodborne infections in the United States and a high mortality rate in Asia, including Taiwan. Numerous scoring systems have been created to estimate the mortality risk in the emergency department (ED). However, there are no specific scoring systems to predict the mortality risk of Vibrio bacteremia. Therefore, this study modified the existing scoring systems to better predict the mortality risk of Vibrio bacteremia. Methods: Cases of Vibrio bacteremia were diagnosed based on the results from at least one blood culture in the ED. Patient data were extracted from the electronic clinical database, covering January 2012 to December 2021. The primary outcome was in-hospital mortality.This study used univariate and multivariate analyses to evaluate the mortality risk. Results: This study enrolled 36 patients diagnosed with Vibrio bacteremia, including 23 males (63.9%) and 13 females (36.1%), with a mean age of 65.1 ± 15.7 years. The in-hospital mortality rate amounted to 25% (9/36), with 31.5% in V. vulnificus (6/19) and 17.6% in V. non-vulnificus (3/17). The non-survivors demonstrated higher MEDS (10.3 ± 2.4) than the survivors (6.2 ± 4.1) (p = 0.002). Concerning the qSOFA, the survivors scored 0.3 ± 0.5, and the non-survivors displayed a score of 0.6 ± 0.7 (p = 0.387). The AUC of the ROC for the MEDS and qSOFA was 0.833 and 0.599, respectively. This study modified the scoring systems with other predictive factors, including BUN and pH. The AUC of the ROC for the modified MEDS and qSOFA reached up to 0.852 and 0.802, respectively. Conclusion: The MEDS could serve as reliable indicators for forecasting the mortality rate of patients grappling with Vibrio bacteremia. This study modified the MEDS and qSOFA to strengthen the predictive performance of mortality risk for Vibrio bacteremia. We advocate the prompt initiation of targeted therapeutic interventions and judicious antibiotic treatments to curb fatality rates. Full article
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19 pages, 336 KiB  
Article
Geriatric Population Triage: The Risk of Real-Life Over- and Under-Triage in an Overcrowded ED: 4- and 5-Level Triage Systems Compared: The CREONTE (Crowding and R E Organization National TriagE) Study
by Gabriele Savioli, Iride Francesca Ceresa, Maria Antonietta Bressan, Gaia Bavestrello Piccini, Viola Novelli, Sara Cutti, Giovanni Ricevuti, Ciro Esposito, Yaroslava Longhitano, Andrea Piccioni, Zoubir Boudi, Alessandro Venturi, Damiano Fuschi, Antonio Voza, Roberto Leo, Abdelouahab Bellou and Enrico Oddone
J. Pers. Med. 2024, 14(2), 195; https://doi.org/10.3390/jpm14020195 - 9 Feb 2024
Viewed by 1175
Abstract
Elderly patients, when they present to the emergency department (ED) or are admitted to the hospital, are at higher risk of adverse outcomes such as higher mortality and longer hospital stays. This is mainly due to their age and their increased fragility. In [...] Read more.
Elderly patients, when they present to the emergency department (ED) or are admitted to the hospital, are at higher risk of adverse outcomes such as higher mortality and longer hospital stays. This is mainly due to their age and their increased fragility. In order to minimize this already increased risk, adequate triage is of foremost importance for fragile geriatric (>75 years old) patients who present to the ED. The admissions of elderly patients from 1 January 2014 to 31 December 2020 were examined, taking into consideration the presence of two different triage systems, a 4-level (4LT) and a 5-level (5LT) triage system. This study analyzes the difference in wait times and under- (UT) and over-triage (OT) in geriatric and general populations with two different triage models. Another outcome of this study was the analysis of the impact of crowding and its variables on the triage system during the COVID-19 pandemic. A total of 423,257 ED presentations were included. An increase in admissions of geriatric, more fragile, and seriously ill individuals was observed, and a progressive increase in crowding was simultaneously detected. Geriatric patients, when presenting to the emergency department, are subject to the problems of UT and OT in both a 4LT system and a 5LT system. Several indicators and variables of crowding increased, with a net increase in throughput and output factors, notably the length of stay (LOS), exit block, boarding, and processing times. This in turn led to an increase in wait times and an increase in UT in the geriatric population. It has indeed been shown that an increase in crowding results in an increased risk of UT, and this is especially true for 4LT compared to 5LT systems. When observing the pandemic period, an increase in admissions of older and more serious patients was observed. However, in the pandemic period, a general reduction in waiting times was observed, as well as an increase in crowding indices and intrahospital mortality. This study demonstrates how introducing a 5LT system enables better flow and patient care in an ED. Avoiding UT of geriatric patients, however, remains a challenge in EDs. Full article

Review

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12 pages, 444 KiB  
Review
Drinking from the Holy Grail—Does a Perfect Triage System Exist? And Where to Look for It?
by Anna Ingielewicz, Piotr Rychlik and Mariusz Sieminski
J. Pers. Med. 2024, 14(6), 590; https://doi.org/10.3390/jpm14060590 - 31 May 2024
Viewed by 158
Abstract
The Emergency Department (ED) is a facility meant to treat patients in need of medical assistance. The choice of triage system hugely impactsed the organization of any given ED and it is important to analyze them for their effectiveness. The goal of this [...] Read more.
The Emergency Department (ED) is a facility meant to treat patients in need of medical assistance. The choice of triage system hugely impactsed the organization of any given ED and it is important to analyze them for their effectiveness. The goal of this review is to briefly describe selected triage systems in an attempt to find the perfect one. Papers published in PubMed from 1990 to 2022 were reviewed. The following terms were used for comparison: “ED” and “triage system”. The papers contained data on the design and function of the triage system, its validation, and its performance. After studies comparing the distinct means of patient selection were reviewed, they were meant to be classified as either flawed or non-ideal. The validity of all the comparable segregation systems was similar. A possible solution would be to search for a new, measurable parameter for a more accurate risk estimation, which could be a game changer in terms of triage assessment. The dynamic development of artificial intelligence (AI) technologies has recently been observed. The authors of this study believe that the future segregation system should be a combination of the experience and intuition of trained healthcare professionals and modern technology (artificial intelligence). Full article
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12 pages, 3670 KiB  
Review
Mechanical Thrombectomy via Transbrachial Approach in the Emergency Management of Acute Ischemic Stroke Patients with Aortic Pathologies: Our Experience and Literature Review
by Aida Iancu, Raluca Tudor, Dana Simona Chita, Catalin Juratu, Anca Tudor, Florina Buleu, Daian Popa and Silviu Brad
J. Pers. Med. 2024, 14(2), 216; https://doi.org/10.3390/jpm14020216 - 18 Feb 2024
Viewed by 981
Abstract
Study design: Mechanical thrombectomy (MT) via the transbrachial approach (TBA) is a very rare option used in cases of patients with aortic pathologies and acute ischemic stroke (AIS) due to the insufficient evidence in the literature, the difficulty from a technical point of [...] Read more.
Study design: Mechanical thrombectomy (MT) via the transbrachial approach (TBA) is a very rare option used in cases of patients with aortic pathologies and acute ischemic stroke (AIS) due to the insufficient evidence in the literature, the difficulty from a technical point of view and the result of this technique influenced by the complications that frequently accompany it. Background: Only a few cases of patients with aortic pathologies and acute ischemic stroke where MT via TBA were reported in the literature, and its application in the emergency management of AIS has still not been dealt with in detail. Objectives: Out of a need to clarify and clearly emphasize the effectiveness of this approach in emergency MT via TBA in patients with AIS and aortic pathologies, this literature review and case report has the following objectives: the first one is the presentation of an emergency MT via transbrachial approach performed in a 44-year-old patient with AIS and diagnosed aortic coarctation during transfemural approach (TFA), with successful reperfusion in our department and the second one is to review the cases reports of patients with different aortic pathologies and AIS reperfusion therapy performed by MT via TBA from the literature. Methods: A total of nine cases (one personal case and eight published cases) were revised in terms of aortic pathologies type, reperfusion therapy type, and the complication of both mechanical thrombectomy and local transbrachial approach. Results: Mechanical thrombectomy through the transbrachial approach was the first choice in more than half of these cases (55.55%, n = 5 cases) in the treatment of acute ischemic stroke in the presence of previously diagnosed aortic pathologies. In one-third of all cases (33.33%, n = 3, our case and 2 case reports from the literature), the transbrachial approach was chosen after attempting to advance the guiding catheter through the transfemoral approach and intraprocedural diagnosis of aortic pathology. In only one case, after an ultrasound evaluation of the radial artery that showed a monophasic flow, MT was performed via TBA. Local transbrachial complication was reported in one case, and in two other cases, it was not stated if there were such complications. Hemorrhagic transformation of AIS was reported in two cases that underwent MT-only cerebral reperfusion via TBA, one with acute aortic dissection type A and our case of previously undiagnosed aortic coarctation. In the cases in whom short and long-term follow-up was reported, the outcome of treatment, which was not exclusively endovascular (77.77% cases with only MT and 33.33% with association of first thrombolysis and after MT), was good (six from nine patients). In two case reports, the outcomes were not stated, and one patient died after a long hospitalization in the intensive care unit from respiratory complications (our patient). Conclusions: Being a clinical emergency, acute ischemic stroke requires urgent medical intervention. In patients with aortic pathologies, where acute ischemic stroke emergency care is a challenge, mechanical thrombectomy via the transbrachial approach is a safe alternative method for cerebral reperfusion. Full article
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Other

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9 pages, 6676 KiB  
Case Report
Cardiac Arrest and Complete Heart Block: Complications after Electrical Cardioversion for Unstable Supraventricular Tachycardia in the Emergency Department
by Adina Maria Marza, Claudiu Barsac, Dumitru Sutoi, Alexandru Cristian Cindrea, Alexandra Herlo, Cosmin Iosif Trebuian and Alina Petrica
J. Pers. Med. 2024, 14(3), 293; https://doi.org/10.3390/jpm14030293 - 9 Mar 2024
Viewed by 1878
Abstract
Synchronous electrical cardioversion is a relatively common procedure in the emergency department (ED), often performed for unstable supraventricular tachycardia (SVT) or unstable ventricular tachycardia (VT). However, it is also used for stable cases resistant to drug therapy, which carries a risk of deterioration. [...] Read more.
Synchronous electrical cardioversion is a relatively common procedure in the emergency department (ED), often performed for unstable supraventricular tachycardia (SVT) or unstable ventricular tachycardia (VT). However, it is also used for stable cases resistant to drug therapy, which carries a risk of deterioration. In addition to the inherent risks linked with procedural sedation, there is a possibility of malignant arrhythmias or bradycardia, which could potentially result in cardiac arrest following this procedure. Here, we present a case of complete heart block unresponsive to transcutaneous pacing and positive inotropic and chronotropic drugs for 90 min, resulting in multiple cardiac arrests. The repositioning of the transcutaneous cardio-stimulation electrodes, one of them placed in the left latero-sternal position and the other at the level of the apex, led to immediate stabilization of the patient. The extubation of the patient was performed the following day, with full recovery and discharge within 7 days after the insertion of a permanent pacemaker. Full article
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