BackgroundFew guidelines exist for the initial management of wounds in disaster settings. As wounds sustained are often contaminated, there is a high risk of further complications from infection, both local and systemic. Healthcare workers with little to no surgical training often provide early wound care, and where resources and facilities are also often limited, and clear appropriate guidance is needed for early wound management.MethodsWe undertook a systematic review focusing on the nature of wounds in disaster situations, and the outcomes of wound management in recent disasters. We then presented the findings to an international consensus panel with a view to formulating a guideline for the initial management of wounds by first responders and subsequent healthcare personnel as they deploy.ResultsWe included 62 studies in the review that described wound care challenges in a diverse range of disasters, and reported high rates of wound infection with multiple causative organisms. The panel defined a guideline in which the emphasis is on not closing wounds primarily but rather directing efforts toward cleaning, debridement, and dressing wounds in preparation for delayed primary closure, or further exploration and management by skilled surgeons.ConclusionGood wound care in disaster settings, as outlined in this article, can be achieved with relatively simple measures, and have important mortality and morbidity benefits.

ObjectivesThis study aims to determine the correlation of the caval index, inferior vena cava (IVC) diameter, and central venous pressure (CVP) in patients with shock in the emergency room.Materials and methodsThis is a prospective double-blind observational study conducted in the emergency room of a tertiary care center. All patients who presented with shock and had a central venous catheter insertion performed were enrolled. The caval index was calculated as a relative decrease in the IVC diameter during the normal respiratory cycle. The correlation of CVP and the caval index were calculated by Pearson’s product–moment correlation coefficient.ResultsAmong the 30 patients enrolled, the median age was 59.90±21.81 years and 17 (56.7%) patients were men. The summary statistics that were generated for the participants’ characteristics were divided into CVP <10 cm H2O, 10–15 cm H2O, and >15 cm H2O. The correlation of the CVP measurement with the ultrasound IVC caval index was r=−0.721 (P=0.000) by two-dimensional mode ultrasound and r=−0.647 (P=0.001) by M-mode. The correlations of CVP with the end-expiratory IVC diameter were r=0.551 (P=0.002) by two-dimensional mode ultrasound and r=0.492 (P=0.008) by M-mode. The sensitivity and specificity of the caval index were calculated to predict the CVP. The results showed that the cut-off points of the caval index were 30, 20, and 10 at CVP levels <10 cm H2O, 10–15 cm H2O, and >15 cm H2O, respectively.ConclusionThe caval index calculated from the IVC diameter measured by bedside ultrasound in the emergency room has a good correlation with CVP.

BackgroundThe Society for Academic Emergency Medicine (SAEM) Geriatric Emergency Medicine Task Force recommends assessment of delirium for all elderly emergency department (ED) patients. Little is known about emergency physicians' (EPs) opinions regarding care of delirious elderly patients. We sought to determine the knowledge and practice experience of members of the Thai Association for Emergency Medicine regarding the care of delirious elderly ED patients.MethodsWe surveyed all Thai emergency physicians from July to September 2013 using a brief online survey as this does not include any non-trained physician working in the private/provincial/community EDs, still a significant part of the ED workforce in Thailand.ResultsWe had a response rate of 50% (239/474) of which 95% (228/239) completed the survey. Respondents largely reported that <10% of their patients experience delirium. Eighty-five percent of the respondents recognized delirium as a problem that required active intervention, and 76% of the respondents thought it was underdiagnosed in the ED. Only 24% of the respondents reported routinely screening delirium in the ED and 16% reported using a specific screening tool for delirium assessment. Forty-two percent of the respondents reported treating delirium with a long acting benzodiazepine and 29% reported using haloperidol. Forty percent of respondents thought that oversedation was the most common complication associated with drug treatment of delirium.ConclusionsBasic knowledge and perceptions surrounding the recognition, diagnosis, and treatment of delirium in elderly ED patients by Thai EPs vary. Most of the Thai EPs consider delirium in the ED an emergency condition, while far fewer screen for this condition. Future research and quality improvement should determine which single screening tool is appropriate for EPs in regular practice as well as how to standardize delirium management in the ED.

Sepsis is a common presentation in the emergency department and a common cause of intensive care unit admissions and death. Accurate triage, rapid recognition, early resuscitation, early antibiotics, and eradication of the source of infection are the key components in delivering quality sepsis care. Evaluation of the patient’s volume status, optimal hemodynamic resuscitation, and evaluation of patient response is crucial for sepsis management in the emergency department.

As it was uncorrelated with traumatic MHI, serum cleaved tau protein proved to be an unreliable biomarker to use in the early detection of and decision-making for traumatic MHI patients at the emergency department.

The trauma team activation criteria improved acute trauma care in the ED which was demonstrated by the decreased EDLOS and mortality rate. A high ISS is the sole parameter predicting mortality.

Purpose Trauma is a major health problem in developing countries and worldwide which requires many resources and much time in an emergency department (ED). Although Advanced Trauma Life Support (ATLS) is the gold standard, operator dependence can affect the quality of care. The objective was to identify differences in numbers and time to lifesaving interventions, investigation, ED length of stay, and mortality between an in-house protocol and conventional practice. Methods This was a single-center prospective non-randomized study for adult trauma patients in the ED. The trauma protocol was developed from the recent ATLS guideline. Results Thirty-two and 41 cases were in the in-house protocol group and conventional practice group, respectively. Endotracheal intubation was done more frequently in the in-house protocol group (84% vs. 59%, p = 0.03). Intercostal drainage tube insertion was done faster (6–26 min, median 11 min vs. 15–84 min, median 35 min, p = 0.02) and pre-arrival notification by emergency medical service increased in the in-house protocol group (66% vs. 30%, p = 0.01). Hypothermia in the operating room was found only in the conventional practice group (62% vs. 0, p = 0.007) and a warm blanket was used significantly more often in the in-house protocol group (25% vs. 0, p < 0.001). A directed acyclic graph with multivariate analysis was used to identify confounders. Time to Focused Assessment Sonography in Trauma was significantly shorter in the in-house protocol group (6.5–15.6 min, median 11 min, p = 0.019). Conclusion In addition to the ATLS guideline, the trauma protocol could improve trauma care by reduced time to investigation, early notification of the trauma team in pre-hospital situations, reduced incidence of hypothermia in the operating room, and increased use of a warm blanket.

BackgroundSince early goal-directed therapy (EGDT) became standard care in severe sepsis and septic shock patients in intensive care units many years ago, we suppose that the survival rate of severe sepsis and septic shock patients improves if the resuscitative procedure is quickly implemented and is initiated in the emergency room.ObjectiveWe aimed at recording emergency department time to improve our patient care system as well as determine the rate at which EGDT goals can be achieved. The second analysis is to find out how much we can improve the survival rate.MethodsThis was a prospective observational study in an emergency room setting at a tertiary care facility where EGDT was applied for resuscitation of severe sepsis and septic shock patients. The data recorded were the initial vital signs, APACHE II (Acute Physiology and Chronic Health Evaluation II) score, SAP II (Simplified Acute Physiology II) score, SOFA (Sequential Organ Failure Assessment) score, time at which EGDT goals were achieved (central venous oxygen saturation [ScvO2] >70%), initial and final diagnosis, and outcome of treatment. The t-test and Mann–Whitney U-test were used to compare between the achieved goal and nonachieved goal groups.ResultsThere were 63 cases of severe sepsis in the study period. Only 55 patients submitted a signed consent form and had central line insertion. Twenty-eight (50.9%) cases were male. Thirty-nine (70.9%) patients achieved the goal, and the mean SAP II score was 8. There were no statistically significant differences between the two groups (P-value =0.097). Thirty of the 39 patients (70.9%) survived in the achieved goal group, which was a statistically significant improvement of the survival rate when compared with only one of 16 patients (6.3%) surviving in the nonachieved goal group (P<0.001).