Point-of-care ultrasound (POCUS) is increasingly used in airway assessment, but its role in predicting difficult intubation in the emergency department remains unclear. A short systematic review of MEDLINE and EMBASE identified four prospective observational studies that met the inclusion criteria and underwent analysis. The studies evaluated ultrasound-derived airway parameters including hyomental distance, tongue thickness and anterior neck soft tissue thickness, and correlated these measurements with Cormack-Lehane grading. Several POCUS parameters demonstrated fair to excellent diagnostic accuracy for predicting difficult laryngoscopy. However, variability in study populations, measurement techniques and diagnostic thresholds limits the generalisability of the findings. The bottom line is that while POCUS is promising, it should not be used alone for difficult airway assessment. Further research with larger, diverse populations is needed.
A short evidence review was conducted to evaluate whether inhaled isopropyl alcohol (IPA) is an effective non-pharmacological treatment for acute nausea in adults presenting to the emergency department (ED). MEDLINE, EMBASE and the Cochrane Library were searched from database inception to the date of search using controlled subject headings and free-text terms. Following screening, six relevant studies were identified, comprising two systematic reviews/meta-analyses, two randomised controlled trials and two implementation studies. Current evidence suggests that inhaled IPA provides rapid short-term relief of acute nausea and may reduce the need for conventional antiemetics. Implementation studies further demonstrate that IPA can be administered rapidly, reduce treatment costs and integrate effectively as a simple, self-directed intervention within ED care pathways. Importantly, no included study evaluated nausea and vomiting of pregnancy or hyperemesis gravidarum, and several studies explicitly excluded pregnant patients. Although inhaled IPA appears to be an inexpensive, readily available and well-tolerated intervention for acute nausea in the ED, its efficacy and safety during pregnancy remain unknown. Well-designed pregnancy-specific randomised controlled trials are required before its use can be recommended in pregnancy.
The increasing prevalence of permanent pacemakers (PPMs) and implantable cardioverter defibrillators (ICDs) has led to a rising number of device malfunctions, which can have painful or even life-threatening consequences. As device technology advances, emergency personnel frequently face uncertainty in the initial management of these complex patients, given limited access to device reprogramming or interrogation outside specialised cardiology settings. This paper presents practical algorithm-based approaches for the immediate treatment of presumed PPM and ICD malfunctions in the prehospital and emergency department setting to support timely effective emergency care until expert consultation is available.
A short cut review of the literature was carried out to examine whether there is evidence for the use of intranasal epinephrine in comparison to intramuscular epinephrine to achieve rapid symptom control in patients presenting with anaphylaxis. 113 papers were found of which 8 were directly relevant to the clinical outcome. Seven studies were case series, six of which were published only as conference abstracts and one was an open-label phase III study. 22 studies were also identified, which assessed the pharmacodynamic and pharmacokinetic properties; these were not analysed. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. The clinical bottom line is that, to date, there is insufficient evidence to determine whether intranasal epinephrine is as effective as intramuscular epinephrine in anaphylaxis. Intramuscular epinephrine remains the standard of care.
BACKGROUND:Electric-scooters (e-scooters) are popular worldwide although there are concerns about their regulation and safety. Since 2019, 59 deaths have been reported in the UK involving e-scooters; 10 under 18 years old. In the UK riding privately owned e-scooters is illegal unless on private land. We reviewed e-scooter injuries in patients presenting to Emergency Departments of three UK Paediatric Major Trauma Centres. METHODS:This was a retrospective observational study of e-scooter-related injuries in patients under 16 years-old from January 2019 to December 2024 at Alder Hey Children's Hospital (AH), Sheffield Children's Hospital (SCH) and Royal Manchester Children's Hospital (RMCH). Patients were identified via electronic triage records and cross-referenced with trauma lists. At RMCH, a change in software limited data collection to 2023-2024. Descriptive statistics were used with 95% CIs for key proportions. RESULTS:477 patients presented with increasing incidence over the 6 year period. Median age was 12 years (IQR 10-13), with a male predominance (64.4%). Most injuries occurred to the rider (94.8%) and ≥80% were private e-scooters. 2.5% occurred on private land.Most common injuries were limb (40.6% lower, 36.2% upper), head (24.1%), and facial (18.4%) injuries. 10.4% of head injuries had an Abbreviated Injury Scale (AIS) score of 3 or 4, indicating major trauma necessitating imaging, hospital admission, and surgical intervention. Of the most seriously injured (AIS 3 or 4), 48% were from a collision with a motor vehicle or stationary object. Only 1.8% were wearing a helmet; 13.4% were admitted and 6.9% required surgery. Most injured children (74%) lived in the most deprived areas (Index of Multiple Deprivation (IMD) 1/2). CONCLUSION:E-scooter related injuries are rising. Limb, head and facial injuries were most common, with head injuries being most severe, this has serious life-changing implications for families and significant impact on healthcare resources. There is a need for greater public awareness, clear public health messaging and review of government legislation to prevent further injuries and deaths.
BACKGROUND:Ambulance clinicians play a key role in decision-making when care home residents experience deteriorations in their health. An emerging evidence base suggests ambulance clinicians weigh up risk during decision-making but provides limited insights into how they do so. Therefore, this study aimed to explore ambulance clinicians' experiences of balancing and managing risk(s) when attending calls to care homes. METHODS:Online semistructured interviews were conducted with 22 ambulance clinicians working in a variety of roles across seven NHS Ambulance Trusts in the UK. Data were analysed thematically using a constructivist approach. RESULTS:Three themes describe the ways ambulance clinicians manage risk when attending calls to care homes. The first theme outlines five forms of risk that ambulance clinicians weigh up, including risks to residents, themselves as decision-makers, their interpersonal relationships, their employing organisation and wider healthcare services. The second theme outlines the actions ambulance clinicians undertake to manage risk. Involving others in decision-making is a key action through which ambulance clinicians manage risk but doing so introduces the need to negotiate with others. Therefore, the third theme explores the multiple factors that shape ambulance clinicians' experiences of weighing up risks and negotiating with others. These factors align with the forms of risks ambulance clinicians manage during decision-making and include resident, decision-maker, interpersonal, organisational and systemic factors. CONCLUSIONS:This study highlights the complexity involved in ambulance clinicians' decision-making in care homes. The findings identify a number of important implications for research, policy and practice. This includes the need for further work to develop cross-sector practices and policies of accountability, to improve the number and quality of advance care plans and to ensure the current and future ambulance workforce are equipped to undertake the complex negotiation work involved in managing risks during decision-making in care homes.
Intraosseous (IO) access is a technique increasingly used within trauma and emergency settings where immediate vascular access is required. It provides an effective alternative to intravenous access, particularly in paediatric patients where intravenous access is difficult, or where previous attempts have been unsuccessful. However, concerns remain regarding potential complications associated with IO use, including potential long-term adverse outcomes.A short cut review of the literature was carried out to determine long-term outcomes of IO access in paediatric patients requiring emergency vascular access. A total of 282 unique papers were found, of which 11 observational studies (three prospective, eight retrospective) included data on patients relevant to the clinical question; these are discussed in the paper. Across these studies, severe long-term complications following paediatric IO access were rare. Only one study reported a single case of osteomyelitis following IO access. No evidence of growth disturbance, venous thrombosis or fat embolism was identified, while isolated cases of compartment syndrome, fracture and extravasation were reported at low frequency. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated.The clinical bottom line is that severe complications are rarely reported with paediatric IO lines. Emergency clinicians should not be deterred from inserting or retaining IO lines when definitive intravenous access has yet to be established.
BACKGROUND:Neurodiversity, including autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD) and learning difficulties, can increase vulnerability to violence. However, the epidemiology of violence-related Emergency Department (ED) attendance among neurodiverse patients remains unknown, as does the extent to which they engage with support services. Hospital-based Violence Intervention Programmes represent a potential strategic response, yet their need for and effectiveness in identifying and supporting neurodiverse patients is unexplored. METHODS:A whole-population cross-sectional exploratory study of 3 993 439 Welsh residents (2012-2024) using anonymised routine data. Data linkage identified violence-related ED attendances, neurodiversity diagnoses and comorbid conditions. Multivariable logistic regression models explored associations between neurodiversity and violence-related attendance. There were 9584 patients eligible for Violence Prevention Team (VPT) interventions at two intervention sites and exploratory analyses assessed patients acceptance of support. RESULTS:There were 73 222 ED violence-related attendances. ADHD (n=3511) and learning difficulty (n=1641) were each independently associated with increased violence-related attendance (ADHD, OR 1.67, 95% CI 1.61 to 1.74; mild learning difficulty, OR 1.33, 95% CI 1.25 to 1.40), whereas ASD (n=1148) was associated with a lower likelihood of violence-related attendance (OR 0.71, 95% CI 0.67 to 0.76). Of the eligible patients, VPTs contacted 4007 (41.8%); 2560 engaged with support while 1180 refused. Males and individuals with a history of alcohol misuse, substance misuse, or being a looked-after child were more likely to refuse support. In contrast, diagnoses of ASD, ADHD, and learning difficulties were not associated with support refusal. CONCLUSION:ADHD and learning difficulty are over-represented among violence-related ED attendees; however, neurodiversity does not predict unwillingness to engage with intervention services. Hospital-based violence prevention programmes are feasible within UK ED and can identify neurodiverse patients. Resource limitations currently restrict coverage. These findings support the need for sustained violence prevention services to optimise identification and support of vulnerable populations. TRIAL REGISTRATION NUMBER:ISRCTN68945844.
OBJECTIVE:The optimal timing of epinephrine during out-of-hospital cardiac arrest (OHCA) remains uncertain, particularly for neurological recovery. We examined the association between time-to-epinephrine and clinical outcomes in adult OHCA in Korea. METHODS:We conducted a nationwide retrospective cohort of emergency medical service (EMS)-treated, non-traumatic adult OHCA (2019-2021). Patients were classified as early (≤20 min) or delayed (>20 min) based on arrest-to-first epinephrine. The primary outcome was favourable neurological status at discharge (Cerebral Performance Category (CPC) 1-2); secondary outcomes were return of spontaneous circulation (ROSC) and survival to discharge. We applied 1:1 propensity-score matching and multivariable logistic regression, including continuous (per 1-minute and 5-minute delays) and 5-minute bin analyses of time-to-epinephrine, with effect modification assessed by initial rhythm. RESULTS:Among 10 726 patients, 3589 (33.5%) received epinephrine within 20 min. In the matched cohort (n = 5,734), delayed administration was associated with lower survival (4.46% vs 7.74%; aOR 0.56, 95% CI 0.44-0.71) and lower likelihood of favourable neurological outcome (2.13% vs 3.77%; aOR 0.56, 95% CI 0.40-0.79), compared with early administration. In continuous models, each 1-minute delay was associated with lower odds of good CPC (aOR 0.964, 95% CI 0.942 to 0.987); a 5-minute delay corresponded to aOR 0.833 (95% CI 0.741 to 0.937) and bin-wise estimates showed a marked drop beyond 30 min (aOR 0.048, 95% CI 0.006 to 0.393). CONCLUSION:Early epinephrine administration within 20 min of cardiac arrest onset was associated with higher rates of ROSC, survival to discharge and favourable neurological recovery in this EMS setting. These findings support the importance of timely advanced life support delivery, including early epinephrine, although cautious interpretation is warranted.
A short systematic review was undertaken to assess whether the use of non-supine positioning is associated with increased first-pass success in emergency department (ED) intubation. Medline, Embase and Google Scholar databases were searched. Six prospective studies were found, including two randomised trials. A positive association was demonstrated between patient angulation and first-pass success in three studies. These results support the protocolised use of inclined positioning for ED intubation.
Intranasal (IN) ketamine offers an alternative to intravenous procedural sedation in the Paediatric Emergency Department. A review of the literature was carried out to assess evidence for the efficacy of IN ketamine as an alternative to IV ketamine for use as procedural sedation. 150 individual papers were found, of which eight were included as studies providing data relevant to the clinical question. The author, date, country of publication, group studied, study type, outcomes, key results and study weaknesses were tabulated. The clinical bottom line is that in paediatric patients requiring sedation, IN ketamine has a slightly lower likelihood of success than intravenous ketamine; however, offers a useful needle-free alternative. With a clear explanation of the evidence to parents and shared decision-making, it should be considered in severely needle-phobic children.
INTRODUCTION:Paediatric head injuries are common emergency presentations and highly distressing for families. The prehospital phase is often the first point of contact with healthcare, where parents rely on paramedic assessment and decision-making under uncertainty. While clinical aspects of prehospital care are well studied, little is known about how families experience this stage and children's perspectives are largely absent. This study explores how parents and children interpret and experience prehospital care following a child's head injury. METHODS:This qualitative study used semistructured interviews with parents and where appropriate their children following ambulance transport to a regional tertiary children's hospital emergency department. Purposive sampling captured variation in age, injury severity and family background. Interviews were audio-recorded, transcribed verbatim, anonymised and analysed using reflexive thematic analysis, with reflexivity addressing the researcher's clinical background. Ethical approval was granted (REC 23/WM/0261; IRAS 329465). FINDINGS:14 parents and three children participated. Parents' experiences centred on building trust in paramedic decision-making and views on non-conveyance. Trust was shaped by communication, emotional tone, prior experience and recognition of parental instinct. Acceptance of reassurance and non-conveyance depended on transparent decision-making, structured assessment and clear safety-netting, while fear of deterioration and previous negative experiences drove resistance. Children described feeling safe through paramedic presence and communication and valued being spoken to directly, reassured and told what would happen next. CONCLUSION:Families' experiences of paediatric prehospital care are shaped by both clinical clarity and relational behaviour. Strong communication, shared decision-making and meaningful involvement of parents and children support confidence, perceived safety and overall experience during this critical phase of care.
BACKGROUND:Paediatric out-of-hospital clinical deterioration (POCD) is rare but carries a high risk of adverse outcomes if not recognised early. Despite its clinical importance, there is no agreed definition of POCD and this conceptual inconsistency limits research comparability and the development of evidence-based prehospital assessment. This study aims to develop an expert consensus-based definition of POCD. METHODS:A three-round online modified Delphi study was conducted with a multidisciplinary panel of UK clinicians with expertise in paediatric emergency and prehospital care. In Round 1, participants completed open-ended questions to describe and define POCD and propose relevant indicators. In Round 2, participants rated agreement with 14 definition statements synthesised from Round 1 and 21 indicators using a four-point Likert scale. Consensus was predefined as ≥75% agreement. In Round 3, borderline items were rerated, agreed items were confirmed, two indicators were added from Round 2 comments and participants were asked to prioritise the most important five clinical indicators for each paediatric age group. RESULTS:30 participants participated in Round 1, with 28 completing Round 2 and 26 completing Round 3. Consensus was achieved on a definition describing POCD as 'a progressive or acute worsening of a child's clinical condition over time, identified through observable trends rather than isolated measurements, occurring within a relevant clinical context and carrying a risk of serious adverse outcomes if unrecognised or untreated'. Of the 23 indicators assessed, core indicators consistently prioritised across all age groups were airway patency, respiratory rate, work of breathing, oxygen saturation, skin colour or perfusion and level of consciousness. CONCLUSION:This study provides the first consensus-based definition of POCD and identifies key indicators to support its recognition in prehospital care. These findings offer a shared conceptual framework to inform future research.
