Aim Successful acute migraine treatment potentially prevents emergency room (ER) consultations but requires that the diagnosis of migraine was given earlier. The aim of this study is to quantify the problem of missed migraine diagnosis prior to ER visits. Methods Inclusion criterion for this single-center prospective study was the presentation at the ER for acute headache. Patients with acute migraine attacks were assessed for previous migraine attacks, and whether they were given a diagnosis of migraine in the past. Results Of 137 patients with migraine diagnosis at discharge, 108 (79%) had previous headache attacks fulfilling the criteria for migraine according to The International Classification of Headache Disorders 3rd edition (ICHD-3). Of those, 54 (50%) received the diagnosis for the first time. Conclusion Half of the migraine patients (50%) presenting in the ER for headache could have been diagnosed earlier. This highlights the need for better detection and treatment of migraine by pre-hospital healthcare providers, as earlier diagnosis and specific acute treatment could have prevented the ER visit.

Background: Acute abdomen is a frequent reason for consultation in the emergency department. Acute diverticulitis is common, especially in elderly patients. Computer tomography (CT) and sonography are available for imaging. In order to minimize the number of CT scans, systematic ultrasound as first line imaging is performed in many centers. Little is known about the accuracy of point-of-care ultrasound (POCUS) in diagnosing acute diverticulitis by emergency physicians. The aim of this retrospective study is to determine, whether ultrasound can be used as first diagnostic measure in suspected cases. Methods: We performed a retrospective analysis at the emergency department of the University Hospital Bern, Switzerland from 2012–2019. In our department, an ultrasound is done for patients with suspected diverticulitis. The test characteristics of conclusive ultrasound exams were compared to CT, which is considered as the gold standard. Results: A total of 705 patients were identified by our screening of medical records. 609 (86%) patients had to be excluded, because no imaging (12%), only a CT (55%) or only a sonography has been performed (10%) and because of absence of consent (9%). The data of 96 (14%) patients were available for analysis. 48 patients had a conclusive ultrasound, 48 patients had an inconclusive ultrasound exam. The overall accuracy of POCUS is 79% for diverticulitis and the rate of false positive exams was 25%. Discussion: In this study, experienced examiners showed higher accuracy, highlighting the importance of training and skill level. However, the rate of inconclusive ultrasound exams remains a concern, indicating the need for further standardization and training. Moreover, POCUS demonstrated limited sensitivity for detecting complications, emphasizing the complementary role of CT, particularly in cases of suspected abscesses or perforations Conclusion: POCUS is a valuable tool in experienced hands for diagnosing AD, but its utility is limited in less experienced examiners. Additional imaging should be considered in patients with inconclusive ultrasound or high clinical suspicion for complications. Standardization of imaging protocols and further training of examiners may improve diagnostic accuracy. However, the study's limitations, including selection bias and variability among examiners, warrant cautious interpretation of the results.

The use of handheld ultrasound devices from a technical and data protection point of view, device properties, functionality, documentation, indications, delegation of performance, applications by doctors, students and non-medical staff is examined and discussed.

L'échographie Point-of-Care occupe désormais une place bien établie en Suisse.

Background Many countries report a significant increase in emergency department (ED) visits. Patients with musculoskeletal disorders account for a large proportion of non-urgent cases. Objective Characterization and evaluation of a new service that provides immediate access to physiotherapy for patients in the ED. Method To characterize a new service at the Department of Emergency Medicine, Bern University Hospital, and to evaluate first experiences with it, a mixed methods approach was chosen. Data was collected from the electronic patient file and from a logbook kept by the physiotherapists. In addition, guideline-based interviews with involved health care staff were conducted. Results During the 63 days of the pilot study 79 patients were treated by physiotherapists. The most frequently reported patient complaint was back pain (47 %). Interventions included taking the medical history, performing manual tests and multimodal treatment and developing recommendations for further treatment. In 59 % of patients no medical imaging and in 58 % no additional physiotherapy was prescribed. Patients rated the physiotherapeutic service as very good or excellent (88 %). Physiotherapy was experienced as positive and appreciated by the other professions, and all interviewees emphasized the added value for patients. Conclusion The pilot study indicates that the physiotherapeutic consultation service has the potential to improve quality of care. The findings of this study are therefore valuable when considering the introduction of such a service in an ED.

ZusammenfassungEs wird der Einsatz von Handheld-Ultraschallgeräten unter technischen und datenschutzrechtlichen Gesichtspunkten, Geräteeigenschaften, Funktionalität, Dokumentation, Indikationen, Delegation der Leistung, Anwendungen durch Ärzte, Studierende und nichtärztliches Personal beleuchtet und diskutiert.

Background Systematic imaging reduces the rate of missed appendicitis and negative appendectomies in patients with suspected acute appendicitis (AA). Little is known about the utility of ultrasound as a first diagnostic measure in patients with suspected AA. The aim of this retrospective study is to determine whether ultrasound, performed by emergency physicians or radiologists, can be used as first diagnostic measure in suspected cases to rule out AA and to avoid unnecessary CT. Methods We performed a retrospective analysis at the ED of the University Hospital Bern, Switzerland, from 2012 to 2014. Our standard protocol is that all adult patients suspected of appendicitis receive an ultrasound as their first imaging test, either by an emergency physician or a radiologist. The test characteristics of conclusive and inconclusive ultrasound exams were compared with a pragmatic gold standard. Results The study included 508 patients with suspected AA. 308 patients (60.4%) had a conclusive ultrasound. Among these, sensitivity for appendicitis was 89.6% (95% CI 82.1% to 94.3%), specificity 93.8% (89.1% to 96.6%), the positive predictive value was 87.98 (80.84 to 92.71) and the negative predictive value was 94.65 (91.18 to 96.80). The remaining 200 (39.4%) patients had an inconclusive ultrasound exam. 29% (59/200) of these patients ultimately had appendicitis. Less experienced emergency physician sonographers came to a definitive conclusion in 48.1% (95% CI 36.9% to 59.5%), experienced emergency physician sonographers in 76.0% (68.4% to 82.5%) and radiologists in 52.4% (44.5% to 60.2%). Conclusion A conclusive ultrasound of the appendix performed by either emergency physicians or radiologists is a sensitive and specific exam to diagnose or exclude AA in patients with suspected AA. Because of 6% false negative exams, clinical follow-up is mandatory for patients with negative ultrasound. An inconclusive ultrasound warrants further imaging or a follow-up visit, since 29% of patients with inconclusive ultrasound had an AA.

Eine Hämorrhagie ist in 30–40 % der Patienten, die im Rahmen eines Traumas versterben, todesursächlich und die häufigste vermeidbare Todesursache. Für nichtkomprimierbare Blutungen im Bereich des Abdomens oder des Beckens wird in den letzten Jahren zunehmend (wieder) die Anwendung der „resuscitative endovascular balloon occlusion of the aorta“ (REBOA) zur temporären Blutungskontrolle diskutiert. Seit August 2020 steht im Schockraum des Universitären Notfallzentrums des Universitätsspital Bern die REBOA als Therapieoption im Rahmen der Schwerverletztenversorgung zur Verfügung. Wir berichten in dieser Fallserie unsere Erfahrungen aus allen 7 Anwendungen im Laufe des ersten Jahres.

Durch die REGA erfolgte die Vorstellung eines 71-jährigen Patienten mit akuter Dyspnoe. Ungefähr 30–60 Minuten vor deren Auftreten hatte er sechs Tabletten eines amygdalinhaltigen Nahrungsergänzungsmittels eingenommen.

Zusammenfassung. Die akute Gelenkschwellung ist ein relativ häufiger Konsultationsgrund auf der Notfallstation. Nach Durchführung der Routineabklärungen (klinische Untersuchung, Labor, evtl. Röntgen), kommt der ätiologischen Klärung der Gelenkschwellung eine bedeutende Rolle zu, wobei besonders die septische Arthritis nicht verpasst werden darf. Entsprechend soll die Indikation zur Gelenkpunktion grosszügig gestellt werden. Während die Punktion bei grösseren und einfach zugänglichen Gelenken (z. B. Knie) landmarkengestützt erfolgen kann, so empfiehlt es sich bei kleineren und / oder schlechter zugänglichen Gelenken (insbesondere Hüfte, Schulter), die Punktion Ultraschall-gestützt durchzuführen. Es hat sich gezeigt, dass im Vergleich zum landmarkengestützten Verfahren die Ultraschall-geführte Punktion schmerzärmer und mit besserem Punktionserfolg durchgeführt werden kann. Laboranalytisch wichtig sind die Bestimmung der Zellzahl inkl. Differenzierung, die Suche nach Kristallen sowie die mikrobiologischen Untersuchungen bestehend aus Gram-Präparat und Kultur. Therapeutisch stehen bei der septischen Arthritis die arthroskopische Spülung und antibiotische Therapie, bei den Kristallarthropathien die lokale Infiltration mit einem Kortikosteroid und / oder die systemische Therapie mit einem nicht-steroidalen Antirheumatikum im Vordergrund. Verschiedene Aspekte der Gelenkpunktion werden in diesem Artikel beleuchtet, inklusive Asepsis, Landmark- und Ultraschall-gestützte Technik der Gelenkpunktion sowie Präanalytik und Interpretation der Punktionsresultate.

•There is a growing cohort of patients with advanced or end-stage chronic diseases who require palliative care in acute medical settings.•POCUS has the potential to streamline improve patient satisfaction, streamline diagnostic strategies, optimise patient length of stay, expedite timely symptomatic relief and reduce complications.•As the availability of POCUS equipment increases, we expect it to become standard of care in acute palliative care.

Background Guidelines recommend endotracheal intubation in trauma patients with a Glasgow coma scale (GCS) < 9 because of the loss of airway reflexes and consequential risk of airway obstruction. However, in patients with acute alcohol intoxication guidelines are not clear. Thus, we aimed to determine the proportional incidence of intubation in alcohol intoxication and compare the clinical characteristics of intubated and non-intubated patients, as well as reasons for intubation in all patients and in the subgroup of patients with reduced GCS (< 9) but without traumatic brain injury. Methods We performed a retrospective analysis of all consultations to an urban ED in Switzerland that presented with an acute alcohol intoxication between 1st June 2012 and 31th Mai 2017. Patient and emergency consultations’ characteristics, related injuries, intubation and reason for intubations were extracted. As a subgroup analysis, we analysed the patients with a GCS < 9 without a traumatic brain injury. Results Of 3003 consultations included from 01.06.2012 to 31.05.2017, 68 were intubated, leading to a proportional incidence of 2.3% intubations in alcohol-intoxication. Intubated patients had a lower blood alcohol concentration (1.3 g/kg [IQR 1.0–2.2] vs. 1.6 g/kg [IQR1.1–2.2], p = 0.034) and less often suffered from chronic alcohol abuse (1183 [39.4%] patients vs. 14 [20.6%], p = 0.001) than non-intubated patients. Patients with trauma were intubated more often (33 patients [48.5%] vs. 742 [25.3%], p < 0.001). In subgroup analysis, 110/145 patients (74.3%) were not intubated; again, more intubated patients had a history of trauma (9 patients [25.7%] vs. 10 [9.1%], p = 0.011). Conclusions Intubation in alcohol-intoxicated patients is rare and, among intoxicated patients with GCS < 9, more than two thirds were not intubated in our study - without severe complications. Trauma in general, independent of the history of a traumatic brain injury, and a missing history of chronic alcohol abuse are associated with intubation, but not with blood alcohol concentration. Special caution is required for intoxicated patients with trauma or other additional intoxications or diseases.

Acute joint swelling is a common presentation to the emergency department. Although routine investigations like clinical exam. labs and eventually x-ray are usually obtained, definitive diagnosis must be established since timely recognition of septic arthritis in particular is crucial. Definitive diagnosis is achieved by performing an arthrocentesis of the affected joint. While arthrocentesis of larger joints and large effusions (e.g. knee) are relatively easy to perform using the landmark-technique, smaller and less accessible joints (shoulder. elbow, hip) are more difficult to access and it is therefore recommended to use ultrasound guidance. Compared with the landmark-technique, ultrasound-guided arthrocentesis is more successful and less painful. Synovial fluid should be analyzed for cell count with differential, crystals as well as for microbiological analysis such as Gram-stain and culture. Once the diagnosis of septic arthritis has been established, irrigation of the joint should be performed by orthopedic surgery. Antibiotic therapy should be withheld until the sampling of synovial fluid has been completed. After exclusion of septic arthritis, acute arthritis due to crystal arthropathy (CPPD or gout) is treated with either glucocorticoid-infiltration of the joint or with nonsteroidal anti-inflammatory drugs. In this article, the different technical aspects of arthrocentesis are discussed, including asepsis, landmark- and ultrasound-guided access. preanalytics and interpretation of the laboratory results.

AIM:To investigate the characteristics of Emergency Department (ED) presentations due to acute paracetamol intoxication.METHODS:Retrospective observational study of patients presenting to the ED of Bern University Hospital between May 1, 2012, and October 31, 2018, due to a paracetamol overdose (defined as intake of >4 g/24 h). Cases were identified using the full-text search of the electronic patient database and were grouped into intentional (suicidal/parasuicidal) and unintentional intoxications (e.g., patient unaware of maximal daily dose).RESULTS:During the study period, 181 cases were included and 143 (79%) of those were intentional. Compared to the patients in the unintentional group, patients in the intentional group were more often female (85% vs 45%, p < 0.001) and younger (median age 23.0 vs 43.5 years, p < 0.001), more frequently suffered from psychiatric comorbidities (93%, (including 49% with borderline personality disorder) vs 24%, p < 0.001), and paracetamol was more often taken as a single dose (80% vs 13%, p < 0.001). Although the median daily ingested dose was lower in the unintentional than in the intentional group (8.2 g vs 12.9 g, p < 0.001), patients in the unintentional group presented later (29% vs 84% within 24 h of ingestion, p < 0.001), included more cases of acute liver failure (nine (24%) vs six (4%), p < 0.001), and were more often hospitalised (24% vs 52% treated as outpatients, p=0.002). There were no significant differences between the groups regarding drug-induced liver injury (seven cases (5%) in the intentional and one (3%) in the unintentional group) or fatalities (one in each group).CONCLUSIONS:The majority of presentations due to paracetamol poisoning were intentional, most commonly in female patients with borderline personality disorder. Patients with unintentional paracetamol intoxication had worse outcomes with respect to acute liver failure and hospitalisation. Future preventive measures should raise awareness of paracetamol toxicity in the general population and encourage particular attention and frequent follow-ups when prescribing paracetamol for vulnerable groups.

We aimed to determine the incidence of all vestibular symptoms in a large interdisciplinary tertiary emergency department (ED) and to assess stroke prevalence, and frequency of other life-threatening aetiologies. In this 1-year retrospective study, we manually screened all medical records of 23,608 ED visits for descriptions of vestibular symptoms. Symptoms were classified according to the International Classification of Vestibular Disorders of the Bárány Society. We evaluated all patients older than 16 years in whom vestibular symptoms were the main or accompanying complaint. We extracted clinical, radiological, and laboratory findings as well as aetiologies from medical records. We identified a total of 2596 visits by 2464 patients (11% of ED visits) who reported at least one vestibular symptom. In 1677/2596 visits (64.6%), vestibular symptoms were the main reason for the ED consultation. Vestibular symptoms were classified as dizziness (43.8%), vertigo (33.9%), postural symptoms (6.5%), or more than one symptom (15.8%). In 324/2596 visits (12.5%), cerebrovascular events were the aetiology of vestibular symptoms, and in 355/2596 visits (13.7%), no diagnosis could be established. In 23.8% of visits with vestibular symptoms as the main complaint, the underlying condition was life-threatening. Frequency and impact of vestibular symptoms in patients visiting the ED were higher than previously reported, and life-threatening aetiologies such as strokes are common. Therefore, awareness among physicians regarding the importance of vestibular symptoms has to be improved.