Background: Sternal osteomyelitis following median sternotomy is an extremely uncommon type of deep sternal wound infection. It is considered a life-threatening complication that may develop after cardiothoracic surgery (2). Its occurrence is relatively low, ranging from 0.2% to 8%, with an associated mortality rate ranging from 8% to 45% (2). Due to this reason, a high index of suspicion is required in the Emergency Department setting to reach ultimate diagnosis. Case presentation: We detail a case of a middle-aged man with a history of aortic dissection repair 2 years ago who visited the emergency department with a 4-day history of chest pain and low-grade fever. Clinical evaluation revealed a tender sternal mass and diagnostic testing revealed elevated inflammatory markers and cardiac enzymes. CT angiogram displayed a destructive sternal lesions. He was admitted with a preliminary diagnosis of sternal osteomyelitis and received a multidisciplinary treatment approach, involving cardiac surgery and infectious... Continue Reading

Introduction: Patients with Chronic Obstructive Pulmonary Disease (COPD) frequently require non-invasive ventilation (NIV) strategies to manage both acute exacerbations and chronic respiratory failure. The progression of COPD often leads to respiratory muscle fatigue and hypercapnia, necessitating timely intervention to prevent further clinical deterioration. NIV has become a cornerstone in the management of COPD due to its ability to reduce the need for intubation, improve gas exchange, and alleviate the work of breathing. Moreover, its use in both hospital and home settings has been associated with enhanced quality of life and reduced hospital readmissions. Aims / Objectives: This systematic review aims to evaluate the efficacy of High Flow Nasal Cannula (HFNC) therapy as a sole strategy for improving clinical outcomes in COPD patients. Materials / Methods: A comprehensive search of the existing literature was conducted across multiple databases which includes, PubMed, Scopus, and CINAHL, with a date restriction of 10 years... Continue Reading

Introduction: Emergency medicine requires quick decision-making, effective communication, and strong clinical skills. Training must prepare practitioners to provide optimal care in emergencies. Simulation training has been shown to improve processes and patient outcomes, as highlighted by Ajmi et al. This quality improvement project (QIP) aimed to evaluate the impact of monthly simulation training on the confidence levels of emergency medicine trainees. The hypothesis was that increased frequency of simulation training would improve trainee confidence. The primary outcome was to increase simulation minutes during monthly teaching days, while the secondary outcome focused on improving the quality of simulation experiences through qualitative measures. Methods: This single-center QIP was conducted at Cambridge University Hospital. Pareto charts, fishbone, and driver diagrams were used to identify focus areas and implement changes. Interventions were tested using the Plan-Do-Study-Act (PDSA) methodology over eight months. Results: Nineteen data points were collected during the study. The pre-intervention median simulation... Continue Reading

Introduction: Acute ischemia of the bowel is associated with mortality rates of up to 80%. While early detection is key to appropriate management, the utility of investigative modalities is limited by poor sensitivity and specificity. Objectives: This report outlines the case of a patient with investigation results unremarkable for underlying ischemia, where clinical suspicion alone led to its diagnosis. Case Report: A 37-year-old female presented to a tertiary hospital ED with severe, generalized, abdominal pain for several hours after eating at a restaurant. She had a known history of treatment for breast cancer, as well as dihydropyrimidine dehydrogenase (DPD) deficiency. On examination, the patient was tachycardic and she had vague tenderness was in the right upper and left lower quadrants. A venous blood gas demonstrated normal lactate. Initial CT abdomen and pelvis with intravenous (IV) contrast showed minimal bowel edema only. Pain persisted despite high-dose opioids, and was out of... Continue Reading

Background: Acute right lower quadrant (RLQ) abdominal pain is commonly associated with appendicitis; however, alternative diagnoses, such as right-sided diverticulitis, should be considered to avoid misdiagnosis and unnecessary surgical interventions. Right-sided diverticulitis, though more prevalent in Asian populations and older adults, can occur in young individuals and mimic acute appendicitis. Case Presentation: We report a case of a 33-year-old female presenting with RLQ pain, loss of appetite, and low-grade fever. Laboratory findings revealed leukocytosis (WBC count of 16,000/µL with 87% polymorphonuclear neutrophils) and an elevated C-reactive protein (CRP) level (85 mg/L). Initial point-of-care ultrasound (POCUS) revealed interloop fluid in the right lower abdomen, suggesting inflammation. This finding, coupled with clinical symptoms, led to the suspicion of acute appendicitis. However, computed tomography (CT) imaging demonstrated right iliac fossa fat stranding, mural thickening of the cecum extending to the terminal ileum, and a calcific fecalith within a diverticulum, confirming right-sided diverticulitis. The... Continue Reading

Patients who present to the Emergency Department (ED) are often unselected when they arrive in the department. Increased demand in the ED of hospitals is a significant concern for healthcare systems globally. One of the goals of establishing a "Rapid Assessment and Treatment" (RAT) area within most modern EDs is that senior clinicians can assess and initiate life-saving treatment on unwell patients. We collected data between April and December 2023, investigating the outcome of 45,951 patients who were processed in the RAT sections of the department against recommended best standards. Data comparison with quality standard from NICE guidelines, RCEM, RCP and Academy of Medical Royal Colleges and the American Heart Association (AHA). Time from arrival to assessment (RAT note by a clinician) (1) Time to Antibiotic (AB): AB administration with 1h as recommended by the Academy of Medical Royal Colleges (2) Time to Analgesia: initial assessment for the pain within... Continue Reading

Background: Computed tomography pulmonary angiography (CTPA) is the go-to method for diagnosing suspected pulmonary embolism (PE), especially in patients with a high likelihood of the condition. The Royal College of Radiologists endorses CTPA due to its speed, conclusiveness, and availability, making it superior to isotope scanning in many cases. Aims: This audit aims to evaluate whether CTPA is being used correctly as the primary imaging test for suspected PE in our hospital, based on established referral guidelines. Methods: We retrospectively analysed 178 patients (105 females, 73 males; ages 17-94) who were seen for suspected PE in January and February. We gathered data on patient demographics, referral details, clinical notes, adherence to local protocols, chest X-ray (CXR) results, D-dimer levels, and CTPA findings. The two-levels Wells Score was used to gauge the likelihood of PE before testing. Results: Of the 178 patients, 13% had PE confirmed by CTPA, 59% had other... Continue Reading

Introduction In emergency medicine, accurate triage is vital for patient outcomes and resource management. The Canadian Triage and Acuity Scale (CTAS) has been essential in training healthcare providers to make prompt and precise triage decisions.1 With the rise of artificial intelligence (AI), chatbots are being considered for their potential to support or even replace human decision-making in various medical situations. This study aims to assess the agreement between AI chatbot triage decisions and those made by experienced emergency physicians using CTAS. Methods This study involved a comparative analysis between an AI chatbot and two expert emergency physicians, each with over ten years of experience. We used a dataset of 60 emergency case scenarios, which have been utilized for over 8-10 years to train medical personnel at the start of their careers.1 The AI chatbot received training materials on CTAS and triage before being tasked with assigning appropriate triage levels for... Continue Reading

INTRODUCTION Acute Respiratory Distress Syndrome (ARDS) is characterized as a condition that shows rapid onset of widespread inflammation in the lungs. Diagnosing this critical condition early and accurately is crucial for improving overall patient outcomes, as delayed intervention can lead to severe complications and increased mortality rates. Lung Ultrasonography (LUS) has proven to be a promising non-invasive strategic tool in the early identification and management of patients with ARDS, particularly in clinical settings where traditional screening modalities are limited. Its portability, ease of use, and ability to provide real-time dynamic imaging make LUS an invaluable asset in resource-constrained environments. Additionally, LUS has demonstrated reliability in detecting hallmark features of ARDS, such as interstitial syndrome and alveolar consolidations, thereby enhancing diagnostic precision and guiding therapeutic decisions. AIMS / OBJECTIVES This systematic review aims to further evaluate the diagnostic and predictive values of the LUS in relation to ARDS across the variety... Continue Reading

Background: Pain management in children can be challenging in the Emergency Department and therefore focusing efforts on optimising care and ensuring a positive experience is essential.1,2,3 Aim: This quality improvement project aimed to improve pain score assessment and re-evaluation of pain, against Royal College of Emergency Medicine (RCEM) national guidance, for patients under the age of 18, who presented to two Children's Emergency Departments. Methodology: Prospective PDSA cycles were planned over an 8-month time period (September 2023 - April 2024) and mapped the following sequence of interventions: 1) Application of a standardised pain assessment tool at triage 2) Introduction of an allocated team member to co-ordinate dedicated pain rounds for all patients Results: Patients included were aged 2-17 (52% male and 48% female). Initial pain score assessment at triage increased from 36% (18/50) to 94% (47/50) across summative sequenced interventions. The subsequent addition of an allocated team member improved analgesia... Continue Reading

Background: Subcapsular liver hematoma is spontaneous bleeding between the Glisson's capsule and the liver parenchyma. It is estimated to occur in 1-2% of patients with pre-eclampsia. Case presentation: A 39-year-old woman, gravida 7, para 6, at 27+3 weeks gestation, with a known case of gestational diabetes, was transferred by ambulance from the primary clinic to the emergency department as a case of pre-eclampsia. In the primary clinic, she complained of epigastric pain and vomiting that started 1 day ago. She denied headache, visual changes, chest pain, dyspnea, edema or per vaginal bleed. On physical examination, she was hypertensive, her abdomen was tender to palpation, with no peritoneal signs or hepatomegaly, and her cardiorespiratory examination was unremarkable. However, her neurologic exam showed brisk deep tendon reflexes. Initial Investigations revealed thrombocytopenia (platelet count: 78,000/mL), transaminitis (AST: 2882 IU/L and ALT: 1825 IU/L), LDH elevation (>1800 IU/L), and 3+ proteinuria on urinalysis. She... Continue Reading

Introduction: Breastfeeding has long been recognized by healthcare professionals as the most beneficial feeding practice for infants, providing essential nutrients and fostering a strong mother-infant bond. This practice enhances infant growth, boosts immunity, and reduces disease risk, while also aiding mothers in postpartum recovery. The World Health Organization (WHO) advocates exclusive breastfeeding for the first six months and continued breastfeeding up to two years alongside other foods. Kangaroo Mother Care (KMC), a method involving skin-to-skin contact between mother and low birth weight or preterm infants, is another vital practice. KMC promotes infant health and development by stabilizing heart rate, maintaining body temperature, and improving oxygenation. Additionally, KMC supports increased breast milk production, crucial in areas with high infant mortality due to malnutrition and gastrointestinal diseases. Background: Despite the recognized benefits of breastfeeding and KMC, there remains a gap in implementation and awareness among mothers, particularly in specific regions. This study... Continue Reading

Background: Morel-Lavallee lesions are rare, closed traumatic degloving soft tissue injuries caused by blunt trauma. They result from the shearing force that separates the dermis from the underlying fascia. A high index of suspicion is required, as missed diagnoses can lead to complications such as infection, pressure necrosis, pseudocyst formation, and chronic fluid collections. Case Presentation: A 48-year-old patient reattended the emergency department with complaints of left leg swelling and bruising, following a fall from a horse two weeks prior. She had sustained injuries to the left leg. At her initial presentation, a computed tomography (CT) scan from head to pelvis, along with X-rays of the left femur, was performed. No acute fractures or visceral injuries were identified. However, over the next two weeks, she developed progressive swelling and bruising of the left thigh. On examination, there was ecchymosis of the left lateral thigh, along with a large, fluctuant swelling... Continue Reading

Background: Emphysematous cystitis is a potentially fatal complication of acute urinary tract infection, with a reported mortality rate of 7-10%. It predominantly affects elderly patients with poorly controlled diabetes and can progress to emphysematous pyelonephritis or require surgical intervention. Early recognition and initiation of antibiotics are crucial for favourable outcomes. Case Presentation: A 79-year-old female with a history of poorly controlled type 2 diabetes mellitus (HbA1c 79 mmol/mol), chronic kidney disease (stage 4), hypertension, and left ventricular systolic dysfunction (EF 37%) presented with fever, dysuria, lower abdominal pain, and vomiting for three days. She was febrile, tachycardic (100 bpm), hypotensive (BP 100/50 mmHg), and had suprapubic tenderness. Initial venous blood gas revealed a lactate of 3 mmol/L and base excess of -4. Point-of-care ultrasound (POCUS) performed in the emergency department revealed A-lines within the bladder wall, loss of well-defined bladder borders, and sedimentation. These findings raised concern for emphysematous cystitis,... Continue Reading

Background: Abdominal trauma poses a complex challenge in emergency medicine, with diverse injury patterns and prognostic outcomes. This study aims to decipher these patterns, elucidate factors influencing patient prognosis at a tertiary trauma center, and optimize patient care. Methods: A retrospective analysis was conducted on trauma patients admitted with abdominal injuries over a two-year period. Data on demographics, injury mechanisms, diagnostic imaging, injuries sustained, surgical interventions, and outcomes were meticulously collected from the patient record system "SALAMTAK." The collected data were then analyzed and studied. Results: Out of the 201 patients analyzed, 87% were males and 13% females. The study found that road traffic accidents (RTA) accounted for 55% of cases as the most common mechanism of injury, while stabbing accounted for only 1.4% of cases as the least common mechanism. Furthermore, 44% of patients sustained extra-abdominal injuries (excluding brain injuries), making it the most common type of injury. The... Continue Reading

Background: Spontaneous Isolated Superior Mesenteric Artery Dissection is a rare vascular event with anincidence rate of 0.06%. The increasing use of diagnostic imaging studies-Computed tomography angiography(CTA) or Magnetic resonance angiography(MRA) has resulted in its early recognition and treatment. Though it is a rare cause of acute abdomen,it could be potentially fatal and should be recognized early in the ED after excluding other common causes as delay in treatment can lead to life threatening complications. Case Presentation: We present a 63 year old male with a past medical history of hypertension who presented to the ED with sudden onset bilateral flank pain,initially associated with giddiness, sweating and an episode of vomiting.Later the pain started radiation to the periumbilical region.He also reported burning micturition and increased frequency of urination from the past 2 days.Upon arrival to the ED,the patient was in severe pain with pain score of 9/10, with a blood pressureof... Continue Reading

Background: Diabetic ketoacidosis (DKA) and non-ST elevation myocardial infarction (NSTEMI) are severe conditions that occasionally coexist. DKA arises from insulin deficiency, leading to hyperglycemia, ketosis, and acidosis, while NSTEMI results from myocardial oxygen supply-demand mismatch, often due to coronary artery disease (CAD). Both conditions can be fatal if mismanaged. NSTEMI occurs in approximately 3% of DKA hospitalizations in the U.S. [1]. The interplay between DKA and NSTEMI is bidirectional: DKA exacerbates CAD, potentially triggering ischemia, while NSTEMI worsens metabolic disturbances in DKA. Troponin elevation in DKA patients is linked to increased cardiac risk, and DKA complicates myocardial infarction with nonobstructive coronary arteries (MINOCA), raising mortality and major adverse cardiovascular events (MACE) [2]. Case Report: A 51-year-old male with diabetes, hypertension, and dyslipidemia presented with 2 days of severe chest pain radiating to the left arm, nausea, vomiting, and dyspnea. He had a history of suspected acute coronary syndrome 15 years... Continue Reading

Introduction: Drones are revolutionizing emergency healthcare by offering faster response times—cutting them by over 50%—which can significantly improve survival rates and outcomes. They represent an eco-friendly, cost-effective alternative to traditional response methods. Current applications include AED delivery for out-of-hospital cardiac arrest (OHCA), real-time patient monitoring, and transportation of organs and medications. Despite these benefits, widespread adoption is hindered by regulatory, technical, and social challenges, including airspace restrictions, battery limitations, safety, bystander reactions, privacy concerns, and logistical issues. The UK and UAE were selected for their established drone infrastructure, progressive regulation, and contrasting healthcare systems and geographies. Objectives: This scoping review assesses the benefits, challenges, and current landscape of drone integration in the UK and UAE EMS. It seeks to inform global policymakers and stakeholders and represents explicitly the first study focused on these two countries. Methods: Following PRISMA-ScR guidelines, a systematic search of PubMed, Embase, and ProQuest was conducted for... Continue Reading

Background: A biphasic reaction in anaphylaxis is described as a recurrence of anaphylaxis symptoms in the absence of re-exposure to the initial trigger, and typically occurs between the first 6-12 hours, but up to 72 hours following the first reaction. The reported incidence of this phenomenon in literature is variable. As such, some hospitals practise admitting patients to observation units following the index reaction for further monitoring. However, guidelines on the recommended duration of observation following anaphylaxis are limited. Objectives: We aimed to evaluate the incidence and predictors of biphasic reactions in patients presenting to the Emergency Department (ED) with anaphylaxis, and its subsequent implications on the utility of admissions to observation units as well as the recommended duration of stay. Methods: This was a retrospective study comprising patients aged 21 years old and above who were admitted to the observation unit in a tertiary hospital in Singapore in the... Continue Reading

Introduction: Limb ischemia from jellyfish envenomation is exceedingly rare. Only 15 cases have been reported in literature. Case Report: A 15-year-old boy developed a painful rash over both arms and left thigh immediately after a jellyfish sting. He received anti-tetanus treatment, analgesia, and calamine lotion the same day. Six days later, he visited the Emergency department with numbness over his left hand. Although comfortable, the patient had rashes over his left distal forearm and wrist and his left 3rd to 4th fingers, thumb, palm and thenar eminence were cyanotic with compromised sensation, capillary refill and left radial pulse CT angiogram showed symmetrical severe attenuation of the distal left forearm arteries with possible occluded segments with smooth tapering along the forearm. Intravenous heparin, nitrogylcerin, alprostil and antibiotics were administered. Reperfusion was achieved and he was discharged 3 days later. The patient subsequently made a full recovery with sensation and function all... Continue Reading