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In 2022, the Supreme Court decision in Dobbs v Jackson Women's Health Organization reneged the Constitutional right to an abortion. Many states now enforce laws that ban abortions. There are significant conflicts between state abortion laws and federal regulations that mandate proper assessment, treatment, and stabilization of patients who present for emergency care. This conflict places physicians in an untenable position when treating patients who have a pregnancy that endangers their life. In states that deem abortion a felony, transfer of these patients can extricate the physician, who is in a difficult position. Currently, it is the only reasonable option for hospitals and physicians who are trapped between conflicting state laws and Emergency Medical Treatment and Labor Act rules and regulations.

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PURPOSE: We report the case of an acute type B dissection with high-risk features treated with multilayer stent. CASE REPORT: A 50-year-old female patient presented to the emergency department with an acute type B aortic dissection. Conservative medical treatment did control blood pressure but did not alleviate her dissection symptoms. She was treated endovascularly with multilayer stents extensively covering the whole dissected area. HThe aortic arch side branches, visceral arteries and renal arteries remained patent after treatment. The recovery was uneventful, and she was discharged the day after the intervention. At 6- and 12-month follow-up, the patient remained asymptomatic, the true lumen volume increased and all side branches remained patent. CONCLUSION: We present a case of the use of a multilayer stent for acute type B aortic dissection. This technique allows to treat the whole dissection with low risk of paraplegia or side branch occlusion. Long-term results of ongoing clinical studies should confirm the place of the multilayer stent as a treatment option for type B aortic dissection.

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BACKGROUND: Emergency general surgery (EGS) admissions account for a large proportion of surgical care and represent the majority of surgical patients who suffer in-hospital mortality. Health care systems continue to experience growing demand for emergency services: one way in which this is being increasingly addressed is dedicated subspecialty teams for emergency surgical admissions, most commonly termed "emergency general surgery" in the United Kingdom. This study aims to understand the impact of the emergency general surgery model of care on outcomes from emergency laparotomies. METHODS: Data was obtained from the National Emergency Laparotomy Audit database. Patients were dichotomized into EGS hospital or non-EGS hospital. Emergency general surgery hospital is defined as a hospital where >50% of in-hours emergency laparotomy operating is performed by an emergency general surgeon. The primary outcome was in-hospital mortality. Secondary outcomes were intensive therapy unit (ITU) length of stay and duration of hospital stay. A propensity score weighting approach was used to reduce confounding and selection bias. RESULTS: There were 115,509 patients from 175 hospitals included in the final analysis. The EGS hospital care group included 5,789 patients versus 109,720 patients in the non-EGS group. Following propensity score weighting, mean standardized mean difference reduced from 0.055 to <0.001. In-hospital mortality was similar (10.8% vs. 11.1%, p = 0.094), with mean length of stay (16.7 days vs. 16.1 days, p < 0.001) and ITU stay (2.8 days vs. 2.6 days, p < 0.001) persistently longer in patients treated in EGS systems. CONCLUSION: No significant association between the emergency surgery hospital model of care and in-hospital mortality in emergency laparotomy patients was seen. There is a significant association between the emergency surgery hospital model of care and an increased length of ITU stay and overall hospital stay. Further studies are required to examine the impact of changing models of EGS delivery in the United Kingdom. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

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INTRODUCTION: Because small children can be transported by private vehicles, many children seek emergency care outside of Emergency Medical Services (EMS). Such transports may access the closest emergency departments (EDs) without knowledge of their pediatric competence. This study quantifies this practice and the concept of mandatory pediatric readiness. METHODS: The electronic health records of 3 general EDs and 2 pediatric EDs were queried for all pediatric and young adult visits for the year 2022. Data collected included patient age, ED type, arrival mode (EMS/police or private mode), and disposition (admission/transfer or discharge). Study patients were categorized as "small children" if aged younger than 10 years, "large children" if 10 to 18 years, and "young adult" if 19 to 40 years. Associations between mode of arrival, ED type, and disposition were analyzed through χ 2 and analysis of variance. RESULTS: The study population included 37,866 small children, 19,108 large children, and 68,293 young adults. When compared with EMS/police transports, a private arrival mode was selected by 96.1% of small children, 90.0% of large children, and 85.4% of young adults ( P < 0.0001). For the admission/transfer patients, private transportation was selected by 87.4% of small children, 73.8% of large children, and 78.8% of young adults ( P < 0.0001). For admitted/transferred children, the private mode was used by 80.4% of those in the general ED and 81.9% in the pediatric ED ( P > 0.41). CONCLUSIONS: Pediatric patients seeking ED care overwhelmingly arrive through a private mode regardless of the severity of their problem or type of ED in which treated. Emergency Medical Services programs and state hospital regulatory agencies need to recognize this practice and assure the pediatric competence of every ED within their system.

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PURPOSE: The aims of this study were to estimate the type and frequency of different medical emergencies that occurred over the study period (twelve years) and discuss the lessons learned and the modifications made in the curriculum to better equip dental students and faculty in their management. MATERIALS AND METHODS: A retrospective study was conducted to evaluate all medical emergencies that needed activation of the response team at our school from 2008 to 2020. RESULTS: The emergency response system was activated 250 times during the 12-year period. There were 132 medical emergencies in the pre-doctoral clinic and 105 events in the post-doctoral clinic (p 0.0680). Most of the emergencies occurred in patients between 45 and 64 years of age. Syncope occurs most often followed by adverse cardiovascular, respiratory, anxiety, and hypoglycemic events. CONCLUSIONS: Medical emergencies occurring in a dental school provide a unique opportunity for students to gain experience in their management. The key lies in preparing the students and faculty to prevent them from occurring, but should these occur, then they should be able to promptly recognize symptoms and institute prompt intervention.

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This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

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This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

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Nurse knowledge and expertise in Emergency Medical Treatment and Labor Act (EMTALA) are a prerequisite to meet emergency department practice laws and regulatory standards. EMTALA is a federal law that requires anyone coming to an emergency department for care to be stabilized and treated, regardless of their insurance status or ability to pay. Regulatory standard infractions resulting from an EMTALA violation complaint may include (1) penalties and/or fines, (2) future unannounced Centers for Medicare & Medicaid Services surveys, (3) documented Centers for Medicare & Medicaid Services deficiencies that require timely response, action plans, and audit for expected outcomes, (4) Medicare/Medicaid nonpayment for services, and (5) termination of a hospital's Medicare agreement. The consequences of EMTALA violations target physicians and hospitals; however, nurses are most often the first provider the patient encounters upon arrival to the emergency department. It is therefore essential that nurses maintain a proficient understanding of EMTALA laws, which requires special training, monitoring, periodic competency assessment strategies, and continuing education throughout their career. Furthermore, additional clinician education is needed on how to manage the complex expectations that are imposed on health care providers by regulatory policy. Doing this promotes safe, effective, patient-centered, timely, and efficient health care regulations from the beginning of one's introduction to the health care industry and throughout his or her career. This article seeks to ( a ) emphasize nursing staff's responsibility for EMTALA adherence, ( b ) identify the gaps among health care quality, safety, and nursing workforce competency standards that are imposed to meet the demands of EMTALA laws, and ( c ) provide recommendations for continuing education, monitoring, and periodic competency assessment strategies that may strengthen EMTALA compliance.

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Importance: Pediatric readiness is essential for all emergency departments (EDs). Children's experience of care may differ according to operational challenges in children's hospitals, community hospitals, and rural EDs caused by recurring and sometimes unpredictable viral illness surges. Objective: To describe wait times, lengths of stay (LOS), and ED revisits across diverse EDs participating in a statewide quality collaborative during a surge in visits in 2022. Design, Setting, and Participants: This retrospective cohort study included 25 EDs from the Michigan Emergency Department Improvement Collaborative data registry from January 1, 2021, through December 31, 2022. Pediatric (patient age <18 years) encounters for viral and respiratory conditions were analyzed, comparing wait times, LOS, and ED revisit rates for children's hospital, urban pediatric high-volume (≥10% of overall visits), urban pediatric low-volume (<10% of overall visits), and rural EDs. Exposures: Surge in ED visit volumes for children with viral and respiratory illnesses from September 1 through December 31, 2022. Main Outcomes and Measures: Prolonged ED visit wait times (arrival to clinician assigned, >4 hours), prolonged LOS (arrival to departure, >12 hours), and ED revisit rate (ED discharge and return within 72 hours). Results: A total of 2 761 361 ED visits across 25 EDs in 2021 and 2022 were included. From September 1 to December 31, 2022, there were 301 688 pediatric visits for viral and respiratory illness, an increase of 71.8% over the 4 preceding months and 15.7% over the same period in 2021. At children's hospitals during the surge, 8.0% of visits had prolonged wait times longer than 4 hours, 8.6% had prolonged LOS longer than 12 hours, and 42 revisits occurred per 1000 ED visits. Prolonged wait times were rare among other sites. However, prolonged LOS affected 425 visits (2.2%) in urban high-pediatric volume EDs, 133 (2.6%) in urban pediatric low-volume EDs, and 176 (3.1%) in rural EDs. High visit volumes were associated with increased ED revisits across sites. Conclusions and Relevance: In this cohort study of more than 2.7 million ED visits, a pediatric viral illness surge was associated with different pediatric acute care across EDs in the state. Clinical management pathways and quality improvement efforts may more effectively mitigate dangerous clinical conditions with strong collaborative relationships across EDs and setting of care.

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In this paper, the actions needed to manage specific medical emergencies are discussed. Each emergency requires a correct diagnosis to be made for effective and safe management. The basis of management in contemporary dental practice avoids the intravenous route where drugs are required to treat the emergency.

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Traumatic dental injuries (TDIs) in the paediatric population are common and frequently seen in general dental practice. The management of TDIs can be challenging and, in most cases, the General Dental Practitioner is tasked with the initial assessment and emergency treatment. Patients and their families typically attend with elevated levels of distress, which is complicated by the limited dental experience of some children. Behaviour management is essential and helps prepare patients for dental care at both their emergency and follow-up appointments. Early and accurate diagnosis in combination with appropriate treatment contributes to favourable outcomes for traumatised teeth. Early discussions with or referral to paediatric dental teams for management of complex TDIs is encouraged, however shared follow-up care is beneficial over the long-term. In specific cases, initial dental treatment can be delayed by a few days to a subsequent appointment, allowing the dental team to book sufficient time for the treatment and for the patient and their families to prepare. Education of the patients and adults with parental responsibility is essential to manage expectations, explain likely complications and encourage attendance for long-term follow-up visits. This paper discusses the management of paediatric patients to aid the primary care practitioner in providing effective immediate and long-term care.

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Emergency care in the UK is in crisis, and stories of long waits, poor care and harm have become commonplace. This situation can no longer be ignored. This article looks at some of the ways in which emergency care can be resuscitated.

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INTRODUCTION: Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables. METHODS AND ANALYSIS: Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model. ETHICS AND DISSEMINATION: Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.

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BACKGROUND: As emergency department (ED) leaders started integrating geriatric emergency guidelines on a facultative basis, important variations have emerged between EDs in care for older patients. The aim of this study was to establish a consensus on minimum operational standards for Geriatric ED care in Belgium. METHODS: A two-stage modified Delphi study was conducted. Twenty panellists were recruited from Dutch and French speaking regions in Belgium to join an interdisciplinary expert panel. In the first stage, an online survey was conducted to identify and define all possible elements of geriatric emergency care. In the second stage, an online survey and online expert panel meeting were organized consecutively to determine which elements should be recognized as minimum operational standards. RESULTS: Between March 2020 and February 2021, the expert panel developed a broad consensus including ten statements focusing on the target population, specific goals, availability of geriatric practitioners and quality assurance. Additionally, the expert panel also determined which protocols, materials and accommodation criteria should be available in conventional EDs (39 standards) and in observational EDs (57 standards). CONCLUSIONS: This study presents a consensus on minimum operational standards for geriatric emergency care in two ED types: the conventional ED and the observational ED. These findings may serve as a starting point towards broadly supported minimum standards of care stipulated by legislation in Belgium or other countries.

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BACKGROUND AND OBJECTIVE: Pediatric firearm injuries increased during the coronavirus disease 2019 pandemic, but recent trends in firearm injury emergency department (ED) visits are not well described. We aimed to assess how pediatric firearm injury ED visits during the pandemic differed from expected prepandemic trends. METHODS: We retrospectively studied firearm injury ED visits by children <18 years old at 9 US hospitals participating in the Pediatric Emergency Care Applied Research Network Registry before (January 2017 to February 2020) and during (March 2020 to November 2022) the pandemic. Multivariable Poisson regression models estimated expected visit rates from prepandemic data. We calculated rate ratios (RRs) of observed to expected visits per 30 days, overall, and by sociodemographic characteristics. RESULTS: We identified 1904 firearm injury ED visits (52.3% 15-17 years old, 80.0% male, 63.5% non-Hispanic Black), with 694 prepandemic visits and 1210 visits during the pandemic. Death in the ED/hospital increased from 3.1% prepandemic to 6.1% during the pandemic (P = .007). Firearm injury visits per 30 days increased from 18.0 prepandemic to 36.1 during the pandemic (RR 2.09, 95% CI 1.63-2.91). Increases beyond expected rates were seen for 10- to 14-year-olds (RR 2.61, 95% CI 1.69-5.71), females (RR 2.46, 95% CI 1.55-6.00), males (RR 2.00, 95% CI 1.53-2.86), Hispanic children (RR 2.30, 95% CI 1.30-9.91), and Black non-Hispanic children (RR 1.88, 95% CI 1.34-3.10). CONCLUSIONS: Firearm injury ED visits for children increased beyond expected prepandemic trends, with greater increases among certain population subgroups. These findings may inform firearm injury prevention efforts.

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BACKGROUND: Previous studies have shown varying results on the validity of the rapid emergency triage and treatment system (RETTS), but have concluded that patient age is not adequately considered as a risk factor for short term mortality. Little is known about the RETTS system's performance between different chief complaints and on short term mortality. We therefore aimed to evaluate how well a model including both RETTS triage priority and patient age (TP and age model) predicts 3-day mortality compared to a univariate RETTS triage priority model (TP model). Secondarily, we aimed to evaluate the TP model compared to a univariate age model (age model) and whether these three models' predictive performance regarding 3-day mortality varies between patients with different chief complaints in an unsorted emergency department patient population. METHODS: This study was a prospective historic observational cohort study, using logistic regression on a cohort of patients seeking emergency department care in Stockholm during 2012-2016. Patient visits were stratified into the 10 chief complaint categories (CCC) with the highest number of deceased patients within 3 days of arrival, and to "other chief complaints". Patients with priority 1 were excluded. RESULTS: The studied cohort contained 1,690,981 visits by 788,046 different individuals. The TP and age model predicted 3-day mortality significantly and substantially better than both univariate models in the total population and in each studied CCC. The age model predicted 3-day mortality significantly and substantially better than the TP model in the total population and for all but three CCCs and was not inferior in any CCC. There were substantial differences between the studied CCCs in the predictive ability of each of the three models. CONCLUSIONS: Adding patient age to the RETTS triage priority system significantly and substantially improves 3-day mortality prediction compared to RETTS priority alone. Age alone is a non-inferior predictor of 3-day mortality compared to RETTS priority. The impact on 3-day mortality prediction of adding patient age to RETTS priority varies between CCCs but is substantial for all CCCs and for the total population. Including age as a variable in future revisions of RETTS could substantially improve patient safety.

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AbstractInformed consent is a necessary component of the ethical practice of surgery. Ideally, consent is performed in a setting conducive to a robust patient-provider conversation, with careful consideration of risks, benefits, and outcomes. For patients with medical or surgical emergencies, navigating the consent process can be complicated and requires both careful and expedited assessment of decision-making capacity. We present a recent case in which a patient in need of emergency care refused intervention, requiring urgent capacity assessment and a modification to usual care.

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