No abstract

The in-hospital mortality of patients with severe sepsis and septic shock (SSSS) is high. In this study we examined the diagnostic and prognostic accuracy of the emergency severity index (ESI), the modified early warning score (MEWS), and the mortality in emergency department (ED) sepsis (MEDS) score. This is a single-centre, prospective and observational study of 151 consecutive patients presenting to the ED of the Nuremberg Hospital with suspected sepsis (age 68.3 ± 18 years, 54.3 % men, 45 % with SSSS, in-hospital mortality of SSSS: 27.8 %). In this study, 37.7 % of the studied patients had a urinary tract infection (n = 57/151), 33.8 % a pneumonia (n = 51/151), 8.6 % an acute abdominal infection (n = 13/151), and in 12.6 % the focus of infection was not further specified or identifiable (n = 19/151). The diagnostic and prognostic accuracy was analyzed by means of the receiver operating characteristic (ROC) curve. The areas under curve (AUC) in terms of diagnostic accuracy were 0.609, 0.641, and 0.778 for the ESI, MEWS, and MEDS score respectively. The AUCs concerning prognostic accuracy were 0.617, 0.642, and 0.871 for ESI, MEWS, and MEDS score respectively.By using the MEDS score systematically, critically ill patients with sepsis could be detected in the ED. Finally, the MEDS score provides the basis for a risk adjusted disposition management that follows objective criteria.

Many patients presenting with syncope to a German ED are elderly, and multiple comorbidities are common. Technology-intensive testing in patients with syncope has a low diagnostic yield and consumes resources. The introduction of standards for the evaluation of syncope in the ED would be helpful.

This study demonstrated that implementation of standardized CAP care bundles in the ED is associated with a 21% relative risk reduction of in-hospital mortality. Standardization of diagnostic and therapeutic processes in the ED improves outcome of patients hospitalized for CAP.

Evaluating patients with acute chest pain presenting to the emergency department remains an ongoing challenge. The spectrum of etiologies in acute chest pain ranges from minor disease entities to life-threatening diseases, such as pulmonary embolism, acute aortic dissection or acute myocardial infarction (MI). The diagnosis of acute MI is usually made integrating the triad of patient history and clinical presentation, readings of 12-lead ECG and measurement of cardiac troponins (cTn). Introduction of high-sensitivity cTn assays substantially increases sensitivity to identify patients with acute MI even at the time of presentation to the emergency department at the cost of specificity. However, the proportion of patients presenting with cTn positive, non-vascular cardiac chest pain triples with the implementation of new sensitive cTn assays increasing the difficulty for the emergency physician to identify those patients who are at need for invasive diagnostics. The main objectives of this mini-review are 1) to discuss elements of disposition decision made by the emergency physician for the evaluation of chest pain patients, 2) to summarize recent advances in assay technology and relate these findings into the clinical context, and 3) to discuss possible consequences for the clinical work and suggest an algorithm for the clinical evaluation of chest pain patients in the emergency department.