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Screening for carbon monoxide exposure in selected patient groups attending rural and urban emergency departments in England: a prospective observational study.

ABSTRACT: Carbon monoxide (CO) exposure does not produce a classical toxidrome and so it is thought that it may easily be missed, allowing patients to continue to be exposed to CO. The aim of this study was to determine the proportion of raised carboxyhaemoglobin (COHb) levels in a targeted population of patients presenting to four emergency departments (EDs) in England.A prospective observational study undertaken over a 9-month period.Four EDs; one in a rural/suburban area and three serving urban populations.1758 patients presenting to the EDs with chest pain, exacerbation of chronic obstructive pulmonary disease (COPD), non-traumatic headache, seizures or flu-like symptoms.Measures COHb levels measured using a pulse CO-oximeter or venous sample. Patients with COHb levels ?2.5% (non-smokers) or ?5% (smokers) completed a questionnaire assessing potential sources. Patients were defined to be positive for CO exposure if they had a positive COHb and either an identified source or no other reason for their raised level.Proportion of positive patients was: overall-4.3%; COPD-7.5%; headache-6.3%; flu-like-4.3%; chest pain-3.3%; seizures-2.1%. A variety of gas and solid (predominantly charcoal) fossil fuel sources were identified.This study showed that 4.3% of patients presenting to EDs with non-specific symptoms had unexpectedly raised COHb levels 1.4% of patients had a source of CO identified. Study limitations included non-consecutive recruitment, delays in COHb measurements and a lack of ambient CO measurements, which precludes precise determination of incidence. However, this study should alert clinicians to consider CO exposure in patients presenting with non-specific symptoms, in particular headache and exacerbation of COPD, and if necessary refer patients for suitable public-health follow-up, even in the presence of low COHb readings. Further research should include standardised scene assessments.

SUBMITTER: Clarke S

PROVIDER: S-EPMC3533103 | biostudies-literature | 2012

REPOSITORIES: biostudies-literature

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Screening for carbon monoxide exposure in selected patient groups attending rural and urban emergency departments in England: a prospective observational study.

Clarke Simon S Keshishian Catherine C Murray Virginia V Kafatos George G Ruggles Ruth R Coultrip Elizabeth E Oetterli Sam S Earle Daniel D Ward Patricia P Bush Stephen S Porter Crispin C

BMJ open 20121213 6

<h4>Objectives</h4>Carbon monoxide (CO) exposure does not produce a classical toxidrome and so it is thought that it may easily be missed, allowing patients to continue to be exposed to CO. The aim of this study was to determine the proportion of raised carboxyhaemoglobin (COHb) levels in a targeted population of patients presenting to four emergency departments (EDs) in England.<h4>Design</h4>A prospective observational study undertaken over a 9-month period.<h4>Setting</h4>Four EDs; one in a r ...[more]

PMID: 23242237

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Project description:Children constitute 6-10% of all patients attending the emergency department (ED) by emergency medical services (EMS). However, discordant EMS use in children occurs in 37-61% with fever as an important risk factor. We aimed to describe EMS utilisation among febrile children attending European EDs. This study is part of an observational multicentre study assessing management and outcome in febrile children up to 18 years (MOFICHE) attending twelve EDs in eight European countries. Discordant EMS use was defined as the absence of markers of urgency including intermediate/high triage urgency, advanced diagnostics, treatment, and admission in children transferred by EMS. Multivariable logistic regression analyses were performed for the association between (1) EMS use and markers of urgency, and (2) patient characteristics and discordant EMS use after adjusting all analyses for the covariates age, gender, visiting hours, presenting symptoms, and ED setting. A total of 5464 (15%, range 0.1-42%) children attended the ED by EMS. Markers of urgency were more frequently present in the EMS group compared with the non-EMS group. Discordant EMS use occurred in 1601 children (29%, range 1-59%). Age and gender were not associated with discordant EMS use, whereas neurological symptoms were associated with less discordant EMS use (aOR 0.2, 95%CI 0.1-0.2), and attendance out of office hours was associated with more discordant EMS use (aOR 1.6, 95%CI 1.4-1.9). Settings with higher percentage of self-referrals to the ED had more discordant EMS use (p < 0.05). Conclusion: There is large practice variation in EMS use in febrile children attending European EDs. Markers of urgency were more frequently present in children in the EMS group. However, discordant EMS use occurred in 29%. Further research is needed on non-medical factors influencing discordant EMS use in febrile children across Europe, so that pre-emptive strategies can be implemented. What is Known: •Children constitute around 6-10% of all patients attending the emergency department by emergency medical services. •Discordant EMS use occurs in 37-61% of all children, with fever as most common presenting symptom for discordant EMS use in children. What is New: •There is large practice variation in EMS use among febrile children across Europe with discordance EMS use occurring in 29% (range 1-59%), which was associated with attendance during out of office hours and with settings with higher percentage of self-referrals to the ED. •Future research is needed focusing on non-medical factors (socioeconomic status, parental preferences and past experience, healthcare systems, referral pathways, out of hours services provision) that influence discordant EMS use in febrile children across Europe.

Project description:ObjectiveTo assess sex differences in presentation and management of febrile children with respiratory symptoms attending European Emergency Departments.Design and settingAn observational study in twelve Emergency Departments in eight European countries.PatientsPreviously healthy children aged 0-<18 years with fever (≥ 38°C) at the Emergency Department or in the consecutive three days before Emergency Department visit and respiratory symptoms were included.Main outcome measuresThe main outcomes were patient characteristics and management defined as diagnostic tests, treatment and admission. Descriptive statistics were used for patient characteristics and management stratified by sex. Multivariable logistic regression analyses were performed for the association between sex and management with adjustment for age, disease severity and Emergency Department. Additionally, subgroup analyses were performed in children with upper and lower respiratory tract infections and in children below five years.ResultsWe included 19,781 febrile children with respiratory symptoms. The majority were boys (54%), aged 1-5 years (58%) and triaged as low urgent (67%). Girls presented less frequently with tachypnea (15% vs 16%, p = 0.002) and increased work of breathing (8% vs 12%, p<0.001) compared with boys. Girls received less inhalation medication than boys (aOR 0.82, 95% CI 0.74-0.90), but received antibiotic treatment more frequently than boys (aOR 1.09, 95% CI 1.02-1.15), which is associated with a higher prevalence of urinary tract infections. Amongst children with a lower respiratory tract infection and children below five years girls received less inhalation medication than boys (aOR 0.77, 95% CI 0.66-0.89; aOR 0.80, 95% CI 0.72-0.90).ConclusionsSex differences concerning presentation and management are present in previously healthy febrile children with respiratory symptoms presenting to the Emergency Department. Future research should focus on whether these differences are related to clinicians' attitudes, differences in clinical symptoms at the time of presentation and disease severity.

Project description:BackgroundHospital emergency departments play a crucial role in the initial assessment and management of suspected COVID-19 infection. This needs to be guided by studies of people presenting with suspected COVID-19, including those admitted and discharged, and those who do not ultimately have COVID-19 confirmed. We aimed to characterise patients attending emergency departments with suspected COVID-19, including subgroups based on sex, ethnicity and COVID-19 test results.Methods and findingsWe undertook a mixed prospective and retrospective observational cohort study in 70 emergency departments across the United Kingdom (UK). We collected presenting data from 22445 people attending with suspected COVID-19 between 26 March 2020 and 28 May 2020. Outcomes were admission to hospital, COVID-19 result, organ support (respiratory, cardiovascular or renal), and death, by record review at 30 days. Mean age was 58.4 years, 11200 (50.4%) were female and 11034 (49.6%) male. Adults (age >16 years) were acutely unwell (median NEWS2 score of 4), frequently had limited performance status (46.9%) and had high rates of admission (67.1%), COVID-19 positivity (31.2%), organ support (9.8%) and death (15.5%). Children had much lower rates of admission (27.4%), COVID-19 positivity (1.2%), organ support (1.4%) and death (0.3%). Similar numbers of men and women presented to the ED, but men were more likely to be admitted (72.9% v 61.4%), require organ support (12.2% v 7.7%) and die (18.2% v 13.0%). Black or Asian adults tended to be younger than White adults (median age 54, 50 and 67 years), were less likely to have impaired performance status (43.1%, 26.8% and 51.6%), be admitted to hospital (60.8%, 57.3%, 69.6%) or die (11.6%, 11.2%, 16.4%), but were more likely to require organ support (15.9%, 14.3%, 8.9%) or have a positive COVID-19 test (40.8%, 42.1%, 30.0%). Adults admitted with suspected and confirmed COVID-19 had similar age, performance status and comorbidities (except chronic lung disease) to those who did not have COVID-19 confirmed, but were much more likely to need organ support (22.2% v 8.9%) or die (32.1% v 15.5%).ConclusionsImportant differences exist between patient groups presenting to the emergency department with suspected COVID-19. Adults and children differ markedly and require different approaches to emergency triage. Admission and adverse outcome rates among adults suggest that policies to avoid unnecessary ED attendance achieved their aim. Subsequent COVID-19 confirmation confers a worse prognosis and greater need for organ support.RegistrationISRCTN registry, ISRCTN56149622, http://www.isrctn.com/ISRCTN28342533.

Dataset Information

Screening for carbon monoxide exposure in selected patient groups attending rural and urban emergency departments in England: a prospective observational study.

Publications

Screening for carbon monoxide exposure in selected patient groups attending rural and urban emergency departments in England: a prospective observational study.

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