Management of the aggressive emergency department patient: Non-pharmacological perspectives and evidence base

Introduction: Aggression in the Emergency Department (ED) remains an ongoing issue, described as reaching epidemic proportions, with an impact on staff recruitment, retention, and ability to provide quality care. Most literature has focused on the definition (or lack of) core concepts, efforts to quantify the phenomenon or provide an epidemiological profile. Relatively little offers evidence-based interventions or evaluations of the same. Aim: To identify the range of suggested practices and the evidence base for currently recommended actions relating to the management of the aggressive Emergency Department patient. Methods: A meta-synthesis of existing reviews of violence and aggression in the acute health-care setting, including management of the aggressive patient, was undertaken. This provided the context for critical consideration of the management of this patient group in the ED and implications for clinical practice. Results: An initial outline of issues was followed by a systematic search and 15 reviews were further assessed. Commonly identified interventions are grouped around educational, interpersonal, environmental, and physical responses. These actions can be focused in terms of overall responses to the wider issues of violence and aggression, targeted at the pre-event, event, or post-event phase in terms of strategies; however, there is a very limited evidence base to show the effectiveness of strategies suggested. Clinical Implications: The lack of evidence-based intervention strategies leaves clinicians in a difficult situation, often enacting practices based on anecdote rather than evidence. Local solutions to local problems are occurring in a pragmatic manner, but there needs to be clarification and integration of workable processes for evaluating and disseminating best practice. Conclusion: There is limited evidence reporting on interventional studies, in addition to identification of the need for high quality longitudinal and evaluation studies to determine the efficacy of those responses that have been identified

Eye movement and visuomotor arm movement deficits following mild closed head injury

Based on increasing evidence that even mild closed head injury (CHI) can cause considerable neural damage throughout the brain, we hypothesized that mild CHI will disrupt the complex cerebral networks concerned with oculomotor and upper-limb visuomotor control, resulting in impaired motor function. Within 10 days following mild CHI (Glasgow Coma Scale 1315, alteration of consciousness <20 min), we compared 30 patients (15-37 years) and 30 matched controls on different types of saccades, oculomotor smooth pursuit (sine and random), upper-limb visuomotor performance and several neuropsychological tests known to be sensitive to head trauma. Simple reflexive saccades were not impaired, whereas, on the antisaccade task, the CHI group demonstrated prolonged saccadic latencies, a marginally higher number of directional errors and poorer spatial accuracy. The CHI group exhibited more directional errors and impaired motor accuracy on memory-guided sequences of saccades and produced fewer self-paced saccades within 30 s. Most measures of sinusoidal and random oculomotor smooth pursuit showed no deficits, with the exception of a prolonged lag on random smooth pursuit in the CHI group. While arm movement reaction time and arm steadiness were not impaired, the CHI group showed decreased arm movement speed and decreased upper-limb motor accuracy. Conversely, after controlling for IQ, the CHI group had few head trauma-related neuropsychological deficits. These results indicate that multiple motor systems can be impaired following mild CHI and that this can occur independently of neuropsychological impairment. Our study also indicates that quantitative tests of oculomotor and upper-limb visuomotor function may provide sensitive markers of cerebral dysfunction, suggesting the potential use of such tests to supplement patient assessment. To our knowledge, this study is the first to demonstrate the presence of oculomotor or visuomotor deficits following mild CHI.status: publishe

The Extent of Soft Tissue and Musculoskeletal Injuries after Earthquakes; Describing a Role for Reconstructive Surgeons in an Emergency Response

Background: Earthquakes are the leading cause of natural disaster-related mortality and morbidity. Soft tissue and musculoskeletal injuries are the predominant type of injury seen after these events and a major reason for admission to hospital. Open fractures are relatively common; however, they are resource-intense to manage. Appropriate management is important in minimising amputation rates and preserving function. This review describes the pattern of musculoskeletal and soft-tissue injuries seen after earthquakes and explores the manpower and resource implications involved in their management. Methods: A Medline search was performed, including terms "injury pattern" and "earthquake," "epidemiology injuries" and "earthquakes," "plastic surgery," "reconstructive surgery," "limb salvage" and "earthquake." Papers published between December 1992 and December 2012 were included, with no initial language restriction. Results: Limb injuries are the commonest injuries seen accounting for 60 % of all injuries, with fractures in more than 50 % of those admitted to hospital, with between 8 and 13 % of these fractures open. After the first few days and once the immediate lifesaving phase is over, the management of these musculoskeletal and soft-tissue injuries are the commonest procedures required. Conclusions: Due to the predominance of soft-tissue and musculoskeletal injuries, plastic surgeons as specialists in soft-tissue reconstruction should be mobilised in the early stages of a disaster response as part of a multidisciplinary team with a focus on limb salvage.</p