Royal College of Emergency Medicine (RCEM) Best Practice Guidelines are produced by a variety of special interest groups or convened expert advisory groups which sit under the umbrella of the College’s Quality in Emergency Care Committee (QECC).1 They are produced to bridge the gap between systematically derived evidence-based recommendations and the need for emergency clinicians to provide quality care and advice to patients, or to respond to evolving trends. Unlike National Institute for Health and Care Excellence (NICE) guidelines, which are costly to produce, incorporate calls for evidence ..read more

Clinical introduction A previously healthy 46-year-old man experienced acute mid-calf pain while playing paddle tennis. He treated himself with non-steroidal anti-inflammatory drugs and local cold application, and took a rest. One week later, he consulted the ED due to persistent pain and swelling in the area. Examination revealed tenderness to palpation of the medial belly of the gastrocnemius muscle. A point-of-care ultrasound was performed (figure 1). Question What is the most likely diagnosis? Morel-Lavallée lesion Pyomyositis Complicated Baker’s cyst ‘Tennis leg’ injury Answer: D Rupture ..read more

In this edition of the Emergency Medicine Journal, Dr Cooper and her colleagues explore the facilitators and barriers to the effectiveness of different general practitioner service models in or alongside EDs (GP-ED).1 The availability of these services in the UK expanded in response to a 2017 budget commitment of £100 million to enhance A&E services including the colocation of on-site GP services.2 The authors observed that the demand for ED services is influenced by a range of individual, department and wider system factors, but that colocated GP/ED service models did not reduce attendanc ..read more

Background Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context. Methods We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interv ..read more

Since electronic cigarettes (e-cigarettes) first appeared in the tobacco product marketplace over a decade ago, they have been evaluated as another tool for promoting successful smoking cessation. The randomised controlled trial by Pope et al reported in this issue of the Emergency Medicine Journal, adds to a growing literature on the use of e-cigarettes as a smoking cessation intervention, providing evidence in a novel, pragmatic setting—emergency departments (EDs).1 A 2024 Cochrane review reported high-certainty evidence for their effectiveness, primarily from randomised controlled trials, s ..read more

Clinical introduction A 57-year-old man presented acutely with involuntary movements of his left hand. He had hypertension, chronic kidney disease and chronic obstructive pulmonary disease. These movements were best described as sudden, recurrent and arrhythmic loss of tone and power of the left wrist and fingers (video 1). They were most prominent when extending the left wrist, but were absent when the arms were at rest and were not elsewhere. There were no additional neurological deficits. Serum urea, ammonia, sodium, potassium, calcium, magnesium, phosphate and glucose levels were normal. H ..read more

Background Management of acute kidney injury (AKI) in the ED can be difficult due to uncertainty regarding the aetiology. This study investigated the diagnostic value of venous system ultrasound for determining the aetiological subtypes of AKI in the ED. Methods This multidisciplinary prospective cohort study was conducted in a single academic ED over the course of a year. Adult patients with AKI were evaluated using the venous excess ultrasound (VExUS) score, which is a four-step ultrasound protocol. The protocol begins with the inferior vena cava (IVC) measurement and examines organ flow pat ..read more

This month’s update comes from the Emergency Department at Northern General Hospital, Sheffield. We used a multimodal search strategy, drawing on free open-access medical education resources and literature searches. We identified the five most interesting and relevant papers (decided by consensus) and highlight the main findings, key limitations and clinical bottom line for each paper. Worth a peek—interesting, but not yet ready for prime time. Head turner—new concepts. Game changer—this paper could/should change practice. A non-inferiority randomised controlled trial comparing nebulised ketam ..read more

A short cut review of the literature was carried out to examine the evidence supporting antithrombotic treatment and/or endovascular therapy to reduce mortality and/or prevent future stroke following blunt cerebrovascular injury (BCVI). Five papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that in patients with BCVI confirmed by CT angiography, there is limited evidence to support sc ..read more

High-sensitivity troponin (hsTn) is used with ECG and clinical evaluation to stratify patients attending ED as low risk for acute myocardial infarctions (AMI). Diagnostic pathways incorporate a single test threshold for stratification with these assays. The Siemens Atellica VTLi Point-Of-Care-hsTnI assay (POC-hsTnI) has an 8 min turn-around which may expedite decision-making. Although a single-test low-risk (‘rule-out’) threshold for this assay has been reported,1 it was desirable to determine a threshold specifically for New Zealand ED settings and intended end-users. From 3 November 2022 to ..read more