Our Editor’s Choice for this issue comes from Collis et al, presenting the first national description of nightclub-related mortality in the UK. They combine systematic media surveillance with coronial verification, and the findings will resonate with anyone who has worked an overnight shift in a city emergency department (ED): trauma and MDMA toxicity are recurrent themes, and the victims...]]>
The study confirms what many in emergency medicine would expect: trauma and 3,4-Methylenedioxymethamphetamine (MDMA) toxicity dominate nightclub-related mortality, and the victims are overwhelmingly young. The median age of 22 is striking. The age-stratified analysis adds nuance: drug-related deaths are clustered under age 25, with trauma more broadly spread. This distinction suggests that different risk groups may benefit from different interventions: drug education and harm reduction for younger attendees and violence prevention strategies for a wider demographic.
Five deaths associated with physical restraint...]]>
Nightclubs, often perceived as safe spaces for entertainment, can nevertheless harbour hidden dangers. Despite their popularity among young adults, the prevalence and characteristics of fatalities associated with nightclub attendance remain unknown. This research aimed to characterise the nature and frequency of nightclub-related deaths in the UK.
We conducted a retrospective observational study using media reports and coroner verification to identify and characterise nightclub-related deaths in the UK between 2009 and 2024. Nightclub-related deaths encompassed those found deceased inside the venue and those who died within a few hours of attendance, typically on the same night. Articles were screened by hand, and included articles underwent standardised data extraction. Data were corroborated by searching open-source legal proceedings and communicating with the responsible coroner.
There were 89 deaths associated with 75 nightclubs, with a median victim age of 22 years (range 16–54 years) and a rate of 5.9 per annum. Trauma-related injuries 45/89 (51%) and drug-related toxicity 36/89 (40%) were the primary causes. Blunt head injuries 19/45, mostly related to altercations 13/19, and penetrating trauma from knife injuries 17/45 accounted for most trauma deaths. MDMA was named as a cause in almost all drug-related deaths, 34/36 (94%), occurring at a rate of 2.4 per annum. Of the 89 victims, seven were under 18-years-old. Only 25/75 (33%) of the nightclubs with a fatal incident remained open under the same name.
Using open-source media and coroners, this study identified nearly six deaths per year associated with UK nightclubs. Victims are predominantly young adults, with trauma and drug toxicity the leading causes. These findings underscore the need for targeted interventions, including enhanced safety measures and harm reduction strategies, to prevent future tragedies.
An acute scrotum is an urological emergency. One of its most important causes is testicular torsion, which can result in testicular necrosis unless quickly diagnosed and treated. Along with point-of-care ultrasound (POCUS), the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score can be used to differentiate between testicular torsion and other causes of an acute scrotum. However, their diagnostic performance when undertaken by emergency physicians (EPs) and paediatricians in the emergency department (ED), as opposed to urologists/radiologists, is uncertain.
This retrospective observational study investigated patients aged ≤15 years with an acute scrotum who visited a paediatric tertiary care hospital’s ED between March 2018 and August 2022. The diagnostic accuracy of the TWIST score and POCUS when performed by EPs and paediatricians to diagnose testicular torsion was calculated. Each TWIST score served as a cut-off. For practical purposes, a cutoff ≥3 points was used for sensitivity and the negative predictive value (NPV), and a cutoff ≥5 points was used for specificity and the positive predictive value (PPV). The final diagnosis served as the reference standard.
Of 512 patients, 55 (11%) had testicular torsion. The TWIST score had 91% sensitivity (95% CI 80%–97%), 95% specificity (95% CI 93% to 97%), 63% PPV (95% CI 50% to 75%) and 99% NPV (95% CI 97% to 100%). When positivity was defined as either impaired testicular blood flow or the whirlpool sign, the sensitivity, specificity, PPV and NPV were 96% (95% CI 87% to 100%), 95% (95% CI 93% to 97%), 70% (95% CI 58% to 80%) and 100% (95% CI 98% to 100%) respectively.
Although the TWIST score and POCUS had high diagnostic accuracy for paediatric testicular torsion when performed by EPs or paediatricians in the ED, the non-negligible, false-negative rate indicated that the TWIST score should be used for risk stratification rather than as an exclusionary method.
Recent global events have highlighted an increasing risk of chemical, biological, radiological and nuclear (CBRN) incidents, emphasising the urgent need for enhanced preparedness in the health sector worldwide, especially in low-income countries where burden of exposure is high and limited resources pose significant challenges to effective response. This study aims to develop an assessment tool to evaluate hospital preparedness for CBRN incidents in Lebanon, a low-resource country at high risk for CBRN incidents.
A two-round modified Delphi method was conducted on 21 January 2025 at the American University of Beirut Medical Center (AUB-MC) involving 11 subject matter experts with various expertise in the CBRN medical and public health fields. The experts used a weblink to vote on the inclusion of tool items, with a predefined consensus at 70% or higher.
Consensus was established for 88 items with the completion of the Delphi study representing 92% of the total number of items. The items were classified into nine essential categories for CBRN preparedness planning that included: facility information, policies and planning, governance, communication (internal/external), training, safety and security, decontamination, pharmaceutical countermeasures, recovery phase and post event management planning. Access to CBRN experts as part of response team, pharmaceutical inventory, gender-related cultural factors particularly in decontamination protocols and preparedness drills emerged as distinctive features within this assessment tool. Parameters concerning special populations and emergency medical services were excluded from the assessment tool.
A comprehensive expert-developed hospital assessment tool for CBRN preparedness was created to enhance CBRN preparedness in resource-limited settings like Lebanon. The standarised tool facilitates the evaluation of Lebanese hospitals’ readiness. It also guides policymakers and health authorities in developing targeted policies and strategic interventions to strengthen the health sector’s CBRN incidents response capabilities.
Ambulance personnel are routinely exposed to emotionally demanding and high-stress situations, making adequate support initiatives crucial for their mental health. Previous research suggests that ambulance workers’ subjective experience of perceived support is more strongly associated with mental health outcomes than measures of specific types of support. However, the relationship between specific types of received support and the overall perception of receiving support remains unclear. This study investigates how different types of support and the overall amount of support types used are associated with perceived support among ambulance personnel.
In this cross-sectional study of 389 ambulance personnel, regression analyses were applied to examine the associations between six types of received support and perceived support. We adjusted for covariables and support outside work. Additionally, a generalised linear model was used to assess the association between the total number of support types used and perceived support.
This study demonstrates that four specific types of received support (debriefing/defusing, formal peer support, informal managerial support and informal collegial support) were significantly positively associated with perceived support among ambulance personnel (debriefing/defusing: B=2.44, SE=0.77, t=2.80, 95% CI 0.90 to 3.90; formal peer support: B=2.35, SE=1.19, t=1.83, 95% CI 0.02 to 4.67; informal managerial support: B=2.08, SE=0.80, t=2.54, 95% CI 0.48 to 3.59; informal collegial support: B=4.21, SE=1.90, t=2.87, 95% CI 0.47 to 7.83). Additionally, the number of support types used was associated with higher levels of perceived support.
These findings highlight the need for a multifaceted support strategy, focusing on both specific support types as well as availability of several parallel support initiatives, in organisational prevention strategies.
The increased use of CT in emergency departments (ED) has led to a rise in incidental detection of pneumomediastinum (PNM). As this finding can be associated with oesophageal perforation (OP), clinicians face a diagnostic dilemma on whether further invasive investigation (such as endoscopy) is required. This study aimed to identify clinical, biochemical and radiological predictors of OP in patients with PNM, to develop a non-invasive diagnostic approach.
A retrospective analysis of adult patients with CT-confirmed PNM was conducted from January 2016 to December 2022 at a tertiary hospital in Queensland, Australia. Data were collected from electronic medical records on demographics, presenting features, vital signs at presentation and 6–24 hours, laboratory results and specific CT findings. Univariable analyses identified candidate predictors of OP, and multivariable logistic regression was used to determine independent predictors.
Among 336 patients with PNM, 22 (6.5%) had confirmed OP. Dysphagia (p<0.001) and vomiting (p=0.002) on presentation were significant univariable predictors of OP. No asymptomatic patients were found to have OP. None of the measured laboratory markers (including white cell count, C-reactive protein and lactate) were predictive of OP. Key CT findings associated with OP were mediastinal free fluid, pleural effusion and oesophageal wall disruption (all p<0.001). Multivariable analysis identified that the combination of mediastinal free fluid plus oesophageal wall disruption was the strongest predictor of OP with a sensitivity of 86.4% and specificity of 98.4%.
Clinical features such as dysphagia and vomiting, together with specific CT signs (mediastinal fluid, pleural effusion and oesophageal wall disruption), strongly predict OP in patients with PNM. Patients who are asymptomatic and lack these high-risk features are unlikely to have an OP and can probably be managed conservatively without invasive testing. These findings may help clinicians risk-stratify patients with PNM and avoid unnecessary admissions and invasive procedures.
To evaluate the diagnostic accuracy of presepsin and procalcitonin (PCT) for sepsis and septic shock (Sepsis-3) in the emergency department (ED) based on the Sepsis-3 definition, where early diagnosis remains challenging due to the lack of rapid and reliable diagnostic methods.
This multicentre prospective cohort study recruited adults from eight EDs in Thailand between October 2020 and June 2022. Patients with suspected infection or those who met the quick Sequential Organ Failure Assessment criteria were enrolled. Admission blood samples were analysed for presepsin, PCT, lactate and blood culture, with follow-up presepsin and PCT measurements performed on days 3 and 7, and follow-up for 30-day mortality. Sepsis diagnosis was adjudicated with reference to the Sepsis-3 criteria and blood culture result. Diagnostic accuracy metrics, including the area under the receiver operating characteristics curve (AUROCs), sensitivity, specificity and predictive values of presepsin and PCT were evaluated.
Of 668 included participants, 438 (65.6%) were diagnosed with sepsis and 58 (8.7%) with septic shock. Presepsin levels were significantly higher in patients with Sepsis-3 than in patients without sepsis at ED admission and decreased over time. Presepsin exhibited a slightly higher AUROC for predicting sepsis (AUROC 0.63 (95% CI 0.59 to 0.67)) and septic shock (AUROC 0.73 (95% CI 0.66 to 0.80)) compared with PCT (AUROC for sepsis 0.62, 95% CI 0.58 to 0.66 and septic shock 0.72, 95% CI 0.65 to 0.78). Elevated presepsin and PCT levels were associated with increased mortality within 30 days (OR 2.61, 95% CI 1.73 to 3.92 and OR of 1.62, 95% CI 1.09 to 2.42 consequently).
Presepsin showed slightly higher diagnostic accuracy than PCT, but overall diagnostic accuracy was modest. When interpreted together with clinical assessment and routine tests, presepsin may assist early risk stratification and support, rather than replace, clinical judgement in decisions such as resuscitation or antibiotic initiation.
Emergency department (ED) intubations are high-risk procedures with wide variability in training and governance. Although emergency physicians (EPs) in Ireland are trained to intubate, structured airway governance within EDs is not well described. This quality improvement project aimed to develop and evaluate a sustainable airway governance framework in a large Irish ED.
Using the model for improvement, sequential interventions were implemented between May 2024 and October 2025. Interventions evolved across cycles and included appointment of an emergency medicine (EM) airway lead, Emergency Medicine Airway Registry Ireland (EMARI)-linked QR code data capture, standardised checklists and airway equipment, video laryngoscopy with recording, daily intubation drills, competency-based sign-off and structured multidisciplinary teaching with feedback (Airways, Biscuits, Caffeine). Primary outcome measures were first-pass success (FPS) and complication rates.
Across 156 intubations in 154 patients, EPs were primary intubators in 82.7%. Overall mean FPS was 91.7% and complication rate was 12.3%. Performance metrics were maintained within predefined safety targets (>90% FPS, <15% complications) across all four Plan-Do-Study-Act (PDSA) cycles, despite staff turnover and progressive introduction of interventions. Following implementation of daily drills, senior airway supervision and competency sign-off (PDSA cycle 2), FPS remained consistently above target and complication rates remained low through subsequent cycles. EMARI data capture reached 99.4%, and video capture increased over time to 72%.
A structured airway governance programme combining leadership, checklist standardisation, simulation and continuous feedback was associated with maintenance of FPS>90% with low complication rates over successive PDSA cycles. This pragmatic, replicable framework supports establishment of national EM airway governance standards to maintain procedural competency and patient safety and is replicable in international EDs with similar pre-existing airway management practices.
The Physician Response Unit (PRU) in North East London has developed a learning disability pathway offering prehospital oral dissociative sedation. The choice of combination oral ketamine and oral midazolam was informed by existing literature and expert clinician opinion. Traditional approaches involving intravenous or intramuscular routes can result in physical restraint and psychological distress. Alternatively, high strength parenteral preparations of ketamine and midazolam can be added to a small volume of drink and given to the patient by their carers under the supervision of the PRU team.
In the first year of the pathway, 36 patients were referred and 9 patients went on to require prehospital oral dissociative sedations. There were no moderate, severe or sentinel events and only two minor adverse events. All the patients seen on the pathway were able to tolerate investigations or interventions that previously had been impossible to provide.
]]>Nasal high flow (NHF) is increasingly used in the emergency department (ED) worldwide.
This was an online service-level survey of all UK type-1 EDs serving adults (≥16 years old) between April and May 2025. The survey prototype underwent review from experts in NHF and survey methodology. It was piloted by nine ED clinicians from across the UK. The final 29-question survey...]]>
In the original study, THERM performed significantly better than the National Early Warning Score (NEWS), developed in the UK in 2012.
A 2-month-old male infant presented to the emergency department with right ankle swelling one day following a fall. The injury involved the grandmother slipping while holding the infant, resulting in the ankle being trapped under her body weight. On clinical examination, the infant was afebrile and there was no systemic upset. The right ankle was swollen and bruised; no mass was felt. Spontaneous toe movement was observed, and capillary refill time was <2 s. No other associated injuries or signs of previous trauma were identified. The carers (his parents and grandparents) did not have any record of child abuse and they showed great care of the infant during the interview. There were no safeguarding concerns after assessment of the infant and the family. X-rays of bilateral ankles and feet were taken (
Acute haematogenous osteomyelitis
This was a stark contrast to the initial triage: a stable patient with a low National Early Warning Score (a system for scoring routine physiological observations at the bedside to identify acute illness). The diagnosis was delirium, likely secondary to a urinary tract infection. But I cannot help wondering if it was also (at least in part) because of us.
On paper, he had been triaged appropriately. But in a crowded, overstimulating ED with little natural light, long waits and constant noise, even short delays can lead to steep declines. For frail, older patients who are medically vulnerable, every hour in...]]>
The papers are ranked as:
Worth a peek—interesting, but not yet ready for prime time. Head turner—new concepts. Game changer—this paper could/should change practice.
Topic: sepsis
Outcome rating: head turner
Mortality in septic shock remains high, yet for clinicians and families a clear analysis of factors that might identify patients at risk of high mortality is lacking. Factors associated with early mortality (in-hospital or within 31 days) in adults...]]>