emergency department

Frontal lobe epilepsy- why it matters in the emergency department

Original Articles, Volume 24, Issue 2, Pages 61 – 108 (2025)

Frontal lobe epilepsy is an episodic neurological disorder characterised by recurrent seizures arising from one or both frontal lobes. Seizures may appear atypical and are easily misdiagnosed in the emergency department as nonepileptic attacks (psychological episodes) or parasomnias (sleep disorders). Given the multiple connections and functions of the frontal lobes, Frontal lobe epilepsy presentations are highly variable, including motor, psychic, behavioral or cognitive changes, with a wide differential diagnosis. Prompt diagnosis in the busy emergency department may be difficult, because of complex, often multiple but brief episodes, and sometimes bizarre manifestations; frequent nocturnal presentation, and a wide range of aetiologies. This narrative review summarises clinical and investigation features that help clinicians to reach an accurate and prompt diagnosis.

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A National Survey of Geriatric Emergency Health Care: Insights into Current Practice

Original Articles, Volume 24, Issue 2, Pages 61 – 108 (2025)

Background: Emergency departments (EDs) are increasingly managing elderly patients who present unique clinical challenges. This study explores the current management practices for patients aged 75 years and older in Belgian EDs.
Methods: An electronic survey was sent to 105 heads of Belgian EDs. The Collected data underwent descriptive analysis.
Results: Geriatric protocols, adapted equipment, availability of geriatricians, and paramedical staff improve the quality of care for older patients in the EDs. However, the limited use of geriatric scores, prolonged stays in the ED, and lack of hospital beds are frequent problems that negatively impact quality of care.
Conclusion: Given the variable level of care provided to the elderly in the EDs, care protocols should be standardized and improved at the national scale.

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Emergency Department Treatment of Elevated Blood Pressure in the Headache Patient

Original Articles, Volume 23, Issue 2, Pages 53 – 96 (2024)

Headache accounts for 1 – 3% of emergency department (ED) visits globally and is associated with elevated blood pressure (BP). It is unclear if anti-hypertensive therapy provides benefits. This retrospective study assessed effects of anti-hypertensive therapy in ED headache patients on rescue analgesic need, hospital admissions, and length of stay (LOS). 1385 patients were included. 366 received anti-hypertensive therapy. The anti-hypertensive therapy cohort was older (p < 0.001) with increased odds of admission (p < 0.001) and 2.385 hrs longer ED LOS (p < 0.001). No difference in rescue analgesia was found (p < 0.429). Anti-hypertensive therapy in hypertensive ED headache patients is associated with increased hospital admission and ED LOS, but no difference in rescue analgesia utilization.

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A prospective, observational study of the performance of MEWS, NEWS, SIRS and qSOFA for early risk stratification for adverse outcomes in patients with suspected infections at the emergency department

Original Articles, Volume 20, Issue 2, Pages 89-156 (2021)

Background: Many patients with suspected infection are presented to the emergency Department. Several scoring systems have been proposed to identify patients at high risk of adverse outcomes.

Methods: We compared generic early warning scores (MEWS and NEWS) to the (SIRS) criteria and quick Sequential Organ Failure Assessement (qSOFA), for early risk stratification in 1400 patients with suspected infection in the ED. The primary study end point was 30-day mortality.

Results: The AUROC of the NEWS score for predicting 30-day mortality was 0.740 (95% Confidence Interval 0.682-0.798), higher than qSOFA (AUROC of 0.689, 95% CI 0.615- 0.763), MEWS (AUROC 0.643 (95% CI 0.583-0.702) and SIRS (AUROC 0.586, 95%CI 0.521 - 0.651). The sensitivity was also highest for NEWS≥ 5 (sensitivity 75,8% specificity of 67,4%).

Conclusion: Among patients presenting to the ED with suspected infection, early risk stratification with NEWS (cut-off of ≥5) is more sensitive for prediction of mortality than qSOFA, MEWS or SIRS, with adequate specificity.

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A prospective, observational study of the performance of MEWS, NEWS, SIRS and qSOFA for early risk stratification for adverse outcomes in patients with suspected infections at the emergency department Read More

Predicting poor outcome in patients with suspected COVID-19 presenting to the Emergency Department (COVERED) – Development, internal and external validation of a prediction model

Original Articles, Volume 20, Issue 1, Pages 1-88 (2021)

Background: A recent systematic review recommends against the use of any of the current COVID-19 prediction models in clinical practice. To enable clinicians to appropriately profile and treat suspected COVID-19 patients at the emergency department (ED), externally validated models that predict poor outcome are desperately needed.

Objective: Our aims were to identify predictors of poor outcome, defined as mortality or ICU admission within 30 days, in patients presenting to the ED with a clinical suspicion of COVID-19, and to develop and externally validate a prediction model for poor outcome.

Methods: In this prospective, multi-centre study, we enrolled suspected COVID-19 patients presenting at the EDs of two hospitals in the Netherlands. We used backward logistic regression to develop a prediction model. We used the area under the curve (AUC), Brier score and pseudo-R2 to assess model performance. The model was externally validated in an Italian cohort.

Results: We included 1193 patients between March 12 and May 27 2020, of whom 196 (16.4%) had a poor outcome. We identified 10 predictors of poor outcome: current malignancy (OR 2.774; 95%CI 1.682-4.576), systolic blood pressure (OR 0.981; 95%CI 0.964-0.998), heart rate (OR 1.001; 95%CI 0.97-1.028), respiratory rate (OR 1.078; 95%CI 1.046-1.111), oxygen saturation (OR 0.899; 95%CI 0.850-0.952), body temperature (OR 0.505; 95%CI 0.359-0.710), serum urea (OR 1.404; 95%CI 1.198-1.645), C-reactive protein (OR 1.013; 95%CI 1.001-1.024), lactate dehydrogenase (OR 1.007; 95%CI 1.002-1.013) and SARS-CoV-2 PCR result (OR 2.456; 95%CI 1.526-3.953). The AUC was 0.86 (95%CI 0.83-0.89), with a Brier score of 0.32 and, and R2 of 0.41. The AUC in the external validation in 500 patients was 0.70 (95%CI 0.65-0.75).

Conclusion: The COVERED risk score showed excellent discriminatory ability, also in external validation. It may aid clinical decision making, and improve triage at the ED in health care environments with high patient throughputs.

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Limited Prognostic Utility of a Simplified Vital Sign Based Risk Calculator in Acute Medical Admissions

Original Articles, Volume 19, Issue 3, Pages 113 – 172 (2020)

Background: Accurate efficient prognostication in acute medical admissions remains challenging.Methods: We constructed a Vital Sign based Risk Calculator using vital parameters and Major Disease Categories to predict 30-day in-hospital mortality using a multivariable fractional polynomial model.

Results: We evaluated 113,807 admissions in 58,126 patients. The Vital Sign based Risk Calculator predicted 30-day inhospital mortality to increase from 2 points - 3.6% (95%CI 3.4, 3.7) to 12 points - 14.8% (95%CI 14.0, 15.7). AUROC was 0.74 (95%CI 0.72, 0.74). The addition of illness severity and comorbidity data improved AUROC to 0.90 (95%CI 0.89, 0.90).

Conclusion: The Vital Sign based Risk Calculator is limited by its simplicity; inclusion of illness severity and comorbidity data improve prediction.

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The utility of peripheral venous lactate in emergency department patients with normal and higher lactate levels: A prospective observational study

Original Articles, Volume 19, Issue 3, Pages 113 – 172 (2020)

Objective: to assess the utility of peripheral venous lactate (PVL) in Emergency Department patients.

Methods: arteriovenous agreement was assessed in three subgroups: PVL <2 mmol/l, PVL ≥ 2 mmol/l to < 4 mmol/l and PVL ≥ 4 mmol/l. The predictive value of PVL to predict arterial lactate (AL) ≥2 mmol/l was assessed at different cut-off values. Results: 74 samples were analysed. The venous-arterial mean difference and 95% limits of agreement for the subgroups were 0.25 mmol/l (-0.18 to 0.68), 0.37 mmol/l (-0.57 to 1.32) and -0.89 mmol/l (-3.75 to 1.97). PVL ≥2 mmol/l predicts AL ≥2 mmol/l with 100% sensitivity. Conclusion: PVL <2 mmol/l rules out arterial hyperlactatemia. As agreement declines in higher levels, arterial sampling should be considered.

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Higher In-Hospital Mortality in Patients with Nonspecific Complaints Presenting to the Emergency Department

Original Articles, Volume 18, Issue 4, Pages 205 – 264 (2019)

Background: Nonspecific complaints (NSC) at the Emergency Department (ED) are not well researched yet.

Objective: To investigate the number of patients who could be classified as having NSC early after arrival in the ED using an algorithm.

Method: Retrospective cohort study was conducted among all hemodynamically stable non-trauma adult patients with MTS category orange/yellow visiting the ED. Patients who had no specific complaints/signs, predefined on a list, were categorized as NSC.

Results: In total, 2419 patients, of whom 102 (4.2%) presented with NSC. Hospitalization was more prevalent (85.3% vs. 69.0%, p<0.001) and in-hospital mortality was higher in the NSC-group (11.8% vs. 3.5%, adjusted OR 2.0, 95% CI 1.0-3.9, p=0.04). Conclusion: Using an algorithm it is possible to identify NSC patients who have (worse) outcomes than those classified as SC.

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The prognostic implication of the SOFA score on acutely admitted medical patients

Original Articles, Volume 17, Issue 4, Pages 173 – 240 (2018)

Objectives: To investigate the prognostic implication of the SOFA score on all acutely admitted medical patients, to see how well it could predict 30-day mortality and ICU- admission.

Main outcome measures: Discriminatory power was calculated as AUROC. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit.

Results: AUROC for 30-day mortality was 0.68, (95% CI, 0.64 to 0.71) and ICU admission 0.71, (95% CI, 0.66 to 0.76). Goodness of fit for 30-day mortality and ICU admission was acceptable.

Conclusions: The SOFA score showed average ability to predict 30-day mortality and ICU admission with acceptable calibration. When substituting GCS with AVPU the performance of the SOFA score was unacceptable.

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Unscheduled return visits by patients to a german emergency department are a high risk group for initial wrong diagnosis

Original Articles, Volume 17, Issue 4, Pages 173 – 240 (2018)

The aim was to classify patients who returned unscheduled to an emergency department within 7 days. We categorized the patients’ cases arbitrarily according to the underlying cause of the return. The main causes for returning unscheduled were: “patient related” (24,2%), “illness related” (35,4%), “physician related” (18,3%), “system related” (3,8%) and “other” (21,7%). We also analyzed missed diagnoses, as the literature describes this special patient population as a high risk group. 15,4% of all return cases had a wrong diagnosis. No typical risk constellation/symptom could be found. Vital signs or blood values were within normal limits as well.

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