Clinical and Experimental Emergency Medicine最新文献

Objective: We aimed to compare the 72-hour survival of the endotracheal intubation (ETI) with video laryngoscope (VL), ETI with direct laryngoscope (DL), and supraglottic airway (SGA) in out-of-hospital cardiac arrest (OHCA) patients in Korea.

Methods: This study included adult OHCA patients who received advanced airway management by designated response teams for severe disease, using a nationwide OHCA registry in South Korea from July 2019 to December 2021. The primary outcome was 72-hour survival, and secondary outcomes were survival to hospital discharge and good neurological recovery. Multivariable logistic regression was used, adjusted for confounders, to compare the outcomes among the three airway management methods.

Results: Among 77,629 OHCA cases, 10,857 were included. SGA was attempted in 9,379 cases, ETI with DL in 493 cases, and ETI with VL in 985 cases. The rates of any prehospital ROSC and 72-hour survival were 13.3% and 11.0% for SGA, 16.0% and 11.4% for ETI with DL, and 18.2% and 11.9% for ETI with VL. Compared to SGA, ETI with VL was significantly associated with 72-hour survival: adjusted odds ratio (OR) [95% confidence interval (CI)] 1.34 (1.06-1.70) for ETI with VL and 1.13 (0.81-1.56) for ETI with DL). There was no significant association between the type of AAM and survival to discharge or good neurological recovery.

Conclusion: In an emergency medical service system staffed by advanced emergency medical technician-level providers, ETI with VL might be associated with improved 72-hour survival compared to SGA. However, this short-term benefit did not extend to survival to hospital discharge.

Objective: Sepsis, a life-threatening organ dysfunction, remains a major global health concern. Early detection remains challenging due to nonspecific symptoms. Non-invasive tools such as the Shock Index (SI), Diastolic Shock Index (DSI), Capillary Refill Time (CRT), and Mottling Score (MS) may help assess hemodynamic status and predict mortality, but a comprehensive comparison of their prognostic value is lacking. This study compares the performance of these tools in predicting mortality at 24 hours, 7 days, and 28 days in septic patients.

Methods: A monocentric, prospective observational study was conducted from January to September 2024. Adult patients (≥18 years) with suspected infection and a National Early Warning Score-2 ≥5 were enrolled. Demographic data, vital signs, CRT, MS, and mortality outcomes were recorded at 24 hours, 7 days, and 28 days.

Results: A total of 135 patients were included (median age 85 years, IQR 79-90; 44.4% female). Mortality rates were 15.6% at 24 hours, 25.2% at 7 days, and 35.6% at 28 days. CRT showed the highest predictive value for 24-hour mortality (AUC: 0.829, p<0.01), while MS had the best performance at 7 days (AUC: 0.732, p<0.01) and 28 days (AUC: 0.749, p<0.01). No significant differences emerged in pairwise comparisons.

Conclusion: While no tool was found to significantly outperform others, CRT and MS provide valuable, non-invasive mortality prediction in sepsis. Indeed, CRT is most effective for early risk stratification, while MS correlates with mid- and long-term outcomes, supporting their integration into clinical assessment.

Objective: To develop and validate MEDIVAL, a progressive Chain-of-Thought (CoT) evaluation framework for automated assessment of large language model (LLM)-generated emergency department documentation that aligns with expert clinical judgment in acute care settings.

Methods: We developed a three-tier evaluation framework using Persona-based, Error-enhanced, and Insight-integrated strategies. The framework was tested across four LLMs (GPT-4o, GPT-4.1, Claude- 3.5, Claude-3.7) on 33 emergency department records evaluated by four expert emergency physicians. Each model assessed documents using three progressive CoT strategies across five criteria: Appropriateness, Accuracy, Structure/Format, Conciseness, and Clinical Validity. Evaluations were compared using Spearman's correlation, with differences assessed via Friedman test and Wilcoxon signed-rank test with Bonferroni correction. Reproducibility was evaluated using intraclass correlation coefficient (ICC) analysis.

Results: All models showed improved expert alignment as CoT complexity increased, with Claude-3.7 (r=0.712, P<0.001) and GPT-4o (r=0.702, P<0.001) achieving strongest correlations using Insightintegrated strategy. GPT-4.1 demonstrated largest relative improvement (43.3% increase from r=0.457 to r=0.655, P<0.001). Significant differences were found across strategies (χ²(2)=48.39, P<0.001), although Error-enhanced and Insight-integrated approaches showed a small but statistically significant difference (P=0.002). High reproducibility was confirmed (ICC > 0.919), with Claude-3.5 showing highest consistency (0.997-0.998).

Conclusions: MEDIVAL demonstrates that progressive CoT strategies systematically enhance automated evaluation of emergency department documentation while maintaining high reproducibility. This offers a viable pre-screening tool for reducing expert workload while supporting reliable AI integration into emergency medicine workflows.

Objective: Emergency physicians have become hesitant to treat patients with opioids because of downstream sequelae related to opioid use disorder. We enrolled a prospective cohort to determine whether a patient's experience receiving an IV opioid was associated with multiple opioid prescriptions. Specifically, we tested whether greater improvement in pain and a larger euphoric response could predict which previously opioid-naïve patients exposed to IV opioids would fill > 2 opioid prescriptions in the subsequent six-month period.

Methods: We determined 0-10 pain scores before and 15 minutes after opioid-naïve ED patients were administered IV opioids for treatment of severe pain. We also determined opioid-induced euphoria using 0-10 scales querying how good, how high, and how much euphoria the opioid caused and how likely the participant was to want the opioid again. Six-month outcomes were ascertained using the state prescription monitoring database.

Results: Among 506 patients, 32 (6.3%) filled two or more prescriptions during the six months following the ED visit. There were no differences between those who filled >2 prescriptions and those who did not with regard to pain relief (p= 0.54), how good the medication made participants feel (p=0.91), how high the medication made participants feel (p=0.97), how much euphoria the opioid caused (p=0.23), or how likely the participant was to want the medication again (p=0.37).

Conclusion: Filling >2 opioid prescriptions was uncommon after initial exposure to therapeutic IV opioids and was unrelated to either analgesic efficacy or opioid-induced euphoria.

Background: Abdominal pain is the most common emergency department (ED) chief complaint, with many patients experiencing recurrent episodes due to non-life-threatening etiologies such as Disorders of Gut-Brain Interaction (DGBI). This pilot study aimed to characterize patients with recurrent low-risk abdominal pain, focusing on pain severity, management, biopsychosocial factors, opioid use, and 30- day return visits.

Methods: This prospective observational pilot study enrolled adult ED patients with recurrent abdominal pain at a single academic center between July 2022 and June 2023. Inclusion required at least one similar episode in the prior year with symptom resolution between episodes. Exclusions included unstable clinical status or high-risk conditions. Patient-reported outcomes, social determinants of health, and clinical data were collected. Primary outcomes included pain severity, opioid use, and 30-day return visit rates.

Results: A total of 101 participants were enrolled (mean age 43.7 years; 65.3% female; 70.8% Black). Pain severity was high (mean triage pain score 7.1, SD = 2.6). Frequent prior CT imaging was noted in 56.4% of participants. Opioids were administered in 49.5% of cases, while PROMIS-29 scores highlighted risks of anxiety (mean T-score 56.0, SD = 11.1) and pain interference (T-score 60.8, SD = 8.2). Return visits occurred in 10.9% of participants within 30 days.

Conclusion: In this pilot study, patients with recurrent low-risk abdominal pain showed high symptom burden and healthcare utilization. Targeted interventions addressing biopsychosocial factors and improving pain management are needed to reduce ED revisits and improve outcomes.

Objectives: Foreign body airway obstruction (FBAO) is one of the leading causes of accidental death worldwide. Among the most common causes of FBAO is food. The aim of this study is to provide an overview of the most common foreign bodies in the airway that were removed with an anti-choking suction device.

Methods: In this retrospective cohort study, we analysed a database obtained from LifeVac LLC, which has been collecting data on the use of the LifeVac device since 2016.

Results: We analyzed data from 1,062 patients who experienced FBAO and had the obstruction removed using a LifeVac device. These cases spanned 16 countries, with the majority from the USA (80.3%; 853/1,062), where infants were the most represented age group (26.7%; 283/1,062). The most common foreign body was meat (16.8%; 178/1,062). Most victims had no documented medical conditions (70.2%; 746/1,062). LifeVac device was successful on the first attempt in approximately one-third of cases (36.0%; 382/1,062), and fewer than half of the victims (34.7%; 368/1,062) sought medical attention afterward. The highest success rate for first-attempt removal occurred in the supine position (40.0%; 247/612).

Conclusion: FBAO can occur at any age, but is more common in children, the elderly and people with various health conditions. Some foreign bodies, such as steak, chicken, grapes, candy and hot dog, are thought to be more likely to enter the airway than others. These common foreign bodies and individuals with risk factors require special attention to ensure that such accidents are detected and prevented in time.

Objective: Despite disparities in availability and quality of emergency care, the extent to which countries with different incomes participate in emergency medicine (EM) research remains understudied. This study evaluated academic productivity in the EM field depending on country income.

Methods: Research published in Scopus-indexed journals of the EM subject area since 2004 was analysed quantitatively. Publication, citation, journal impact, and national socioeconomic data were compared. Automated topic modelling was applied using a latent Dirichlet allocation model.

Results: The analysis included 154,458 publications (89.7% in English) from 177 countries, which received 1,817,635 citations. High-income countries (HIC) outperformed upper-middle-income (UMIC), lower-middle-income (LMIC), and low-income countries (LIC) 11, 41, and 72 fold, respectively, by the weighted (per million population per country) number of publications, and 21, 54, and 171 fold, respectively, by the weighted count of citations. The annual number of publications was predicted to considerably rise for HIC, in less extent for UMIC, and far less for LMIC, but not for LIC. Research productivity showed a significant relationship with national socioeconomic indicators. Based on the topic modelling, HIC paid relatively higher attention to advancements in resuscitation, whereas lower income countries were more focused on injuries.

Conclusion: While global research productivity for EM is progressively rising, lower income countries lag far behind high-income ones. Countries with different incomes have distinct priorities in EM research. The development of country-specific EM research agendas would help boost national academic productivity and determine context-appropriate interventions for improving outcomes in emergency care.

Objective: s Abdominal pain is the most common emergency department (ED) complaint, with many patients experiencing recurrent episodes due to Cannabinoid Hyperemesis Syndrome (CHS), a syndrome characterized by pain and vomiting in the setting of chronic cannabis use. This pilot aimed to demonstrate the ability to enroll patients with CHS, characterize patient-reported outcomes (PRO's), and estimate 30-day revisit rates.

Methods: This prospective observational study enrolled adult ED patients with CHS at an academic center and community affiliate. The inclusion required a prior diagnosis of CHS and ED clinician judgment that symptoms at time of enrollment were likely due to CHS. Exclusions included unstable clinical status or other high-risk conditions. Primary outcomes included a characterization of symptoms, assessment of multiple domains of PRO's, measurement of the use of both CT scans and opioid analgesia, and frequency of 30-day ED return visits.

Results: A total of 18 participants were enrolled (mean age 34 years; 55.6% female). Automated chart reviews were completed for each outcome of interest at 30 days and 12 months. Pain severity was high (mean triage pain score 6.4, SD = 4.3) and prior CT imaging was noted in 72.2% of participants in the past five years. Opioids were administered in 22.2% of cases, while PROMIS-29 scores highlighted high risks of anxiety (mean T-score 56.1, SD = 11.5) and how pain interfered with normal activities of living (T-score 62.2, SD = 11.1). Return visits occurred in 16.7% of participants (3/18) within 30 days.

Conclusion: ED patients with CHS show significant burden on PRO's and high 30-day revisits. Future studies should consider interventions that address PRO's and reduce ED revisits.

Objective: To explore the distinctions between different types of traumatic facial fractures in predicting intracranial lesions using data from the National Trauma Registry of Iran (NTRI).

Methods: This retrospective registry-based study analyzed six years of data from four NTRI trauma centers, focusing on patients with facial fractures. Patients with at least one facial fracture were included, with data on demographics, injury mechanisms, fracture patterns, and intracranial lesions. The multiple logistic regression model explored the association between clinical variables and intracranial lesions.

Results: Among 32,525 patients, 1,166 (3.6%) had facial fractures. Motorcycle riders had a higher probability of malar-maxillary fractures than mandibular fractures (p < 0.001). Non-RTA injuries were significantly associated with mandibular fractures compared to malar-maxillary fractures (p < 0.001). Intracranial lesions were identified in 14.8% of patients, with subarachnoid hemorrhage (SAH) (38.4%), subdural hemorrhage (SDH) (19.8%), and epidural hemorrhage (EDH) (18.6%) being the most common. Most intracranial lesions developed in patients with malar-maxillary fractures (N = 82 (47.7%)). Also, patients with malar-maxillary fractures had the highest chance of developing intracranial lesions among different types of facial fractures (OR = 15.33, 95% CI: 6.57 to 35.79, p < 0.001), remained significant after adjustment (adjusted OR (aOR) = 7.20, 95% CI: 2.97 to 17.42, p < 0.001).

Conclusion: Traumatic facial fractures, particularly malar-maxillary fractures, significantly increase the risk of intracranial lesions. Road traffic accidents (RTA) are major contributors to such injuries. Prompt management, especially for malar-maxillary fractures, is critical for reducing risks and improving outcomes, necessitating further research on treatment strategies.

Objective: Children are particularly vulnerable to heat-related illnesses due to their unique physiological and behavioral characteristics. Understanding the epidemiology and clinical features of heat-related illnesses in children is crucial for guiding targeted preventive measures and management strategies. This descriptive study aims to investigate the characteristics of pediatric patients with heat-related illness who were transferred to emergency departments in Japan.

Methods: This study was a secondary analysis of the Heatstroke Study, led by the Heatstroke and Hypothermia Surveillance Committee of the Japanese Association for Acute Medicine. This study included pediatric patients (<18 years) with heat-related illness transferred to emergency departments in the summer from 2017 to 2021. We summarized the circumstances of onset, clinical characteristics, and outcomes.

Results: Of the 3,154 registered patients, 146 children were included. Of them, 60% were male, with a median age of 15 years (interquartile range, 13-16 years). The most cases occurred in August (47%), and most (80%) were associated with sports activities and with outdoor settings (70%). Cases with a body temperature above 40 °C were rare (3%). Most cases were admitted to hospitals (75% to the general ward and 16% to the intensive care unit), and patients admitted to intensive care unit had altered consciousness with increased serum creatinine. There were two cases of mortality, both of which were out-of-hospital cardiac arrest.

Conclusion: Most pediatric cases with heat-related illness were middle or high school students, occurred in August, and were related to outdoor sports activity. Patients admitted to hospitals suffered altered consciousness, dehydration, and acute kidney injury.