Clinical and Experimental Emergency Medicine最新文献

Objective: Etomidate and ketamine are hemodynamically stable induction agents for rapid sequence intubation (RSI) of critically ill patients. Despite their relative stability in terms of hemodynamics, how the choice of agent affects mortality and the success of the procedure is debatable and has not yet been explored via systematic review and meta-analysis. The objective of this systematic review is to compare the efficacy of ketamine and etomidate for RSI in terms of mortality, hemodynamic parameters, and success rate.

Methods: A comprehensive search of PubMed, Embase, and the Web of Science was conducted from the starting date of each database until April 2024. Randomized controlled trials comparing the safety and efficacy of ketamine and etomidate as induction drugs for critically ill patients undergoing RSI were included. The primary outcome was the risk of 28-day mortality, and the secondary outcomes included the success rate and postinduction hypotension. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects meta-analysis.

Results: Four studies with 1,663 patients were meta-analyzed, and no statistically significant difference between the two drugs was found for 28-day mortality (RR, 0.95; 95% CI, 0.72-1.25; heterogeneity I2=39%; level of certainty of evidence per GRADE, moderate), first-pass success rate (RR, 1.00; 95% CI, 0.97-1.03), or postinduction cardiac arrest (RR, 1.10; 95% CI, 0.62-1.96). Postinduction hypotension was higher in the ketamine group (RR, 1.30; 95% CI, 1.03-1.64), but the result was not statistically significant.

Conclusion: Mortality outcomes did not differ when ketamine or etomidate was used for RSI in critically ill patients. Ketamine, however, was associated with a non-significantly higher risk of postinduction hypotension.

Objective: We aimed to determine whether there are similar rates of regional wall motion abnormalities (RWMAs) in patients with acute coronary occlusion myocardial infarction (OMI) with and without ST-elevation myocardial infarction (STEMI) on electrocardiogram (ECG).

Methods: We performed a retrospective review of a database of patients at high risk for acute coronary syndrome with previously established outcomes for the presence of OMI in order to compare rates of RWMA in patients presenting with STEMI(+) OMI versus STEMI(-) OMI. Furthermore, we compared how often the RWMA aligned with the anatomical territory observed on ECG.

Results: Among 808 patients, 551 underwent formal echocardiography, including 256 of 265 OMI patients and 295 of 543 patients with no occlusion. Of the 256 OMI patients that underwent formal echocardiography, only 105 (41.0%) met STEMI criteria. Among them, 94 of 105 (89.5%) STEMI(+) OMI patients had RWMAs compared to 124 of 151 (82.1%) STEMI(-) OMI patients (P=0.10; 95 confidence interval, -1.63% to 15.6%). Both groups had a greater prevalence of RWMA than the non-OMI group (45%). RWMA matched the anatomic territory predicted by ECG in 92.5% of STEMI(+) OMI, 82.3% of STEMI(-) OMI, and 2.9% of the no-occlusion cohort.

Conclusion: Location of RWMAs was well-correlated with ECG findings regardless of the presence or absence of STEMI criteria. A prospective study is warranted to determine the utility of echocardiography in the detection of STEMI(-) OMI.

Objective: Workplace-based assessment (WBA) plays a crucial role in assessing entrustable professional activities (EPAs) in the competency-based medical education era. This pilot study explored the perceptions of residents and assessors of two WBAs for three Korean Society of Emergency Medicine EPAs.

Methods: Eight emergency medicine (EM) residents underwent WBAs, with mini-clinical evaluation exercises (mini-CEX) conducted by nine EM faculty members and multisource feedback (MSF) provided by two internal medicine faculty members and four emergency room nurses, for a total of 69 assessments. We conducted an anonymous online survey to gather feedback on experiences, perceptions, and recommendations for improving WBA, such as mini-CEX and MSF, with responses scored on a 5-point Likert scale.

Results: Of the 23 initial participants, 15 (65.2%) responded, including 5 residents and 10 assessors. EM faculty viewed mini-CEX favorably, noting its strong integration of supervision and effectiveness in assessing resident performance. EM residents reported comfort issues during assessments, preferring immediate feedback and multiple assessors. MSF was generally perceived positively but showed discrepancies in the utilities of rating scales and feedback types, indicating potential areas for improvement.

Conclusion: Two WBAs for three Korean Society of Emergency Medicine EPAs were found to be feasible and acceptable in the context of Korean EM residency training. However, perceptions varied between assessors and residents, necessitating clear communication about WBA objectives and processes. Our findings are useful for shaping future EPA-based training programs, balancing traditional and WBA methods, and enhancing feedback quality.

Point-of-care ultrasound (POCUS) is a valuable tool in the prehospital management of critically ill patients, particularly patients with trauma, dyspnea, or shock. This review aims to evaluate the diagnostic and therapeutic applications, limitations, and implementation challenges of POCUS in prehospital care. Key findings are that ultrasound, particularly the extended Focused Assessment with Sonography in Trauma (eFAST) protocol, offers high specificity in identifying severe hemorrhage in trauma cases, although its sensitivity varies depending on the clinical context and operator experience. In dyspnea, pulmonary ultrasound significantly enhances diagnostic accuracy, aiding early detection of heart failure and other respiratory conditions. For shock, focused echocardiography facilitates rapid diagnosis and timely therapeutic decisions, improving patient outcomes. However, the effectiveness of POCUS is highly dependent on the operator's expertise, and challenges such as time, space, and resource limitations in prehospital settings may impact its use. Furthermore, local studies in Latin America assessing the impact of prehospital ultrasound on morbidity and mortality reduction are lacking. Based on our review, we recommend standardized training programs, increased availability of portable ultrasound devices, and prospective studies on cost-benefit analysis to optimize POCUS implementation in prehospital systems, particularly in resource-limited regions. Prehospital ultrasound has the potential to revolutionize patient care by improving diagnostic precision and reducing time to definitive treatment, but its successful implementation requires strategic integration of technology, education, and research.

Objective: Oral anticoagulant (OAC) use increases the risk of death in conditions like hemorrhagic stroke, trauma, and traumatic brain injury. Early identification of OAC use is critical for timely interventions to mitigate hemorrhage risk and improve survival. We aimed to identify emergency medical services (EMS) care characteristics associated with patients using an OAC.

Methods: We analyzed prehospital data (2018-2020) from the ESO Data Collaborative, focusing on adult (≥18 years) 911 EMS calls. The administered OACs were warfarin, dabigatran, rivaroxaban, and apixaban. We compared EMS call characteristics, patient demographics, response times, and interventions between OAC and non-OAC users. We used univariate logistic regression to identify independent predictors of OAC use.

Results: Of 16,244,550 adult 911 EMS events, 906,575 involved OAC users (56 of 1,000 calls). Those using OAC were older (73.6 years vs. 56.9 years) and more often from nursing homes or long-term care facilities (17.0% vs. 9.2%) but less likely to have trauma (14.7% vs. 18.1%) or cardiac arrest (1.2% vs. 1.4%). The most common EMS primary clinical impressions for OAC users were chest pain (7.4%), altered mental status (7.3%), injury (6.5%), abdominal pain (4.3%), and brain injury (2.8%).

Conclusion: OAC users accounted for 1 in 18 adult EMS encounters. Specific patient and call characteristics were associated with OAC use. These findings should be incorporated into EMS training to facilitate recognition and appropriate management of OAC-related emergencies.

Objective: This study aims to systematically review the ethical and legal discussions regarding the utilization of artificial intelligence (AI) for patient triage and resource allocation in emergency medicine, and to identify the current state of discussions, their limitations, and future research directions.

Methods: A comprehensive literature search was conducted following scoping review methodology. Relevant literature published after January 2020 was searched in the Web of Science, Scopus, CINAHL, PubMed, and Cochrane Library databases. Based on a PCC (population, concept, and context) framework (emergency patients/medical staff; triage, resource allocation; and emergency medicine with AI application), a final selection of 27 articles was analyzed.

Results: The selected literature raised various ethical and legal issues related to the introduction of AI triage systems and AI utilization in emergency medicine, including data privacy, algorithmic bias, automation dependency, accountability, and explainability. In response to these issues, human-centered design, implementation of explainable AI, establishment of regulatory frameworks, continuous verification and evaluation, and ensuring human-in-the-loop were discussed as major solutions. However, discussions on the risks of "persuasive AI" that could mislead users, ethical issues of generative AI, and social validation and patient and public involvement were found to be insufficient.

Conclusion: Ethical and legal discussions regarding AI in emergency medicine are evolving toward seeking concrete solutions at technical, institutional, and relational dimensions. However, in-depth research on ethical challenges, such as reflecting the specificity of rapidly developing AI and the values of emergency medicine, is urgently required.