Clinical and Experimental Emergency Medicine最新文献

Objective: We previously developed and validated an artificial intelligence-based electrocardiogram (ECG) analysis tool (ECG Buddy) in a Korean population. This study investigated the performance of this tool in a US population, specifically assessing the left ventricular (LV) dysfunction score and LV ejection fraction (LVEF)-ECG feature for predicting LVEF <40%. The study used N-terminal pro-B-type natriuretic peptide (NT-ProBNP) as a comparator.

Methods: We identified emergency department (ED) visits from the MIMIC-IV dataset with information on LVEF <40% or ≥40% and matched 12-lead ECG data recorded within 48 hours of the ED visit. The performance of ECG Buddy's LV dysfunction score and the LVEF-ECG feature was compared with those of NT-ProBNP using area under the receiver operating characteristic curve (AUC) analysis.

Results: A total of 22,599 ED visits was analyzed. The LV dysfunction score had an AUC of 0.905 (95% confidence interval [CI], 0.899-0.910), with a sensitivity of 85.4% and specificity of 80.8%. The LVEF-ECG feature had an AUC of 0.908 (95% CI, 0.902-0.913), sensitivity of 83.5%, and specificity of 83.0%. NT-ProBNP had an AUC of 0.740 (95% CI, 0.727-0.752), with a sensitivity of 74.8% and specificity of 62.0%. The ECG-based predictors demonstrated superior diagnostic performance compared to NT-ProBNP (all P<0.001). In the sinus rhythm subgroup, the LV dysfunction score achieved an AUC of 0.913 and LVEF-ECG had an AUC of 0.917, both outperforming NT-ProBNP (AUC, 0.748; 95% CI, 0.732-0.763; all P<0.001).

Conclusion: ECG Buddy demonstrated superior accuracy compared with NT-ProBNP in predicting LV systolic dysfunction, validating its utility in a US ED population.

Objective: Deep vein thrombosis (DVT) is a significant cause of morbidity and mortality worldwide, accounting for substantial healthcare utilization. However, management strategies have evolved, and current data on the incidence, admission rates, and medical management of DVT in the emergency department (ED) setting are needed.

Methods: This cross-sectional study analyzed ED presentations for DVT from 2016 to 2023 using the Cosmos database. Inclusion criteria were patients aged ≥18 years with an ICD-10 code for acute extremity DVT. The outcomes were incidence rates, admission rates, and anticoagulant prescriptions. Data were analyzed using descriptive statistics, and subgroup analyses were performed for upper and lower extremity DVTs.

Results: Of 190,144,463 total ED encounters, 368,044 (0.2%) were due to DVT. Among the DVT cases, 119,986 patients (32.6%) were admitted, at a stable rate during the study period. Apixaban was the most prescribed anticoagulant (40.3%), followed by rivaroxaban (28.3%), enoxaparin (7.9%), warfarin (3.6%), and dabigatran (0.3%). Use of apixaban increased from 12.4% in 2016 to 56.2% in 2023. Lower extremity DVTs accounted for 88.5% of cases, with a 32.1% admission rate, whereas upper extremity DVTs accounted for 11.7% of cases, with a 37.0% admission rate.

Conclusion: This study provides a summary of DVT presentation and management in US EDs during an 8-year period. The findings highlight stable incidence rates, reduced admission rates compared with historical data, and a significant shift toward the use of direct oral anticoagulants, particularly apixaban, for outpatient management. These trends underscore the importance of evidence-based practices and ongoing research to optimize DVT management and improve patient outcomes.

While nonocclusive mesenteric ischemia (NOMI) has been reported in a significant percentage of adults who were resuscitated after cardiac arrest, it is rare in children. This report presents the first known Japanese case of pediatric NOMI after return of spontaneous circulation following cardiac arrest. A 16-month-old boy experienced cardiac arrest due to asphyxiation from foreign bodies in the airway. After receiving 10 doses of adrenaline, with a maximum arrest time of 95 minutes, the patient achieved return of spontaneous circulation. However, 40 hours after onset, the patient developed NOMI, resulting in refractory hypotensive shock with decreased blood pressure, distended abdomen, and increased intravesical pressure. The patient was successfully rescued with two laparotomies and was discharged. Although NOMI is uncommon in children, appropriate treatment can be lifesaving.

Objective: Rapid sequence intubation (RSI) involves the administration of induction agents and neuromuscular blockers before endotracheal intubation (ETI). However, RSI is underutilized outside emergency departments (EDs). We compared RSI adoption rates and ETI outcomes outside and within the EDs and investigated whether RSI adoption affected ETI outcomes outside the EDs.

Methods: This retrospective study included adults who underwent emergency ETI outside the operating room at one university hospital between March 2022 and February 2023. The exclusion criteria included cardiopulmonary resuscitation, intentional RSI avoidance, and tube exchange via an introducer. The primary outcome was first-pass success rate. Secondary outcomes were multiple attempts (≥3), prolonged ETI (>5 minutes), and complications. The association between RSI adoption and outcomes outside the ED was assessed using multivariate logistic regression.

Results: A total of 490 ETI cases was included: 286 occurred outside the ED and 204 within the ED. The mean age was 68.3±14.7 years and 290 were male. Cases outside the ED received fewer RSI attempts than cases within the ED (12.6% vs. 86.8%, P<0.001). The former showed fewer incidents of first-attempt success (62.2% vs. 88.2%, P<0.001), more numerous multiple attempts (11.5% vs. 2.0%, P<0.001), longer total time of ETI (8.4±8.3 minutes vs. 2.5±2.5 minutes, P<0.001), and more frequent complications (32.2% vs. 19.6%, P=0.003). However, multivariate logistic regression revealed no significant association between RSI adoption and these outcomes outside the ED: odds ratio, 1.74 (95% confidence interval [CI], 0.783-3.84), 0.167 (95% CI, 0.022-1.30), 1.04 (95% CI, 0.405-2.69), and 1.50 (95% CI, 0.664-3.40), respectively.

Conclusion: Outside the ED, RSI adoption was lower and ETI outcomes were poorer than those within the ED. However, no association was found between RSI adoption and ETI outcomes outside the ED.

Objective: Acute vestibular syndrome (AVS) is a common symptom experienced by emergency department (ED) patients. Differentiating a peripheral from central etiology poses a challenge, and clinical practice lacks a uniform diagnostic approach. This study aims to provide insight on incidence and diagnostics in ED patients presenting with AVS in the Netherlands.

Methods: This was a multicenter retrospective cohort study of ED patients presenting with AVS in one of two hospitals during a 3-year period. The primary endpoints were incidence, diagnostics, and diagnosis at ED presentation versus follow-up. The secondary endpoint was type of therapy.

Results: Among the 500 AVS cases included, the annual incidence was 0.1%. Eighty-five ED patients (17.0%) were diagnosed with stroke, 285 (57.0%) did not experience stroke, and 130 (26.0%) exhibited an unsure etiology. At follow-up, diagnosis was revised in 145 patients (29.0%), with stroke missed in 29 (5.8%). A triad of clinical tests (head impulse test, observation of nystagmus, test of skew; HINTS) was completed for 106 patients (21.2%), computed tomography (CT) scans were collected in 342 patients (68.4%), and magnetic resonance imaging scans were collected for 153 patients (30.6%). Antiplatelet therapy was prescribed in 135 cases. In 69% of these, the initial diagnosis was revised to no stroke. Among eight patients who received thrombolysis, the initial diagnosis was revised for three. Of those patients in whom stroke was initially not identified, 23 (79%) received suboptimal treatment in lieu of antiplatelet therapy.

Conclusion: The annual incidence of AVS in this Dutch ED cohort is 0.1%. ED diagnosis is often uncertain, with one-third of diagnoses later revised. This study substantiates that clinical practice lacks a uniform diagnostic pathway, with an overuse of CT imaging and underuse of HINTS. Further research on an optimal diagnostic approach is warranted to improve treatment of AVS.

Fluid resuscitation is vital in the treatment of diabetic ketoacidosis (DKA) patients. The purpose of this narrative review is to analyze the role of Plasmalyte in the fluid resuscitation of adult DKA patients. A thorough search was conducted in PubMed, MEDLINE, and Embase. Studies conducted between January 1, 2010, and March 31, 2023, were collected. Of 123 results, five pertinent randomized controlled trials were included. The close resemblance of Plasmalyte's electrolyte composition to that of human plasma, and its role in the prevention of hyperchloremic metabolic acidosis are some of its key benefits in patients with diabetic ketoacidosis. Plasmalyte's role in length of stay, time to resolution of diabetic ketoacidosis, and mortality in DKA patients varied among studies. Hence, further research on these topics is needed.

Objective: We evaluated prognostic factors for pediatric drowning patients. The association between functional outcomes and clinical factors was investigated.

Methods: A retrospective cohort study was conducted using data for pediatric drowning patients from the Korean Community-based Severe Trauma Survey from 2016 to 2020. The primary outcome was a good prognosis at discharge, defined as a Glasgow Outcome Scale score of 5. A multivariable logistic regression analysis was performed to evaluate independent factors associated with the primary outcome.

Results: From 237,616 patients, we identified 406 drowning patients aged ≤19 years (mean age, 8.8 years). At discharge, 41.0% of those patients had a good recovery. The absence of prehospital cardiac arrest (adjusted odds ratio [aOR], 98.7; 95% confidence interval [CI], 32.9-295.8), indoor location (aOR, 4.0; 95% CI, 1.7-9.3), and transfer to a high-volume hospital (aOR, 2.5; 95% CI, 1.1-5.8) were significant independent factors associated with a good outcome. Age, sex, the intent of injury, and prehospital time were not associated with the outcome.

Conclusion: Our study identified independent prognostic factors for drowning patients, highlighting the importance of prehospital conditions and hospital care settings in determining outcomes. These findings could be useful in developing clinical strategies for managing such patients.