Emergency Medicine International最新文献

Objective: Lung recruitment maneuvers (RMs) is an important treatment for acute respiratory distress syndrome (ARDS) patients; however, assessing lung recruitability is imperative to avoid biotrauma and hemodynamic instability. This study aims to investigate whether the cytokine levels in the bronchoalveolar lavage fluid (BALF) of ARDS patients can serve as an indicator of their lung recruitability. Methods: This study included ARDS patients who received mechanical ventilation for over 24 h. Patients were categorized into lung recruitment maneuver effective (RM-E) group and lung recruitment maneuver noneffective (RM-N) group. Interleukin-6 (IL-6), interleukin-8 (IL-8) and interleukin-10 (IL-10) in BALF, lung ultrasound (LUS) scores, and the oxygenation index (P/F) were measured. The differences in cytokine levels between the two groups were compared, and correlations between changes in cytokine levels (ΔIL-6, ΔIL-8, and ΔIL-10), ΔLUS, and ΔP/F were analyzed. Results: Sixty-two patients were included in this study (38 in the RM-E group and 24 in the RM-N group). After the RM, compared with the RM-N group, an increase was observed in ΔIL-6 (p=0.013), ΔIL-8 (p=0.045), ΔIL-10 (p=0.039), and ΔLUS (p=0.045) in the RM-E group. A positive linear correlation was found between ΔIL-6 and ΔLUS (r = 0.504, p < 0.001). The area under the lung recruitment potential curve (AUC) predicted by ΔIL-6 was 0.794, the sensitivity was 94.7%, and the specificity was 70.8%. A positive linear correlation was found between ΔIL-6 and ΔLUS (r = 0.504, p < 0.001). The lung recruitment potential curve's AUC predicted by ΔIL-6 was 0.794, with a sensitivity of 94.7% and specificity of 70.8%. Conclusion: Lower levels of cytokines in BALF were observed in the RM-E group. It is possible that the cytokines in BALF, especially IL-6, could be used to determine the need for RM on the basis of lung recruitability.

Introduction: Pulmonary embolism (PE) poses substantial morbidity and mortality risks, necessitating timely and accurate management in emergency departments (EDs). Objectives: This study explores the trends in PE presentations to US EDs from 2006 to 2018 and assesses the impact of different factors on management and cost. Methodology: This is a retrospective descriptive study conducted using the US Healthcare Cost and Utilization Project (HCUP) PE ED visits database. Data on ED visits, dispositions, and related costs were collected and analyzed. Results: From 2006 to 2018 there were more than 2 million PE ED visits in the US. There was an increase in visits per 100,000 persons from 42.17 in 2006-2008 to 64.27 in 2016-2018 (p value < 0.001). The proportion of uninsured patients declined from 5.07% to 4.70%, and the percentage of Medicaid-insured patients increased. There was a decrease in the admission rates from 92.47% to 75.97% in 2016-2018 (p value < 0.001). The mean cost per admitted patient increased from $32,794 to $47,344 in 2016-2018 (p value < 0.001). Conclusion: From 2006 to 2018, PE ED visits in the US increased with a noticeable decrease in admission rates and length of stay, likely secondary to advancement in diagnostic and therapeutic modalities like computed tomography pulmonary angiography and novel oral anticoagulants. However, the observed rising healthcare costs pose challenges to sustainable management. Further research studies are needed to address cost-effective strategies.

Background: Ischemic stroke is one of the major emergency diseases leading to death and disability worldwide, characterized by its acute onset and the urgent need for prompt medical intervention to reduce mortality and long-term disability. Chronic terminal internal carotid artery and/or middle cerebral artery occlusion (CTI/MCAO) is an important subtype of intracranial artery occlusive disease. The superficial temporal artery-to-MCA (STA-MCA) bypass has been proposed to improve cerebral blood flow (CBF) and cerebrovascular reserve (CVR), potentially enhancing neurological outcomes. However, its safety and efficacy in CTI/MCAO patients remain controversial. Methods: A total of 107 CTI/MCAO patients from Nanjing Brain Hospital, enrolled between July 2019 and June 2022, were divided into surgical and medical treatment groups. Cerebral perfusion and collateral formation were evaluated using pseudocontinuous arterial spin labeling (pCASL) and digital subtraction angiography (DSA). Modified Rankin scale (mRS) score and complication rates were compared between the two groups. In addition, correlations between Matsushima grades, early-arriving flow proportion (EFP), and lesion-side cerebrovascular (LCBV) scores were analyzed. Results: The surgical group showed significantly lower mRS scores than the medical group (p=0.018), with no significant differences in complication rates at the 6-month follow-up (p=0.861). CBF differed significantly among affected MCA segments (p < 0.001), particularly in the insular and opercular regions (M2-M3) (p=0.006). Matsushima grades in unilateral CTI/MCAO patients were negatively correlated with preoperative LCBV scores (γ _s = -0.468, p=0.005) and EFP (γ _s = -0.648, p=0.007). EFP demonstrated high accuracy in predicting LCBV scores in CTI/MCAO patients (AUC = 0.902, p=0.004). Conclusion: STA-MCA bypass surgery improved neurological outcomes in CTI/MCAO patients, particularly those with poor preoperative collateral compensation. EFP may serve as a reliable, noninvasive tool for assessing collateral circulation status in this population.

Introduction: Despite significant medical and technological advancements, cardiac arrest remains a critical public health concern due to its persistently high mortality and morbidity rates. Consequently, research on cardiopulmonary resuscitation (CPR) is of significant importance. Materials and Methods: This study presents a bibliometric analysis of the 100 most-cited articles in the field of CPR identified using the Scopus database without time restrictions. Analyses were conducted using VOSviewer and Bibliometrix software. Original research articles published in English were included. Results: The study revealed contributions from 798 distinct authors across 18 journals, with citation counts ranging from 218 least-cited articles to 1194 most-cited articles. The most recent article was published in 2020, and the most frequently used keywords were "CPR" and "heart arrest." In addition, 20% of the analyzed articles were funded by military organizations. Conclusion: This analysis highlights the significant contributions of emergency medicine researchers and the notable development of CPR literature, particularly between the late 1990s and the early 2000s. While the most-cited studies originated from journals with high H-indices, the citation frequency of these articles showed a consistent decline over time. Furthermore, impactful articles in this field were predominantly published in general medical journals rather than in specialized emergency medicine journals. This study provides a foundational resource for researchers, especially early career academicians, seeking to engage in CPR-related research.

Background: Emergency medicine practitioners encounter significant challenges related to patients who leave emergency departments (EDs) without being seen (LWBS) in the ED. We aimed to assess the characteristics, reasons, and rate of patients who left without being seen in the tertiary teaching hospital ED of King Khalid University Hospital in Riyadh, Saudi Arabia. Methods: A qualitative prospective observational study was conducted from January 4, 2023, to May 17, 2023, among patients who left the ED without being seen in the King Khalid University Hospital, King Saud University Medical City, a tertiary hospital in Riyadh, Saudi Arabia. Data were collected from the ED administrative database, phone surveys, and electronic files of the identified patients. Phone interviews with questionnaires were conducted with patients participating in the study within 1 week of their ED visit. Results: During the study period, 16,682 patients visited the adult ED and 636 (3.81%) remained unseen; 300 patients met the study criteria. Of these, 288 (96%) arrived at the hospital via private car and 12 (4%) used ambulances. Trauma and gastrointestinal, neurological, and cardiovascular complaints were the most common, reported by 24.33%, 18.33%, 12%, and 10% of patients, respectively. In our study, 55 patients (18.3%) experienced prolonged waiting times of more than four hours before leaving the ED. Most patients (75%) inquired about the reasons for not being seen by a physician while waiting; 137 (45.6%) asked a receptionist, 117 (39%) asked a nurse, and 28 (9.3%) asked a doctor. According to 76 (25.3%) patients, they should not have to wait, whereas 82 (27.3%) said that they should wait for an hour. When asked whether they would visit the same ED in the future, 213 (71%) answered yes and 87 (29%) answered no. Conclusion: We conclude that in our center, prolonged waiting time and ED overcrowding are the main reasons why patients leave the ED without seeing a physician. Younger patients are more prone to LWBS, with trauma and gastroenterological complaints being the most common presenting symptoms. The LWBS rate was 3.81% of the total ED visits during the study period.

Introduction: Trauma triage is the use of trauma assessment for prioritizing patients for treatment or transport by injury severity. According to Taiwan Public Health Report, accidents and their adverse events were the sixth leading cause of death and accounted for over 7000 casualties in 2009. However, a lack of accuracy in identifying the severity of a patient's injury and their prehospital information can result in inappropriate triage. This study evaluated the efficacy of field triage guidelines governing trauma team activation in Taipei and explored the characteristics of undertriaged and overtriaged patients. Methods: This study retrospectively observed all patients with trauma transported to the emergency department of a medical center by Taipei City public ambulance from January 1, 2016, to December 31, 2019. A total of 2217 patients were included. The Cribari matrix method was used to assess undertriage and overtriage. A logistic regression was employed to analyze the effect of risk factors in patients with major trauma. Results: In this study, 320 and 1897 patients with trauma had full and limited trauma team activation, respectively. Among them, 664 patients with trauma were older than 65 years, and most of them were injured in a traffic accident. Among patients with major trauma, 24, 214, and 156 patients were aged < 20, 20-65, and > 65 years, respectively. A logistic regression analysis revealed that patients with a Glasgow Coma Scale score of less than 13, with systolic blood pressure level of less than 90, and with respiratory rate over 30 breaths per minute was more likely to be appropriately triaged. Conclusion: The Taipei prehospital field triage guidelines are acceptable but not an ideal tool for identifying patients with major trauma, with an overtriage rate of 48.12% and an undertriage rate of 12.03%. To decrease undertriage or overtriage rates, emergency medical service providers should receive comprehensive training.

Background and Aim: International guidelines recommend early enteral nutrition (EEN) for critically ill patients. However, evidence supporting the optimal timing of EN in patients diagnosed with cardiogenic shock (CS) is lacking. As such, this study aimed to compare the clinical outcomes and safety of EEN versus delayed EN in patients diagnosed with CS. Methods: This retrospective cohort study was conducted using data from the Medical Information Mart for Intensive Care IV version 2.2 database. Patients who received EN within 2 days of admission were assigned to the EEN group. A 1:1 propensity score-matched (PSM) analysis was performed to control for bias in baseline characteristics and ensure the reliability of the results. To exclude the impact of confounders, an adjusted proportional hazards regression model was used to verify the independence between EEN and survival outcomes. Results: Of 1846 potentially eligible patients, 1398 received EEN and 448 received delayed EN. After 1:1 PSM, 818 patients were assigned to the EEN (n = 409) and delayed EN (n = 409) groups. Regarding cumulative survival, patients with CS receiving EEN experienced better 30-, 90-, and 180-day survival outcomes than the delayed EN group (hazard ratio [HR] 0.803 [95% confidence interval [CI] 0.647-0.998], p=0.045; HR 0.729 [95% CI 0.599-0.889], p=0.001; and HR 0.778 [95% CI 0.644-0.938], p=0.008, respectively). After adjusting for confounders, EEN was found to be independently associated with survival outcomes. Moreover, EEN did not increase the risk(s) for ileus, aspiration pneumonia, or gastrointestinal bleeding. Patients who received delayed EN experienced longer hospital stays than those receiving EEN (17 days [interquartile range [IQR] 10-25] versus 12 days [IQR 7-19 days], respectively; p < 0.001). Conclusion: EEN was not associated with harm, but rather with improved survival outcomes in patients diagnosed with CS. Further studies are required to verify these findings.

Background: Physical examination and computed tomography angiography (CTA) are used for diagnosing arterial injury in extremity trauma. In recent years, CTA has been overused to obtain more objective data. Our study aimed to investigate the effect of using CTA for the management of patients with extremity penetrating injuries, specifically in cases where vascular injury was not detected during initial examination. Methods: This retrospective study included patients with penetrating trauma who underwent CTA of the extremities. The demographic data, mechanism of injury, the side of injury, initial vascular exam (normal, soft signs, and hard signs), radiological results, and any orthopedic and vascular intervention performed were recorded. The χ ² test was used for independent variables. A significance level of p < 0.05 was used. We compared the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for physical exam and CTA for identifying arterial injury requiring intervention. Results: Of the 252 patients included in the study, 29 (21.5%) had abnormal vascular physical examination while 26 (10.3%) had an abnormal CTA. The NPV of the hard sign for identifying vascular injury was 95.4%, while the sensitivity was 57.7%, specificity was 100%, and PPV was 100%. The NPV of routine physical examination to determine the requirement for vascular intervention was 100%. The sensitivity and PPV of the soft sign in determining the need for vascular intervention were 65.4% and 77.3%, respectively. Conclusion: Vascular injury was present in all cases that had positive hard signs. CTA imaging and vascular intervention are not necessary in patients who exhibit no hard and/or soft indicators during a thorough physical examination.

Background: White blood cell (WBC) subtypes reflect immune and inflammatory conditions in patients. This study aimed to examine the association between the ratio of platelets to WBC subtypes and mortality outcomes in patients with moderate-to-severe traumatic brain injury (TBI). Method: The Trauma Registry System of the hospital was retrospectively reviewed to gather medical records of 2397 adult patients who were hospitalized from 2009 to 2020 and had moderate-to-severe TBI with a head abbreviated injury scale (AIS) score of 3 or higher. The monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were compared between the survivors (n = 2, 138) and nonsurvivors (n = 259). A multivariate logistic regression analysis was performed to investigate the independent effects of the univariate prognostic factors on mortality outcomes. The survival variations among the PLR subgroups were evaluated by the Kaplan-Meier survival analysis including a log-rank test. Results: The PLR of the deceased patients was considerably lower than that of the survivors (129.5 ± 130.1 vs. 153.2 ± 102.1, p < 0.001). However, no significant differences were observed in monocyte and neutrophil counts, MLR, or NLR between the deceased and survivor groups. A lower PLR was recognized as an independent risk factor for mortality (odds ratio: 1.26, 95% confidence interval: 1.06-1.51, p=0.010). The receiver operating characteristic (ROC) established PLR as the most strong predictor among the three ratios (area under the ROC curve = 0.627, sensitivity = 0.846, and specificity = 0.382, according to the cut-off value = 68.57). When the patient groups were divided by PLR quartile, the Kaplan-Meier analysis showed significantly worse survival in the lowest PLR quartile group (< 83.1) compared with the highest quartile group (≥ 189.1) (p < 0.001). Conclusion: Lower PLR is associated with greater mortality in adult patients with moderate-to-severe TBI. PLR may be a valuable measure for classifying mortality risk in this population.

Objective: This study evaluates the effectiveness and timeliness of posterior decompression and internal fixation in the emergency management of thoracolumbar fractures complicated by spinal cord injuries. Methods: We retrospectively analyzed 40 patients treated at our hospital from January 2019 to February 2022. Each patient underwent posterior decompression and internal fixation, with preoperative and postoperative assessments including vertebral body height, American Spinal Injury Association (ASIA) score, Visual Analog Scale (VAS) score, and urodynamic indices. Results: Postoperative improvements were noted in vertebral body height, with anterior and posterior heights increasing to 12.82 (± 1.23) mm and 3.21 (± 0.64) mm, respectively, and kyphosis angle improving to 14.26 (± 0.32). Significant enhancements were also observed in motor (from 40.78 [± 4.32] to 59.86 [± 1.37]) and sensory (from 45.98 [± 3.20] to 66.92 [± 1.28]) function scores, and a reduction in VAS score from 6.89 (± 0.78) to 1.78 (± 0.32). Urodynamic measurements showed increased maximum urine flow and detrusor pressure postintervention. All surgical wounds healed within two weeks without significant complications. Conclusion: Posterior decompression and internal fixation significantly improve spinal stability, pain, motor, and sensory functions in patients with thoracolumbar fractures and spinal cord injuries, demonstrating its effectiveness and clinical utility.