Emergency Medicine International最新文献

Background: Pulmonary embolism (PE) is a clinical condition frequently encountered in the emergency department (ED), with a high and early mortality rate. ED triage determines the priority of further evaluation of care at the time of patient arrival. Very little is known about the specific role of ED triage in PE. We aimed to evaluate (1) whether the current five-level triage (5LT) system can identify patients with PE and differently prioritize them for medical evaluation and (2) the discriminatory capacity of simplified revised Geneva score (SRGS) toward PE diagnosis when calculated by triage nurses. Methods: A retrospective chart review on ED patients who underwent computed tomography pulmonary angiography (CTPA) in 2023. Based on the CTPA report, patients were categorized into two subgroups: CTPA PE-negative and CTPA PE-positive. We then searched for correlations between PE diagnosis and triage priority level, time from triage to medical evaluation, SRGS, and National Early Warning Score 2 (NEWS2). Results: Of the 196 patients included in the analysis (age 71.1 ± 16.9), 45 (23.0%) were CTPA PE-positive (26 proximal PE and 19 distal PE). There was no correlation between the assigned triage color code and the CTPA results. Although we found a statistically significant difference in the prevalence of CTPA-confirmed PE according to the results of the SRGS (p = 0.014), the SRGS calculated at the time of triage showed a poor prediction accuracy for subsequent PE diagnosis (area under curve [AUC] 0.608). NEWS2 was significantly associated with the triage-assigned priority level (p < 0.001). Conclusions: The current 5LT was unable to differently prioritize patients with or without PE, and it seems unlikely that implementation of SRGS in the triage nurse evaluation will significantly improve the prioritization of patients with suspected PE for medical evaluation. Nonetheless, application of SRGS in triage evaluation may improve the appropriateness of the subsequent clinical pathway for PE diagnosis and risk stratification.

Purpose: Peripheral intravenous catheter (PIVC)-administered noradrenaline offers faster treatment for septic shock but risks complications like phlebitis. We aimed to investigate the relationship between the total noradrenaline dose administered via PIVCs and the development of phlebitis by considering the influence of noradrenaline as a time-dependent covariate. Methods: A post hoc analysis was conducted on prospective multicenter cohort data from 23 intensive care units in Japan. The total noradrenaline dose was included as a time-dependent variable in a multilevel Cox regression model, and smoothing splines assessed nonlinear relationships. The primary endpoint was phlebitis. Directed acyclic graphs were used to define confounding factors for the analysis. Results: The analysis included 3410 PIVCs from 1351 patients, with noradrenaline administered to 70 patients (5.2%) with 91 PIVCs (2.6%). The median dwell time and interquartile range of PIVCs was 46.2 h (21.3-82.9). No significant association was observed between the total noradrenaline dose and the occurrence of phlebitis through analysis using the multilevel Cox regression model with time-dependent covariate, which assumed the linear relationship between phlebitis occurrence and the total noradrenaline dose (hazard ratio 1.06, 95% confidence interval [CI] 0.93-1.20). Spline curve analysis suggested a nonlinear relationship between the total noradrenaline dose and phlebitis, and the risk of phlebitis increased when the total administered dose of noradrenaline exceeded 6 mg as the lower limit of the 95% CI exceeded the significant threshold of 1.0. Sensitivity analyses, including additional potential risk factors, showed consistent results compared with those of the primary analysis. Conclusions: Administering noradrenaline within a total dose not exceeding 6 mg reduces the risk of phlebitis, potentially allowing safer administration through PIVCs. Trial Registration: UMIN Clinical Trials Registry (UMIN-CTR): UMIN000028019.

Background: Due to the increasing concern about selective serotonin reuptake inhibitors (SSRIs) poisoning, specifically the risk of serotonin syndrome (SS), and the QT-prolonging effects of certain SSRIs, we evaluated the clinical presentations and outcomes of patients who overdosed on single SSRIs. Methods: We carried out a cross-sectional study at a Poisoning Emergency referal center in Isfahan, Iran, involving 101 patients who had taken a single SSRI drug and were hospitalized between January 2021 and January 2024. Information on demographics, toxicological features, clinical symptoms, electrocardiogram (ECG) findings, and outcomes was gathered. Results: The average age of the patients was 26.98 ± 10.57 years. Females outnumbered males (male to female ratio was 1:3.8). Sertraline was the most frequently ingested SSRI (43.6%), followed by fluoxetine (18.8%). Gastrointestinal symptoms (nausea and vomiting) were the most common clinical signs (n = 30, 29.7%). Six patients (5.9%) were diagnosed with SS. Only one patient experienced a brief, self-limiting seizure after consuming 4 g of sertraline. ECG showed QT interval prolongation (QT prolongation) in 32 patients (31.6%). One patient developed a first-degree AV block after taking 600 mg of citalopram. There was no significant difference in QT prolongation or SS based on the type of SSRI used. All patients survived without complications. Conclusion: This study indicates that overdosing on a single SSRI typically results in mild to moderate clinical manifestations. Cardiac issues, such as QT prolongation, were relatively common among our patients.

Introduction: Hypovolemia affects the clinical outcomes and efficacy of thrombolytic therapies such as recombinant tissue plasminogen activator (rt-PA). Hence, it plays an essential role in stroke management. Blood urea nitrogen-to-creatinine ratio (BCR) is an indicator of hypovolemia and is a promising area of further investigation. Methods: This study assessed the efficacy of enhanced hydration therapy in patients with acute ischemic stroke (AIS) who had an elevated BCR and were receiving rt-PA treatment. The outcomes between patients with AIS who received enhanced hydration therapy (the study group) and those with AIS who received standard hydration therapy (the historical control group) were compared. Eligible patients received 0.9% NaCl intravenous infusion at a volume of 20 mL/kg body weight. Then, a bolus injection of one-third of the total volume was administered, and the remaining two-third was continuously infused over 8 h. Next, a maintenance infusion of 40-80 mL/h was administered within 16 h. The primary outcomes were 3-month functional recovery and early neurological deterioration. Results: This analysis included 20 patients with AIS and 170 historical controls. The study and historical control groups did not significantly differ in terms of demographic characteristics, baseline stroke severity, and biochemical parameters. However, the study group had a higher prevalence of hypertension than the historical control group. Further, the study group had significantly better 3-month functional outcomes than the historical control group (p=0.018). In particular, 45.0% of patients in the study group and 21.2% in the control group achieved a modified Rankin Scale score of ≤ 2. Based on a subgroup analysis, patients with a lower stroke severity (National Institutes of Health Stroke Scale [NIHSS] scores of 4-10) in the study group exhibited significant improvements in functional outcomes. Meanwhile, patients with a higher stroke severity (NIHSS scores of 11-24) did not present with comparable benefits. The high stroke severity group had a higher complication rate than the low stroke severity group. However, the results did not significantly differ. Importantly, none of the patients who received enhanced hydration therapy developed adverse events. Conclusion: Enhanced hydration therapy can improve outcomes in patients with stroke who had an elevated BCR and who received rt-PA treatment. Further, it is not associated with significant complications.

Background: Pediatric emergencies remain a significant challenge for emergency services. The study aimed to retrospectively analyze invasive measures and medication administered during prehospital care. The analysis focused on invasive procedures (e.g., tracheal intubation and vascular access) performed on pediatric patients (aged 1 month to 12 years) admitted via the Central Emergency Department (ED) or directly to the University Pediatric Intensive Care Unit (PICU) of the University Hospital of Cologne. These findings provide insights into quality assurance and improvement of prehospital care and invasive emergency techniques in pediatrics. Methods: Emergency protocols were evaluated, including parameters such as the Glasgow Coma Scale (GCS) and National Advisory Committee for Aeronautics (NACA) score. Patients were categorized based on diagnosis, medication administration, and invasive emergency techniques. Results: A total of 373 patients were admitted to the ED, and 237 patients were admitted to the PICU between 01/2015 and 05/2020. Sedation was at similar in both groups, while catecholamines were more frequently used in the PICU group. Invasive procedures, such as tracheal intubation, were rare (PICU: 9.5%; ED: 5.8%; p=0.093). Peripheral venous access was performed in 33.7% of PICU cases and 51.2% of ED cases, whereas central venous access was almost never performed. 19 children admitted to the PICU died compared to one in the ED (p < 0.001). Conclusion: Invasive procedures are rarely performed during prehospital care for pediatric patients. Trauma cases predominated in the ED group (99.2%), whereas the PICU group exhibited greater diagnostic variability, including trauma and internal emergencies. This study identified significant gaps in medical documentation. Training for paramedics and emergency health workers should prioritize airway management, including supraglottic airway (SGA) devices, thoracic drainage, and vascular access techniques such as peripheral intravenous (PIV) and intraosseous (IO) access. Additionally, efforts to improve medical documentation should be emphasized to enhance pediatric emergency care.

Objective: The aim of our study was to evaluate the accuracy and reliability of videos available on YouTube and Google showing the use of automated external defibrillators. Methods: Videos available on YouTube and Google between 2020 and 2023 were searched using the search terms "Defibrillator," "Resuscitation," "Basic life support," "Cardiac arrest," "CPR," "Cardiac shock," "Chest trust," or "First aid." Data such as the year the video was uploaded, number of views, and video length were collected. The videos were watched and evaluated by two independent emergency physicians. According to the 6-stage evaluation criteria, 1 point was given if the information given in the video was correct and 0 point was given if no information was given. The maximum score was determined as 6 and the minimum score as 1. Results: Out of a total of 315 videos uploaded to the specified platforms, 29 met the inclusion criteria. After the evaluation, the average score given to the videos was 5.45 ± 1.02. When the videos were categorized as low and medium-high according to their fidelity levels, there was no statistically significant difference between these two groups in terms of the number of views, video length, and the score given (p=0.469, 0.078, and 0.110, respectively). Videos from institutions were shorter, with a median length of 180 s compared to 289 s for noninstitution uploads (p=0.047). Both groups received similar scores, with a median of 6 for each (p=0.257). Conclusion: The main findings of our study were that most of the videos were uploaded by health institutions and were shorter. Video scores did not differ according to the level of loyalty of the mannequins used and the uploading source.

Background: Cardiac arrest, a sudden cessation of cardiac function, necessitates immediate life-saving measures such as cardiopulmonary resuscitation (CPR) to prevent death. Despite poor survival rates and neurological outcomes associated with cardiac arrest, early resuscitation can improve survival. In low- to middle-income countries like Ghana, there are limited data on CPR practices and outcomes, necessitating targeted training programs. Objective: To assess the impact of a basic life support (BLS) training program on knowledge acquisition and training among staff in the Accident and Emergency Department of Korle Bu Teaching Hospital. Methods: A comprehensive BLS training program was conducted over four (4) days and involved 128 staff. Following the American Heart Association (AHA) BLS guidelines, the training sessions included lectures, practical sessions with adult and child CPR mannequins, and pre- and post-training online assessments and evaluations. Results: Most participants were between 31 and 40 years old with the majority being nurses. The mean score for the post-test (13.95) was higher than that for the pretest (12.40). A total of 99% of the respondents agreed that their learning objective for the course was met and exceeded. A total of 74.71% responded that their knowledge of BLS had improved, with nearly 99% agreeing that the instructions for the practical sessions were clear and easy to follow. About 60% of the respondents rated the quality of delivery of the lectures excellent, with 85% satisfied with the time allocated to the training sessions. All participants indicated they would recommend the BLS training course to their colleagues. Conclusion: This study strongly advocates for the integration of ongoing BLS training programs to maintain high standards of emergency medical care, particularly in resource-limited settings as regular BLS training can improve emergency care and patient outcomes.

Background: Although lactated Ringer's (LR) solution is widely used in managing patients with acute kidney injury (AKI), its specific impact on mortality remains unclear. This retrospective cohort study aimed to evaluate the effects of LR administration on survival outcomes in severely ill patients with AKI. Methods: Critically ill patients with AKI were identified using data from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. Propensity score matching (PSM) was employed to address baseline discrepancies between patients who received LR and those who did not. The association of LR administration with survival, duration of hospitalization and intensive care unit (ICU) stay, requirement for renal replacement therapy (RRT), renal function recovery, and hyperkalemia was analyzed using restricted mean survival time (RMST), logistic regression, and linear regression models. Results: A total of 5620 patients with AKI were included. Following PSM, LR administration was associated with prolonged survival at 28 and 90 days compared to non-LR use (28-day survival increase: 1.12 days, 95% confidence interval [CI] 0.62-1.63, p < 0.001; 90-day survival increase: 3.73 days, 95% CI 1.70-5.76, p < 0.001). The survival benefit became more pronounced, with higher LR use linked to more remarkable 90-day survival. However, LR administration did not significantly affect renal function recovery or hyperkalemia incidence. Conclusion: Administering LR to critically ill patients with AKI was associated with improved survival at both 28 and 90 days.

Introduction: Acute aortic dissection (AAD) is a severe condition requiring immediate diagnosis and treatment to reduce high mortality rates. This study investigates laboratory markers that may support the diagnostic process and predict surgical outcomes and mortality in AAD patients. Materials and Methods: This retrospective study analyzed data from 85 patients diagnosed with AAD in an emergency setting. Patients over 18 years of age with a diagnosis of acute dissection were included. Key laboratory and clinical parameters were examined to determine their association with mortality and the likelihood of surgical intervention. Results: The study found that younger patients were more likely to undergo surgery, while parameters such as white blood cells (WBCs), neutrophil, and lymphocyte counts were elevated in those undergoing surgery. Mortality predictors included elevated mean platelet volume (MPV), low pH, bicarbonate (HCO₃), and base deficit levels. Each unit increase in MPV was associated with a threefold increase in mortality risk, and DeBakey Type 1 patients exhibited the highest MPV levels. Discussion: WBC and MPV values were linked with surgical and mortality outcomes, respectively. Blood gas analysis parameters, particularly HCO₃ and base deficit levels, were significant mortality predictors, underscoring the importance of metabolic markers in AAD assessment. The findings suggest that incorporating these laboratory parameters into diagnostic and treatment decisions could improve AAD management.

Background: Early identification of septic patients in the ED is important, but high patient volumes and lengthy wait times often delay workups, and typically used noninvasive triage screening tools such as vital signs and qSOFA have poor sensitivity. Nitric oxide (NO) is a molecule in the blood that has been found to be upregulated in sepsis. Since it has a very short half-life in blood, its measurement can be challenging. We aimed to determine if exhaled NO could be used to help predict bacterial infection and sepsis. Methods: Emergency department patients with concern for infection were assessed for enrollment. Patients were included if blood cultures were ordered by the ED provider. The exhaled breath NO levels of enrolled subjects were measured. A score (vital signs and nitric oxide [VSNO]) was then created that included triage vital signs and NO level. Results: 104 patients (41 female) were enrolled. The median exhaled NO level was 9.8 parts per billion (ppb) (IQR: 5.6-17.0). Sixty-two (60%) patients were diagnosed with bacterial infection, and of those, 54 (52%) patients were diagnosed with sepsis. Using cut points of < 7 or > 12 ppb, the VSNO score demonstrated a sensitivity of 0.89 (95% CI: 0.77-0.96) and a specificity of 0.48 (95% CI: 0.34-0.63) for predicting sepsis. The score showed a sensitivity of 0.82 (95% CI: 0.70-0.91) and a specificity of 0.45 (95% CI: 0.30-0.64) for predicting bacterial infection. Conclusions: Exhaled NO measurement combined with vital signs has a high sensitivity for the detection of bacterial infection and sepsis. In a clinical setting, this score would be immediately available at the point of patient triage and would help to direct downstream evaluation and care. Further research is warranted.