Emergency Medicine Journal最新文献

Background: Cardiac arrest, a critical emergency with high fatality rates, needs accurate early predictors of resuscitation outcomes. End-tidal carbon dioxide (ETCO₂) monitoring, reflecting tissue perfusion and metabolic activity, is highlighted in guidelines for predicting return of spontaneous circulation (ROSC). This systematic review and meta-analysis evaluates the prognostic accuracy of ETCO₂ at various time points and cut-offs to enhance clinical decision-making during cardiac arrest.

Methods: A systematic search of MEDLINE, Embase and the Cochrane Library identified relevant prognostic accuracy studies. Inclusion criteria were original articles reporting prognostic accuracy of ETCO₂ for ROSC prediction in adult cardiac arrest patients. Sensitivity, specificity and 95% CIs were calculated for ETCO₂ measurements at initial, 10 and 20 min using 2×2 contingency tables. A multiple thresholds model was used for meta-analysis, and the Median of Medians method analysed median ETCO2 values.

Results: Fourteen studies with 3186 cardiac arrest patients were included. The optimal ETCO₂cut-off was 19.8 mm Hg at initial (sensitivity 0.75 (95% CI 0.60 to 0.85), specificity 0.53 (95% CI 0.40 to 0.65)), 15.7 mm Hg at 10 min (sensitivity 0.91 (95% CI 0.72 to 0.97), specificity 0.68 (95% CI 0.56 to 0.78)) and 8.5 mm Hg at 20 min (sensitivity 0.95 (95% CI 0.53 to 0.99), specificity 0.78 (95% CI 0.39 to 0.95)). The highest area under the curve (AUC) was 0.88 (95% CI 0.31 to 0.98) at 20 min, followed by 0.82 (95% CI 0.61 to 0.91) at 10 min and 0.67 (95% CI 0.57 to 0.75) initially.

Conclusions: While initial ETCO₂ demonstrates limited prognostic accuracy for ROSC with a pooled AUC of only 0.67, ETCO₂ measurements taken at 10 and 20 min provide a negative predictive value exceeding 0.95 when using a cut-off of 10 mm Hg. However, to meet the stringent criteria for termination of resuscitation (TOR) decisions, a lower cut-off, such as 5 mm Hg, or the incorporation of additional prognostic indicators would be necessary. Serial ETCO₂ monitoring could also be considered as a potential adjunct in current TOR guidelines. Significant variability between studies necessitates cautious interpretation of these results.

Prospero registration number: CRD42024527811.

Introduction: Patients with traumatic out-of-hospital cardiac arrest (OHCA) continue to demonstrate poor outcomes. Although some prehospital studies suggest transfusion is associated with better outcomes, the association of blood transfusion at the emergency department (ED) with sustained return of spontaneous circulation (ROSC) in patients in traumatic OHCA remains unclear.

Methods: This multicentre retrospective study included adult patients with blunt traumatic OHCA who were brought to the National Taiwan University Hospital and affiliated institutions from January 2016 to August 2023. Patients under 18 years old and those who suffered from penetrating injury, burn, hanging or other non-blunt injury were excluded. Blood transfusion was defined as any blood product administration during the ED stay. The outcomes were sustained and any ROSC. The variables analysed included demographics and resuscitation factors. Multivariable logistic regression was conducted, reporting results as adjusted ORs (aORs) with 95% CI.

Results: This study included 442 patients, of whom 64 (14.5%) achieved sustained ROSC, whereas 378 (85.5%) did not. A total of 164 (37.1%) patients received blood transfusions. Among them, 2.4% patients survived to be discharged. Blood transfusion was found to be independently associated with sustained ROSC (aOR 4.58, 95% CI 2.45 to 8.58, p<0.001) whereas thoracostomy was associated with a significantly decreased likelihood of sustained ROSC (aOR 0.26, 95% CI 0.13 to 0.51, p<0.001). Factors independently associated with an increased likelihood of any ROSC included blood transfusion, witnessed arrest, arrest en route, while thoracostomy was associated with decreased likelihood of any ROSC.

Conclusions: Blood transfusion in the ED is associated with increased likelihood of sustained ROSC for patients with blunt traumatic OHCA, potentially serving as a bridge to definitive treatment. However, subsequent cost-effectiveness analysis should be considered for better resource allocation.

Background: The allied health professional (AHP) community has pledged a commitment to research and innovation. Recent literature from both the Northern and Southern hemispheres has explored research capacity and capability among AHPs but lacks specific clinical contexts which could have a direct impact on research activity. Emergency departments (EDs) present a unique environment for conducting research. The aim of this study was to explore current research engagement among AHPs working in the UK EDs and identify facilitators to support and maintain research activity among this workforce.

Methods: A qualitative approach was used, involving online focus groups conducted between September 2023 and January 2024. Participants were identified through national voluntary response sampling via social media and existing emergency medicine networks. Purposive sampling was subsequently undertaken to improve profession-specific representation. All participants were currently employed as AHPs working clinically within UK EDs. Those employed in research roles were excluded. Data were analysed through thematic analysis.

Results: 74 individuals expressed interest, of whom 60 were deemed eligible and invited to participate. 32 consented and 28 attended one of seven focus groups. Data for two participants subsequently identified as imposters were excluded. Professions represented were paramedics, radiographers, physiotherapists and occupational therapists. Three major themes emerged: 'building confidence', 'unrealised potential' and 'collaboration is key'. AHPs lacked confidence to engage in research, with limited visibility of AHPs in academic roles, professional silos and hierarchies cited among professional barriers. Additional specialty barriers included time pressures, performance metrics and protocolised pathways. However, all participants recognised the benefits of engaging in research, and several facilitators were identified, including recent evolutions in AHP roles, a diverse skill set across AHPs and the multidisciplinary nature of ED.

Conclusion: AHPs have potential to improve emergency care through research endeavours but greater value needs to be attributed before any significant growth in research culture is likely realised.

High-pressure pneumatic guns, commonly used in industrial settings for tasks such as painting and cleaning, pose a significant risk of hand injuries since they can generate pressures up to 12 000 pounds per square inch. Despite their rarity, these injuries can have severe consequences, including permanent functional impairment and an elevated risk of amputation. Often underestimated in the community setting, high-pressure injection injuries (HPII) frequently evade early recognition, leading to detrimental outcomes. Using two illustrative cases, this practice review outlines the challenges in recognising and managing these injuries, highlighting the need for increased awareness among emergency healthcare practitioners. Early recognition is challenging and crucial, as it facilitates timely referral to hand specialists for comprehensive management, improving patient outcomes. Standardising diagnostic guidelines is also considered a potentially impactful topic of future work. By addressing these priorities, we can enhance patient care and mitigate the burden of these injuries on individuals and communities.

A short systematic review was undertaken to assess whether use of inhaled methoxyflurane in reduction of anterior shoulder dislocation is associated with an acceptable procedural success rate and decreased time spent in the emergency department. MEDLINE, EMBASE, Cochrane and Google Scholar databases were searched. Eight relevant papers were found. The author, date, country of publication, study type, patient characteristics, relevant results and study weaknesses were tabulated. Our results suggest favourable outcomes with methoxyflurane, but a multicentre randomised trial is needed to fully address this clinical question.

Background: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defines sepsis as a life-threatening organ dysfunction due to a dysregulated host response to infection. Measuring a dysregulated host response is difficult in practice, so patients with organ dysfunction due to other causes, such as an underlying comorbidity or the direct effects of infection, may be diagnosed with sepsis. We aimed to characterise patients diagnosed with sepsis and meeting the Sepsis-3 criteria according to whether organ dysfunction was potentially due to a dysregulated immune response or an alternative cause.

Methods: We undertook a single-centre, retrospective, observational study of patients admitted to hospital with sepsis between 1 January 2022 and 31 December 2022. We reviewed clinical, laboratory and imaging records to determine whether cases met Sepsis-3 criteria and whether organ dysfunction was more likely to be due to a dysregulated immune response or an identifiable alternative explanation.

Results: We analysed 373 cases, of whom 303 (81.2%) fulfilled the Sepsis-3 criteria. Of these, 78 (25.7%, 95% CI 21.4% to 30.0%) had an alternative explanation for their organ dysfunction, with 28 (9.2%) due to exacerbation of a comorbidity, 42 (13.9%) direct effects of infection and 8 (2.6%) involving evidence of respiratory dysfunction based on 'normal' oxygen saturation measurements. Patients with an alternative explanation for their organ dysfunction tended to be less acutely ill (median (IQR) National Early Warning Score 5 (3-8) vs 7 (5-10), p<0.001) and have lower in-hospital mortality (19.2% vs 34.7%, p=0.011) than those who were more likely to have a dysregulated host response.

Conclusion: Around a quarter of patients diagnosed with sepsis and meeting the Sepsis-3 criteria were unlikely to have a dysregulated immune response causing their organ dysfunction. Focusing sepsis diagnosis on those most likely to have a dysregulated immune response could identify patients who are most likely to benefit from sepsis treatment and could improve sepsis care.

Introduction: Emergency department (ED) crowding is an international concern. It results in care being delivered in non-standard treatment spaces including corridors, termed escalation areas in the UK. Limited data suggest their use is widespread. This study aimed to establish the prevalence of UK escalation area use at a national level.

Methods: A prospective cross-sectional point prevalence study was carried out in 165 UK EDs over five snapshots in March 2025 selected to represent a range of expected ED activity. The primary outcome was the proportion of patients receiving care in escalation areas. Secondary outcomes were the number of patients awaiting an inpatient bed, ED occupancy and resuscitation capacity. The presence of paediatric patients and those with mental health presentations in escalation areas is also reported.

Results: Across the five snapshots, 17.7% (n=10 042) of ED patients were receiving care in escalation areas. At each snapshot there were more patients awaiting an inpatient bed than patients in escalation areas. The percentage of escalation area patients in non-clinical areas such as corridors ranged from 54.5% to 61.1%. ED occupancy (patients per cubicle space) ranged from 1.0 (IQR 0.7-1.4) to 2.4 (IQR 1.8-3.1). There was no available resuscitation cubicle at 10.5% (n=17/162) to 26.2% (n=43/164) of sites. Paediatric and mental health patients were receiving care in escalation areas across all time points.

Conclusion: Almost one in five ED patients was experiencing escalation area care during the five snapshots. National guidance states escalation area use is not acceptable; this research demonstrates it is routine. This study supports the hypothesis that, to address ED escalation area care, the focus should be on facilitating the flow of patients who require an inpatient bed out of the ED. Further research should consider the effect of escalation area care on patient level outcomes and the effectiveness of interventions to reduce ED crowding.

Background: The increased use of CT in emergency departments (ED) has led to a rise in incidental detection of pneumomediastinum (PNM). As this finding can be associated with oesophageal perforation (OP), clinicians face a diagnostic dilemma on whether further invasive investigation (such as endoscopy) is required. This study aimed to identify clinical, biochemical and radiological predictors of OP in patients with PNM, to develop a non-invasive diagnostic approach.

Methods: A retrospective analysis of adult patients with CT-confirmed PNM was conducted from January 2016 to December 2022 at a tertiary hospital in Queensland, Australia. Data were collected from electronic medical records on demographics, presenting features, vital signs at presentation and 6-24 hours, laboratory results and specific CT findings. Univariable analyses identified candidate predictors of OP, and multivariable logistic regression was used to determine independent predictors.

Results: Among 336 patients with PNM, 22 (6.5%) had confirmed OP. Dysphagia (p<0.001) and vomiting (p=0.002) on presentation were significant univariable predictors of OP. No asymptomatic patients were found to have OP. None of the measured laboratory markers (including white cell count, C-reactive protein and lactate) were predictive of OP. Key CT findings associated with OP were mediastinal free fluid, pleural effusion and oesophageal wall disruption (all p<0.001). Multivariable analysis identified that the combination of mediastinal free fluid plus oesophageal wall disruption was the strongest predictor of OP with a sensitivity of 86.4% and specificity of 98.4%.

Conclusion: Clinical features such as dysphagia and vomiting, together with specific CT signs (mediastinal fluid, pleural effusion and oesophageal wall disruption), strongly predict OP in patients with PNM. Patients who are asymptomatic and lack these high-risk features are unlikely to have an OP and can probably be managed conservatively without invasive testing. These findings may help clinicians risk-stratify patients with PNM and avoid unnecessary admissions and invasive procedures.