Emergency Medicine Journal最新文献

Background: When delivering nasal high flow (NHF) therapy in a medical ward, a high dependency unit or an intensive care unit, automated oxygen titration increases time spent within a target oxygen saturation (SpO₂) range compared with standard, manually titrated oxygen. This study explores whether this improvement is also seen when titrating oxygen with NHF in an emergency department (ED).

Method: This open-label, parallel groups, randomised controlled trial compared automated to manual oxygen titration using NHF therapy in hypoxaemic adult patients in the Wellington Regional Hospital ED between October 2022 and December 2023. Participants with a prescribed target SpO₂ range who demonstrated a minimum oxygen requirement were eligible for inclusion. A rank-based comparison was used for the primary outcome, the proportion of time spent within the target SpO₂ range of 92%-96%, or 88%-92% if at risk of hypercapnia, among participants achieving ≥30 min of therapy. An interaction term was applied to assess whether the proportion of time spent within target SpO₂ range depended on the prescribed target range itself (SpO₂ 92%-96% or 88%-92%).

Results: 83 participants were screened, 52 were randomised and 49 had data for the primary endpoint. Median (IQR) proportion of time spent within the target SpO₂ range with automated oxygen (n=25) was 96.4% (92.5% to 99.4%) compared with 89.9% (69.8% to 97.2%) with manually adjusted oxygen (n=24); difference (95% CI) 8.0% (1.7% to 16.9%), p=0.01. There was no evidence that the proportion of time spent within target SpO₂ range depended on the selected target SpO₂ range, P-interaction 0.60.

Conclusion: Automatically titrated oxygen therapy significantly increased time spent within a target SpO₂ range, compared with manual oxygen titration in adult patients receiving NHF therapy in the ED.

Background: Emergency departments (EDs) offer a valuable opportunity to intervene to support people to quit smoking. We sought to determine the effectiveness of smoking cessation interventions delivered in the ED setting on rates of abstinence at the longest follow-up.

Methods: We undertook a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines considering only randomised controlled trials (RCTs), based in the ED, where the goal of the intervention was smoking cessation and follow-up was at least 3 months. We systematically searched electronically published literature and trial registries from inception to May 2025. We pooled data using a Mantel-Haenszel random-effects model for behavioural interventions without pharmacotherapy, and using a fixed-effects model for interventions incorporating nicotine replacement therapy (NRT), with results reported as risk ratios (RR) and 95% CIs. The primary outcome was smoking cessation using the strictest available measure, biochemically validated where possible. Risk of bias was assessed using the Cochrane risk of bias tool. Certainty of overall evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation).

Results: Nineteen RCTs met inclusion criteria, of which 17 were deemed suitable for incorporating into meta-analyses. Participants randomised to receive a smoking cessation intervention involving NRT in the ED were significantly more likely to achieve abstinence (RR 1.55, 95% CI 1.27 to 1.89, p<0.0001, 6 RCTs, n=3528, I²=46%). Trials involving behavioural support alone delivered in the ED had an RR of quitting compared with controls of 1.18 (95% CI 0.85 to 1.64, p=0.32, 11 RCTs, N=4711, I²=37%). Of the 17 studies included in the meta-analyses, 14 were at high risk of bias, 1 at low risk and 2 where the risk was unclear. One study incorporated e-cigarettes and was not incorporated in the meta-analysis but demonstrated evidence of effectiveness.

Conclusion: There is moderate certainty evidence that smoking cessation interventions incorporating pharmacotherapy delivered in the ED are effective in supporting smoking cessation.

Introduction: Feedback is a vital yet underused tool for improving clinical outcomes in prehospital emergency care. This study aimed to develop and pilot a novel, theoretically grounded feedback mechanism for helicopter emergency medical service (HEMS) clinicians involved in out-of-hospital cardiac arrest (OHCA) in the East of England, UK.

Methods: Semistructured interviews were conducted in September 2022 with HEMS clinicians from Essex & Herts Air Ambulance, and the feedback process was co-designed with the Essex Cardiothoracic Centre (Essex, UK). Using the COM-B model (Capability, Opportunity, Motivation-Behaviour), we conducted qualitative interviews with prehospitalists (seven paramedics, three prehospital doctors) to explore gaps in existing feedback processes and identify their information needs, then iteratively co-developed a structured feedback proforma with stakeholders.

Results: Three themes emerged, specifically about weaknesses in current feedback and preferences for an improved system: (1) dissatisfaction with current ad hoc, 'punitive' approaches; (2) the educational and emotional importance of timely, targeted feedback; and (3) a strong preference for standardised, confidentiality-compliant delivery methods. The resulting feedback proforma included working diagnoses, key investigations completed, optimisation opportunities and patient outcomes (if already available), to be delivered within 24-48 hours of hospital admission.

Conclusions: Our study underscores the importance of stakeholder-driven development in shaping an effective prehospital feedback mechanism for OHCA aligned to clinicians' needs. By exploring feedback preferences and mapping insights onto the COM-B model, we highlight how knowledge, context and motivation can all steer behavioural change. Further research is needed in diverse emergency medical service contexts to test its impact on clinical practice and patient outcomes.

Objective: To evaluate whether intra-arrest diastolic blood pressure (DBP) and coronary perfusion pressure (CPP) are associated with improved return of spontaneous circulation (ROSC) in cardiac arrest.

Methods: A systematic search (PROSPERO registration: CRD420251042344) was conducted in English on EMBASE, MEDLINE, CINAHL and the Cochrane Library from inception to 1 May 2025. Grey literature sources (trial registries, conference abstracts, Google Scholar) were searched. Key resuscitation experts were contacted to identify unpublished or ongoing studies. The search strategy was peer-reviewed using the Peer Review of Electronic Search Strategies checklist. Eligible studies included randomised controlled trials (RCTs) contributing cohort data, observational studies and case series (≥10 patients) monitoring intra-arrest DBP or CPP in adult patients with cardiac arrest managed in prehospital or emergency department settings. Study selection involved two reviewers independently screening titles and abstracts, and full-text articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias in Non-randomised Studies of Interventions tools. This research received no funding.

Results: 15 studies (n=970 patients) across seven countries were included: 3 RCT-based prospective cohort studies and 12 observational studies. Meta-analysis was not performed due to heterogeneity in study designs. Aziz et al identified a DBP threshold of 35 mm Hg associated with ROSC (p<0.001), reporting a 5% increase in ROSC odds for every 1 mm Hg rise in DBP. This finding was supported by other observational studies reporting significantly higher maximum DBP values in patients with ROSC (34-56.5 mm Hg) compared with those without ROSC. Interventional studies aimed at augmenting DBP or CPP-including resuscitative endovascular balloon occlusion of the aorta-generally reported increases in ROSC, though studies were underpowered and at high risk of bias.

Conclusions: This review demonstrates an association between intra-arrest DBP and CPP and ROSC. DBP may provide a feasible clinical target, but definitive thresholds and their impact on survival to hospital discharge remain undefined.

Prospero registration number: CRD420251042344.

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.