Emergency Medicine Journal最新文献

A shortcut review of the literature was conducted to examine the sensitivity and specificity of point-of-care ultrasound (POCUS) in detecting paediatric skull fractures. A total of 162 publications were screened by title and abstract, 13 studies underwent full text review, and after review of bibliographies of meta-analyses and systematic reviews, a total of 6 articles were included. Details about the author, date of publication, country of publication, patient group studied, study type, relevant outcomes (skull fracture), results and study limitations were tabulated. The clinical bottom line is that, in paediatric patients with a minor head injury, POCUS performed by emergency medicine physicians has a sensitivity ranging between 77% and 100% and a specificity between 85% and 100% for skull fracture detection, and its use in clinical decision-making has yet to be validated.

Introduction: Civilian healthcare workers (HCW) and medical facilities are directly and indirectly impacted by armed conflict. In the Russia-Ukraine war, acute trauma care needs grew, the workforce was destabilised by HCW migrating or shifting roles to meet conflict needs, and facilities faced surge events. Chemical, biological, radiological, nuclear and explosive (CBRNE) exposure risks created unique preparedness needs. In response, an academic and international non-governmental organisation partnership was formed to design, implement and evaluate a locally prioritised training programme in Ukraine.

Methods: Seven in-person training courses (Advanced Trauma Life Support, Trauma Nursing Fundamentals, Pediatric Trauma Fundamentals, Prehospital Trauma Fundamentals, Stop the Bleed, Mass Casualty Management and CBRNE Preparedness) were adapted, translated, taught and evaluated in seven Ukrainian oblasts (regions; Kyiv, Dnipropetrovsk, Zaporizhzhia, Odesa, Lviv, Chernihiv and Mykolaiv) during the war. Topics were determined by available needs assessments and further adapted based on course participant feedback and evolving logistic and security challenges. Change in participant knowledge and confidence levels was assessed through precourse and postcourse knowledge and self-confidence evaluations and follow-up surveys. Initial courses were taught by international instructors and transitioned to Ukrainian instructors as they were trained. Web-based asynchronous videos in Ukrainian were developed to complement and reinforce in-person training.

Results: 4368 participants were trained in 164 courses from August 2022 to April 2023. 223 instructors were trained. Aggregate participant knowledge and self-confidence significantly improved in all courses. Interval follow-up responses indicated that the training was useful and 83.3% had used the skills within 8 weeks of training. Twenty-seven training videos were created which, as of April 2023, have been viewed over 1 700 000 times in 500 cities throughout Ukraine.

Conclusions: Locally prioritised training can be rapidly developed and delivered in an armed conflict setting providing civilians and frontline HCW with the skills and knowledge required to care for patients. Logistics, communication, equipment and security challenges can be overcome through strategic in-country partnerships. Short asynchronous video learning can complement and scale in-person training.

Background: Ultrasound is now readily available in the prehospital setting and its use has been highlighted as one of the top research priorities in prehospital care. Clinical examination remains the standard care for diagnosing lung injury in the prehospital setting, yet this can be challenging and has poor diagnostic accuracy. This review evaluates the accuracy of prehospital ultrasound for the diagnoses of pneumothorax, haemothorax and pulmonary contusions in patients with trauma.

Methods: A systematic review and meta-analysis was conducted. MEDLINE/PubMed, CINAHL, Embase and the Cochrane Library were searched. Only papers reporting on the diagnostic accuracy of lung ultrasound for traumatic pneumothorax, haemothorax or pulmonary contusions; in a prehospital or helicopter emergency medical service setting; and with CT or operative findings as a reference standard, were included. Non-English studies or articles that reported on animal studies were excluded. The Quality Assessment of Diagnostic Accuracy Studies-2 was used to assess the methodological quality of the included studies.

Results: Six observational studies, four with low risk of bias and two with some concerns, reporting on 1908 thoracic ultrasound examinations in patients with trauma, were included. For pneumothorax, meta-analysis yielded pooled sensitivity of 29% (95% CI 22% to 37%, I²=0%) and pooled specificity of 98% (95% CI 97% to 99%, I²=0%). Insufficient data were reported for a reliable meta-analysis on the presence of haemothorax. Only one study reported on the presence of pulmonary contusions and therefore no analysis was conducted.

Conclusion: Prehospital ultrasound is highly specific but has a lower sensitivity for the presence of pneumothorax when compared with hospital studies. Further research is required, alongside education and training of prehospital providers, to further explore the factors that account for the differences observed in this review.

Prospero registration number: CRD42023365034.

Background: Ambulance clinicians use pre-alert calls to inform emergency departments (EDs) about the arrival of critically ill patients. However, there is variation in guidance between local ambulance service policies in terms of what should be pre-alerted and how pre-alerts should happen. We conducted a national online survey to understand the use of ambulance pre-alerts and to inform recommendations for practice and guidance.

Methods: Ambulance clinicians in England involved in pre-alert decision-making were recruited via ambulance trusts and social media to complete an anonymous online survey conducted during May-July 2023. Quantitative data was analysed descriptively using SPSS (version 28) and free-text responses are reported to illustrate the quantitative findings.

Results: We included 1298 valid responses from 10 English ambulance services. There was variation in practice at all stages of the pre-alert process, including the reported frequency of pre-alert (7.1% several times a shift, 14.9% once/two times per month). Most respondents reported that pre-alerts were delivered directly to the ED, but 32.8% reported pre-alerting via an ambulance control room. A third of respondents always used mnemonics to guide a pre-alert (eg, ATMIST (Age, Time of Incident, Mechanism of injury, Injuries, Signs, Treatments)), but 10.2% reported not using any fixed format.The type of guidance used to identify patients for pre-alert varied between clinicians and ambulance services, with local ambulance service guidance being most commonly used, and 20% stating they never use national guidelines. Respondents reported variable understanding of appropriate conditions for pre-alert, with paramedic students particularly wanted further guidance on trauma in older patients and medical pre-alerts. 29% of respondents reported receiving specific pre-alert training, while 50% reported never receiving feedback.

Conclusion: We identified variation in pre-alert processes and practices that may result in uncertainty and challenges for ambulance clinicians providing time-critical care. Guidance and training on the use of pre-alerts may promote more consistent processes and practices.

Background: On-scene improvised and interim decontamination protocols in the Initial Operational Response to chemical incidents aim for rapid intervention to minimise injury before specialist capabilities arrive. This study examines the effectiveness of UK improvised and interim protocols conducted in sequence.

Method: A simulant with methyl salicylate (MeS) in vegetable oil and a fluorophore was applied to participants' shoulders, arms and legs. Participants either received no decontamination or used one of four decontamination protocols: improvised dry, improvised wet, improvised dry followed by interim or improvised wet followed by interim. Remaining simulant on the skin was quantified using gas chromatography tandem mass spectrometry for MeS analysis and UV imaging for fluorophore detection. Additionally, urine samples were collected for 8 hours post application to analyse MeS levels.

Results: Significantly less simulant was recovered from the skin post decontamination compared with no decontamination. There were no differences in the total simulant recovered across all decontamination conditions. However, significantly more simulant was recovered from the shoulder compared with the arm and leg. Variation in simulant recovery from different application areas was significantly higher in improvised-only conditions than in combined conditions. Decontamination did not affect the amount of MeS excreted in urine over 8 hours.

Conclusion: This research supports current practice of starting decontamination as soon as possible after chemical exposure and highlights the importance of implementing interim decontamination following improvised decontamination.

Objectives: Underutilisation of thrombolysis is a major problem in patients with stroke in Bangladesh as patients do not arrive within the therapeutic window due to delays in their way to emergency department. This study aims to assess the time delay from patients' symptom onset to arrival in the hospital and the factors that are associated with it.

Methods: This cross-sectional survey of a prospective cohort of stroke patients was conducted between January and March 2023. 448 stroke patients meeting the inclusion criteria were enrolled in the study from five tertiary-level hospitals in Bangladesh. After obtaining informed consent, trained data collectors conducted face-to-face interviews of the patient/patients' guardians via a pretested structured questionnaire. Stata (V.16) was used to analyse data. Median and IQRs were used to summarise quantitative variables, and qualitative variables were summarised using frequency and relative frequency. Pearson's χ² test and Mann-Whitney U test were used to explore the bivariate relationship between predictor and outcome variables. Finally, a binary logistic regression model was fit to explore the factors associated with delayed arrival (>4.5 hours) at the hospital.

Results: The median age of the patients was 61 years (54-70) and 63% were men. The majority hailed from rural (59.6%) areas and had primary (25.89%) education. The patients had an overall median prehospital delay of 14 (8-28) hours, 3 (1-6) hours of decision delay, 1 (0-2) hours of medical contact delay, and 14 (6.5-25.75) hours of referral delay. Patients with master's education (adjusted OR (AOR): 0.04, p=0.023) and private transport (AOR: 0.26, p=0.029) had a lower chance of late arrival. However, patients having unknown onset, self-medicating, having a previous history of stroke, and being admitted to a private hospital had a significantly higher chance of late arrival.

Conclusion: Nearly 90% of the patients were late to arrive (>4.5 hours) at hospital and referral delay comprises the majority of the prehospital delay. Therefore, fast symptom recognition and the urgency of seeking healthcare as soon as symptoms appear should be the focus of public awareness efforts.