Emergency Medicine Journal最新文献

Management of out-of-hospital cardiac arrest (OHCA) in a pregnant patient is challenging, both logistically and emotionally. This review explores the adaptations to resuscitation in pregnancy; the indications and preparation for prehospital resuscitative hysterotomy (RH); the surgical procedure; and the post-procedure care. Prehospital clinicians should train for RH in their teams to maximise the chances of maternal and fetal survival. Further research is needed to understand the incidence of maternal OHCA, how we can improve the chain of survival and the duration of maternal cardiac arrest before RH becomes futile to inform future guidelines.

We approach emergency department delay-related harm as though it were a distinct condition and explore use of an explicit cost-effectiveness threshold as a guide to management. Based on the reported association of delayed emergency admission with short-term mortality, to prevent loss of one quality-adjusted life year per patient harmed in Ireland, annual resources equivalent to 70 additional bed years, or infrastructure funding for 90 new beds, could be considered cost-effective. The additional commitment represents under 1% of annual public acute hospital sector expenditure in Ireland, an OECD member country.

Background: Young febrile infants are at high risk of invasive bacterial infections (IBIs). Clinical Decision Aids (CDA) such as the Step-by-Step and Paediatric Emergency Care Applied Research Network (PECARN) use Procalcitonin (PCT), limiting their application in settings without PCT access. This study aimed to test the performance of these CDAs in a UK cohort.

Methods: This was a planned analysis of the Febrile Infant Diagnostic Assessment and Outcome Study, a large, prospective multicentre observational study conducted across over 30 sites in the UK. Febrile infants (0-90 days of age) with complete biomarker data, who also underwent PCT testing, were included. Two CDAs, PECARN and Step-by-Step, were applied to the cohort, using their recommended low-risk criteria. The diagnostic performance of the CDAs was analysed.

Results: Of the 1527 infants who completed biomarker testing in the main study, 442 had PCT testing and were included, 22 (5%) were diagnosed with an IBI. PECARN and Step-by-Step CDAs demonstrated sensitivities of 1.00 (95% CI: 0.85 to 1.00) and 0.96 (95% CI: 0.77 to 1.00) respectively. The PECARN CDA performed with a specificity of 0.14 (95% CI: 0.11 to 0.18) identifying 14% of the participants as low-risk and did not misclassify any infants. The Step-by-Step CDA performed with a specificity of 0.15 (95% CI: 0.12 to 0.19) identifying 14% of the participants as low-risk and misclassifying one participant with IBI as low-risk.

Conclusion: Both PECARN and Step-by-Step CDAs demonstrated high sensitivity for detecting IBI in our cohort. While specificity was relatively low, these tools could potentially identify a subset of low-risk infants suitable for less intensive management.

A focused literature review assessed whether starting therapeutic anticoagulation (AC) during or soon after hospitalisation for sepsis-induced new-onset atrial fibrillation (AF) affects stroke or bleeding risk. Four observational studies were identified. None demonstrated a significant reduction in stroke risk with AC, and one large study found a paradoxical increase in stroke among patients taking anticoagulants. Bleeding risk was not consistently increased, and one study reported reduced mortality with AC. Overall, current evidence does not support the routine use of AC for stroke prevention in patients with sepsis-induced new-onset AF. A randomised controlled trial is needed to clarify the role of AC in this population.