Emergency Medicine Journal最新文献

Background: Emergency Medical Services (EMS) studies have shown that prehospital risk stratification and triage decisions in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) can be improved using clinical risk scores with point-of-care (POC) troponin. In current EMS studies, three different clinical risk scores are used in patients suspected of NSTE-ACS: the prehospital History, ECG, Age, Risk and Troponin (preHEART) score, History, ECG, Age, Risk and Troponin (HEART) score and Troponin-only Manchester Acute Coronary Syndromes (T-MACS). The preHEART score lacks external validation and there exists no prospective comparative analysis of the different risk scores within the prehospital setting. The aim of this analysis is to externally validate the preHEART score and compare the diagnostic performance of the these three clinical risk scores and POC-troponin.

Methods: Prespecified analysis from a prospective, multicentre, cohort study in patients with suspected NSTE-ACS who were transported to an ED between April 2021 and December 2022 in the Netherlands. Risk stratification is performed by EMS personnel using preHEART, HEART, T-MACS and POC-troponin. The primary end point was the hospital diagnosis of NSTE-ACS. The diagnostic performance was expressed as area under the receiver operating characteristic (AUROC), sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV).

Results: A total of 823 patients were included for external validation of the preHEART score, final hospital diagnosis of NSTE-ACS was made in 29% (n=235). The preHEART score classified 27% as low risk, with a sensitivity of 92.8% (95% CI 88.7 to 95.7) and NPV of 92.3% (95% CI 88.3 to 95.1). The preHEART classified 9% of the patients as high risk, with a specificity of 98.5% (95% CI 97.1 to 99.3) and PPV of 87.7% (95% CI 78.3 to 93.4). Data for comparing clinical risk scores and POC-troponin were available in 316 patients. No difference was found between the preHEART score and HEART score (AUROC 0.83 (95% CI 0.78 to 0.87) vs AUROC 0.80 (95% CI 0.74 to 0.85), p=0.19), and both were superior compared with T-MACS (AUROC 0.72 (95% CI 0.66 to 0.79), p≤0.001 and p=0.03, respectively) and POC-troponin measurement alone (AUROC 0.71 (95% CI 0.64 to 0.78), p<0.001 and p=0.01, respectively).

Conclusion: On external validation, the preHEART demonstrates good overall diagnostic performance as a prehospital risk stratification tool. Both the preHEART and HEART scores have better overall diagnostic performance compared with T-MACS and sole POC-troponin measurement. These data support the implementation of clinical risk scores in prehospital clinical pathways.

Trial registration number: NCT05243485.

People experiencing the highest levels of social deprivation are more likely to present to emergency care across the spectrum of disease severity, and to have worse outcomes following acute illness. Emergency medicine in the UK and Europe has lagged behind other regions in incorporating social emergency medicine into practice. There is evidence that emergency clinicians have the potential to mitigate health inequalities, through advocacy and intervention supported by high-quality research, while also acknowledging the limitations intrinsic to the environment in which they work.

There are approximately 180 000 deaths per year from thermal burn injury worldwide. Most burn injuries can be treated in local hospitals but 6.5% require specialist burn care. The initial ED assessment, resuscitation and critical care of the severely burned patient present significant challenges and require a multidisciplinary approach. The management of these patients in the resuscitation room impacts on the effectiveness of continuing care in the intensive care unit. The scope of the present practice review is the immediate management of the adult patient with severe burns, including inhalation injury and burn shock. The article uses an illustrative case to highlight recent developments including advanced airway management and the contemporary approach to assessment of fluid requirements and the type and volume of fluid resuscitation. There is discussion on new options for pain relief in the ED and the principles governing the early stages of burn intensive care. It does not discuss minor injuries, mass casualty events, chemical or radiation injuries, exfoliative or necrotising conditions or frost bite.

Background: Ultrasound-guided (USG) erector-spinae plane block (ESPB) may be better than intravenous opioids in treating acute hepatopancreaticobiliary (HPB) pain in the ED.

Methods: This open-label randomised controlled trial was conducted in the ED of a tertiary-care hospital between March and August 2023. All adult patients with severe HPB pain were recruited during times that a primary investigator was present. Unconsenting patients, numeric rating scale (NRS) ≤6, age ≤18 and ≥80 years, pregnant, unstable or with allergies to local anaesthetics or opioids were excluded. Patients in the intervention arm received bilateral USG ESPB with 0.2% ropivacaine at T7 level, by a trained ED consultant, and those in the control arm received 0.1 mg/kg intravenous morphine. Pain on a 10-point NRS was assessed by the investigators at presentation and at 1, 3, 5 and 10 hours after intervention by the treatment team, along with rescue analgesia requirements and patient satisfaction. Difference in NRS was analysed using analysis of co-variance (ANCOVA) and t-tests.

Results: 70 participants were enrolled, 35 in each arm. Mean age was 40.4±13.2 years, mean NRS at presentation in the intervention arm was 8.0±0.9 and 7.6±0.6 in the control arm. NRS at 1 hour was significantly lower in the ESPB group (ANCOVA p<0.001). At 1, 3, 5 and 10 hours, reduction of NRS in the intervention arm (7±1.6, 6.7±1.9, 6.6±1.8, 6.1±1.9) was significantly greater than the control arm (4.4±2, 4.6±1.8, 3.7±2.2, 3.8±1.8) (t-test, p<0.001). Fewer patients receiving ESPB required rescue analgesia at 5 (t-test, p=0.031) and 10 hours (t-test, p=0.04). More patients were 'very satisfied' with ESPB compared with receiving only morphine at each time period (p<0.001).

Conclusion: ESPB is a promising alternative to morphine in those with HPB pain.

Trial registration number: CTRI/2023/03/050595.