Emergency Medicine Journal最新文献

Background and aim: The passage of kidney stones through the ureter creates renal colic, a severe visceral abdominal pain. Renal colic is typically managed with non-steroidal anti-inflammatory drugs and opioids. Yet, these treatments often fail to provide adequate pain relief. The erector spinae plane block (ESPB) has emerged as a potential alternative treatment. This systematic review summarises the current body of evidence on the efficacy and safety of ESPB for renal colic in the ED.

Methods: A systematic review and meta-analysis of randomised controlled trials (RCTs) and case series of ESPB in ED patients were conducted. PubMed, EMBASE, Web of Science and ClinicalTrial.gov databases were electronically searched up to 10 June 2024, for studies that compared ESPB with standard care or placebo. The Cochrane risk of bias-2 tool was used to assess the risk of bias of included studies. Meta-analysis using a random effects model was performed if two or more studies reported the same outcome. The Grading of Recommendations Assessment, Development, and Evaluation tool was used to assess the certainty of the evidence.

Results: Four studies were included, including two RCTs and two case series. A total of 53 patients received an ESPB, compared with 40 patients who received standard care. All studies were rated as having a high overall risk of bias. Meta-analysis showed a large and significant effect of ESPB on pain reduction after 30 min (standardised mean difference (SMD) -1.41 95% CI -1.90 to -0.91) and after 60 min (SMD -1.94 95% CI -3.36 to -0.52), however the level of evidence was downgraded to very low certainty due to substantial heterogeneity (I²=85%), serious concerns of bias and large imprecision. Heterogeneity in other outcome measurements precluded meta-analysis.

Conclusions: Although statistically significant, there is a low certainty regarding the positive effect of ESPB on pain reduction for renal colic in the ED. High-quality RCTs focusing on patient-reported outcomes are needed to establish the merit of ESPB for this indication.

Prospero registration number: CRD42024554077.

Background: Attempting to improve emergency care (EC) advanced clinical practitioner (ACP) training, Health Education England (HEE) South West (SW) implemented a pilot, whereby emergency departments (ED) were provided with enhanced funding and support to help ED consultants deliver teaching and supervision to EC ACPs to ensure more timely completion of EC ACP training compared with previous cohorts training in the region.We explored the experiences of trainee EC ACPs and consultant EC ACP leads working in EDs, which had implemented the new regional pilot.

Methods: We used a qualitative design to conduct semi-structured interviews with trainee EC ACPs and consultant EC ACP leads across five EDs that had implemented the HEE SW pilot. Interview data were analysed thematically.

Results: Twenty-five people were interviewed. We identified four themes: (1) the master's in advanced practice could be better aligned with the Royal College of Emergency Medicine credentialling e-portfolio; (2) EC ACP training needs some flexibility to reflect the individual-'one size does not fit all'; (3) supervision and teaching were recognised as important but requires significant staff capacity that is impacted by external pressures and (4) unclear role expectations and responsibilities hinder role transition and impact role identity.It was notable that EC ACPs primarily spoke about the development of their clinical skills both academically and within the workplace, despite there being other skills mentioned in the multiprofessional framework for advanced practice (leadership and management, education and research).

Conclusion: A clear supervision structure with protected time allocated for teaching and assessment of clinical skills within the ED is essential to facilitate trainee EC ACP progression. However, increasing demands on EDs make this a challenging goal to achieve. Role identity issues continue to persist despite the introduction of new guidance designed to provide more clarity around the ACP role.

Background: The role of video laryngoscopy in critically ill patients requiring emergency tracheal intubation remains controversial. This systematic review and meta-analysis aimed to evaluate whether video laryngoscopy could improve the clinical outcomes of emergency tracheal intubation.

Methods: We searched the PubMed, Embase, Scopus and Cochrane databases up to 5 September 2024. Randomised controlled trials comparing video laryngoscopy with direct laryngoscopy for emergency tracheal intubation were analysed. The primary outcome was the first-attempt success rate, while secondary outcomes included intubation time, glottic visualisation, in-hospital mortality and complications.

Results: Twenty-six studies (6 in prehospital settings and 20 in hospital settings) involving 5952 patients were analysed in this study. Fifteen studies had low risk of bias. Overall, there was no significant difference in first-attempt success rate between two groups (RR 1.05, 95% CI 0.97 to 1.13, p=0.24, I²=89%). However, video laryngoscopy was associated with a higher first-attempt success rate in hospital settings (emergency department: RR 1.13, 95% CI 1.03 to 1.23, p=0.007, I²=85%; intensive care unit: RR 1.16, 95% CI 1.05 to 1.29, p=0.003, I²=68%) and among inexperienced operators (RR 1.15, 95% CI 1.03 to 1.28, p=0.01, I²=72%). Conversely, the first-attempt success rate with video laryngoscopy was lower in prehospital settings (RR 0.75, 95% CI 0.57 to 0.99, p=0.04, I²=95%). There were no differences for other outcomes except for better glottic visualisation (RR 1.11, 95% CI 1.03 to 1.20, p=0.005, I²=91%) and a lower incidence of oesophageal intubation (RR 0.42, 95% CI 0.24 to 0.71, p=0.001, I²=0%) when using video laryngoscopy.

Conclusions: In hospital settings, video laryngoscopy improved first-attempt success rate of emergency intubation, provided superior glottic visualisation and reduced incidence of oesophageal intubation in critically ill patients. Our findings support the routine use of video laryngoscopy in the emergency department and intensive care units.

Prospero registration number: CRD 42023461887.

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.