European Journal of Emergency Medicine最新文献

Background and importance: Patients with major trauma face high rates of coagulopathy, hemorrhage, and organ failure, with prehospital resuscitation strategies critical for stabilization. Comparative evidence on prehospital blood [red blood cells (RBCs) and plasma] and non-blood [intravenous crystalloids and dextran, intravenous crystalloids only, and tranexamic acid (TXA)] resuscitation strategies remains limited and inconclusive.

Objectives: To evaluate and compare the efficacy of prehospital blood and non-blood resuscitation strategies in patients with major trauma using network meta-analysis.

Design, settings, and participants: Network meta-analysis of randomized controlled trials (RCTs). Databases: PubMed, CINAHL, Cochrane Library, and Web of Science and reference lists of relevant previous studies. Participants: patients with major trauma.

Intervention or exposure: Prehospital blood (RBC + plasma, RBC, and plasma) and non-blood (intravenous crystalloids + dextran, intravenous crystalloids only, and TXA) resuscitation strategies.

Outcome measure and analysis: Study outcomes were 24-h and 28-day mortality. Data analysis was performed using Frequentist and Bayesian frameworks on MetaInsight, an R-Language web-based analytical platform, presenting odds ratio (OR) and corresponding 95% confidence interval (95% CI). Ranking of prehospital resuscitation strategies was confirmed by the surface under cumulative ranking.

Main results: A total of 15 RCTs involving 7504 participants were included. Compared with intravenous crystalloids only, RBC + plasma (OR: 0.68, 95% CI: 0.38-1.22), plasma (OR: 0.72, 95% CI: 0.46-1.16), TXA (OR: 0.73, 95% CI: 0.52-1.04), RBC (OR: 0.81, 95% CI: 0.22-3.08), and intravenous crystalloids + dextran (OR: 0.91, 95% CI: 0.65-1.28) demonstrated no significant difference in reducing 24-h mortality. Similarly, TXA (OR: 0.83, 95% CI: 0.35-1.92), intravenous crystalloids + dextran (OR: 0.84, 95% CI: 0.46-1.52), RBC + plasma (OR: 0.88, 95% CI: 0.21-3.73), RBC (OR: 0.94, 95% CI: 0.10-8.64), and plasma (OR: 0.97, 95% CI: 0.38-2.46) revealed no significant difference in reducing 28-day mortality compared with intravenous crystalloids only. Based on ranking probabilities, RBC + plasma (65.8%) for 24-h mortality and TXA (74.6%) for 28-day mortality were ranked highest.

Conclusion: Prehospital blood (RBC + plasma, RBC, and plasma) and non-blood (intravenous crystalloids + dextran and TXA) resuscitation strategies were associated with comparable nonsignificant effects on early and late mortality. Current evidence is insufficient to support the superiority of a single prehospital intervention with future large-scale RCTs needed to clarify role of prehospital blood and non-blood resuscitation strategies.

Background and importance: Peripheral venous line placement is an essential procedure, but sometimes technically complex in emergency departments, particularly among patients with difficult vascular access. First-attempt failure rates are a commonly reported adverse event. Alternative procedures, such as ultrasound-guided peripheral venous line placement, require specialised training and resources, thus limiting their feasibility in urgent settings.

Objective: This trial evaluated the effectiveness of a venous transillumination device compared with the usual method.

Design, settings, and participants: This was a prospective, multicentre, cluster-randomised, and open-label study conducted across three hospitals in France between December 2021 and July 2023. Patients aged greater than or equal to18 years were included if they met at least one of nine predefined criteria for difficult vascular access: extreme BMI; hypotension; nonsupportive environment (e.g. poor lighting, incarceration, and external temperature <3 °C); history of drug abuse; limited venous capital (e.g. chemotherapy, long-term corticosteroid use, and radiotherapy); restricted puncture sites (e.g. arteriovenous fistula, hemiplegia, skin lesions, lymph node dissection, and postmastectomy); dehydration; generalised oedema; and hypothermia.

Interventions: Participants were allocated to either the venous transillumination device group (intervention) or the usual method group (control) based on the week of inclusion.

Outcome measures and analysis: The primary outcome was the percentage of first-attempt success rate. The secondary outcomes included the number of attempts before success, patients' pain, and nurses' stress levels.

Main results: A total of 401 patients were included (181 in the control group and 220 in the intervention group). Median age was 62 (43-76), and 62% were women. Compared with the control group, the first-attempt success rate was significantly higher in the venous transillumination group: 70 vs. 41% [difference in percentage 29% (28 - 30%); P  < 0.001]. The median number of attempts before success was lower [0.0 (0.0-1.0) vs. 1.0 (0.0-2.0); P  < 0.001]. Patients' pain and nurses' stress scores did not differ between groups.

Conclusion: In this study, the use venous transillumination device was associated to a significant improvement of the first-attempt success rate of peripheral venous line placement in patients with difficult access.

Background and importance: Low back pain (LBP) is a common reason for emergency department (ED) visits, but its management remains variable across sites and providers. Opioid use for acute LBP is controversial, and possible gender-related disparities in prescribing practices have been reported in other clinical settings. Understanding whether such disparities exist in ED care is important for ensuring equitable treatment.

Objective: We aimed to determine whether patient gender influences the likelihood of opioid administration in the ED for acute LBP.

Design: Multicenter retrospective observational cohort study.

Settings and participants: Seventeen French EDs participated. Adults aged 20-55 years presenting between 1 January and 1 July 2024, with acute mechanical LBP of less than 6 weeks' duration and without clinical red flags were included.

Exposure: The exposure of interest was patient gender. Pain severity was assessed at triage using the Numeric Rating Scale (NRS).

Outcome measures and analysis: The primary outcome was opioid administration in the ED. Opioid use was first compared between men and women across pain severity categories (mild: NRS 1-3, moderate: 4-6, severe: 7-10). Multivariable logistic regression adjusted for initial NRS was then performed, and sensitivity analyses using multiple imputation addressed missing NRS values.

Main results: A total of 558 patients were included, of whom 236 (42.3%) were women. The median initial NRS was 5.0 [interquartile range (IQR): 3-7]; 61 patients (10.9%) had missing NRS values. Overall, opioids were administered in 43.9% of visits (codeine 12.7%, tramadol 14.9%, and morphine 19.4%). No significant gender differences were observed across pain categories: mild [20.6 vs. 17.9%; odds ratio (OR): 1.19, 95% confidence interval (CI): 0.40-3.39], moderate (50.7 vs. 42.0%; OR: 1.42, 95% CI: 0.78-2.58), and severe (73.3 vs. 72.3%; OR: 1.05, 95% CI: 0.52-2.10). In multivariable analysis, gender was not associated with either opioid use (OR: 1.16, 95% CI: 0.77-1.75) or morphine use (OR: 1.14, 95% CI: 0.69-1.89). Sensitivity analyses yielded similar findings.

Conclusion: In this multicenter retrospective study, gender did not significantly influence opioid or morphine administration in patients presenting with acute low back pain in the ED.