European Journal of Emergency Medicine最新文献

Acute dyspnea is a common symptom whose management is challenging in prehospital settings. Point-of-care ultrasound (POCUS) is increasingly accessible because of device miniaturization. To assess the contribution of POCUS in the prehospital management of patients with acute nontraumatic dyspnea, we performed a systematic review on nontrauma patients of any age managed in the prehospital setting for acute dyspnea and receiving a POCUS examination. We searched seven databases and gray literature for English-language studies published from January 1995 to November 2023. Two independent reviewers completed the study selection, data extraction, and risk of bias assessment. The primary outcome was the assessment of the contribution of POCUS to feasibility, diagnostic, therapeutic, prognosis, patient referral, and transport vector modification. Twenty-three studies were included. The risk of bias assessment identified 3 intermediate-risk, 18 serious-risk, and 2 critical-risk studies. Three studies reported moderate to excellent feasibility for lung POCUS, and three studies reported poor to mediocre feasibility for cardiac POCUS. The median duration of the POCUS examination was less than 5 minutes (six studies). POCUS improved diagnostic identification (seven studies). The diagnostic accuracy of POCUS was excellent for pneumothorax (sensitivity = 100%, specificity = 100%, two studies), very good for acute heart failure (sensitivity = 71-100%, specificity = 72-95%, eight studies), good for pneumonia (sensitivity = 88%, specificity = 59%, one study), and moderate for pleural effusion (sensitivity = 26-53%, specificity = 83-92%, two studies). Treatment was modified in 11 to 54% of the patients (seven studies). POCUS had no significant effect on patient prognosis (two studies). POCUS contributed to patient referrals and transport vectors in 51% (four studies) and 25% (three studies) of patients, respectively. The evidence supports the use of POCUS for managing acute nontraumatic dyspnea in the prehospital setting in terms of feasibility, overall diagnostic contribution, and, particularly, lung ultrasound for acute heart failure diagnosis. Moreover, POCUS seems to have a therapeutic contribution. There is not enough evidence supporting the use of POCUS for pneumonia, pleural effusion, pneumothorax, chronic obstructive pulmonary disease, or asthma exacerbation diagnosis, nor does it support prognostic, patient referral, and transport vector contribution. A high level of evidence is lacking and needed.

Importance: The impact of early antibiotics on mortality in patients with suspected sepsis in the emergency department (ED) remains debated, particularly in patients with less severe presentations or before infection confirmation.

Objective: To evaluate the association between time to antibiotic administration and 28-day in-hospital mortality among patients with suspected sepsis in the ED.

Design, setting, and participants: Post hoc analysis of the 1-bundle emergency department trial, a multicenter, stepped-wedge cluster-randomized controlled trial conducted in 23 EDs in France and Spain. A total of 872 patients with suspected sepsis were included between June 2022 and September 2023. All patients with available data on antibiotic administration were analyzed, and a subgroup of patients with no hypotension was also assessed.

Exposures: Time to antibiotic administration. The effect of time to fluid resuscitation was also assessed.

Main outcomes and measures: The primary outcome was in-hospital mortality at 28 days. Secondary outcomes included all-cause 28-day mortality, ICU length of stay, number of days without vasopressors at day 28, and change in Sequential Organ Failure Assessment score at 72 h.

Results: Among 872 patients (mean age 66 years; 41% female), 859 had available data on antibiotic administration (primary analysis) and 791 (92%) received antibiotics. The median time to antibiotic administration was 61 min (IQR 14-169), with 457 patients (58%) receiving antibiotics within 1 h. In-hospital mortality at 28 days was 14.7% for patients who did not received antibiotic within 1 h versus 9.6% for patients who did [adjusted odds ratio (aOR) 2.00 (1.24-3.23)]. There was an aOR of 1.06 (1.02-1.1) for each hour of delay for antibiotic administration. This effect was confirmed in patients without hypotension [aOR 2.02 (1.08-3.76) for patients who received antibiotics beyond 1 h]. Time to fluid resuscitation was not associated with 28-day in-hospital mortality.

Conclusion and relevance: In patients with suspected sepsis presenting to the ED antibiotic administration beyond 1 h was associated with a two-fold increased 28-day in-hospital mortality. This effect persisted in patients without hypotension.