European Journal of Emergency Medicine最新文献

Objectives: Survivors of out-of-hospital cardiac arrest (OHCA) often develop psychiatric and epilepsy problems. When arrest occurs with trauma, hypoxic-ischemic, and injury-related insults may heighten risks vs. nontraumatic OHCA. This study aimed to estimate 5-year risks of psychiatric disorders and epilepsy after traumatic vs. nontraumatic OHCA, and to examine whether early pharmacologic treatment relates to outcomes.

Methods: This retrospective cohort study utilized deidentified records from the TriNetX U.S. Collaborative Network (January 2010-June 2023). Adults who achieved return of spontaneous circulation and survived longer than 30 days were categorized into traumatic (n = 1477) and nontraumatic (n = 5165) groups. Propensity score matching (1:1, caliper 0.1) was employed to balance the cohorts. Primary outcomes were overall psychiatric disorders including categories of schizophrenia, mood disorders, depressive disorder, other nonpsychotic mental disorders, anxiety disorders (including phobic and other types), and posttraumatic stress disorder (PTSD). The secondary outcome was epilepsy. Kaplan-Meier and Cox models were used to calculate 5-year cumulative incidence and hazard ratios (HRs) with 95% confidence intervals (CI).

Results: The primary outcomes showed that survivors of traumatic OHCA faced greater 5-year risks of overall psychiatric disorders (HR, 1.38; 95% CI, 1.13-1.7) including multiple categories. Hazard ratios of categories were: schizophrenia, 2.23 (95% CI, 1.06-4.68); mood disorders, 1.38 (1.07-1.78); depressive episodes, 1.57 (1.19-2.08); other nonpsychotic mental disorders, 1.51 (1.20-1.92), including phobic anxiety disorders, 1.46 (0.72-2.93) and other anxiety disorders, 1.51 (1.17-1.95); and PTSD, 1.60 (1.02-2.50). The risk of secondary outcome epilepsy increased progressively over time, reaching the highest level at 5 years post-OHCA (HR, 2.06; 95% CI, 1.30-3.26).

Conclusion: Traumatic OHCA survivors had higher long-term risks of psychiatric disorders and epilepsy. Early targeted interventions and structured follow-up may help mitigate these risks, warranting confirmation in future prospective studies.

Background and importance: Rapid sequence intubation in emergency settings may involve opioid pretreatment to blunt hemodynamic responses during laryngoscopy and intubation; however, opioids may lead to postintubation hypotension, increasing morbidity and mortality. Global clinical practice varies significantly, reflecting uncertainty about opioids' benefits and risks.

Objective: Our goal was to evaluate the association between opioid pretreatment and hemodynamic instability, focusing on postintubation hypotension in adult patients undergoing emergency intubation.

Design, settings, and participants: We performed a systematic review of randomized controlled trials and observational studies comparing opioid administration vs. no opioids before adult emergency intubations. Searches included Cochrane, Embase, Medline, Scopus, and Web of Science databases until November 2024. Elective intubations were excluded. Eight (6708 patients) studies met criteria.

Outcomes measure and analysis: The primary outcome was postintubation hypotension, variably defined across studies. Secondary outcomes included hypoxemia, first-attempt success, cardiac arrest, and vasopressor use. Independent reviewers conducted data extraction, risk-of-bias assessments, and certainty evaluation. Results were qualitatively synthesized.

Main results: Among 6708 (2757 opioids and 3951 controls) patients, postintubation hypotension incidence varied widely (risk differences: -12.5% favoring opioids to +13.2% favoring controls). The single low-risk randomized study reported opioids increased hypotension (risk difference: 13%, odds ratio: 2.15, 95% confidence interval: 1.22-3.78). Observational studies yielded inconsistent results. Secondary outcomes showed no consistent differences. Evidence certainty was very low because of risk of bias, inconsistency, and imprecision.

Conclusions: Current evidence regarding opioid pretreatment effect on postintubation hypotension risk during emergency intubation is limited and conflicting.

Background and importance: Emergency airway management in the emergency department (ED) is a high-risk procedure associated with patient outcomes. First-attempt success is a widely recognized quality metric, as multiple attempts are associated with an increased risk of peri-intubation complications. In Brazil, where emergency medicine is a recently established specialty, many ED are staffed by physicians without formal emergency medicine training. The association between emergency medicine training and intubation outcomes in this setting has not been well characterized.

Objective: To assess the association of physician specialty with first-attempt success and immediate peri-intubation complications in Brazilian EDs.

Design: Secondary analysis of a multicenter, prospective cohort study from the Brazilian Airway Registry Cooperation.

Setting and participants: This study included adult patients who underwent tracheal intubation in EDs between March 2022 and April 2024. Patients were excluded if the intubation occurred outside the ED, during cardiopulmonary resuscitation, or for elective procedures. Intubations performed by medical students were also excluded. Physicians were categorized by specialty as emergency medicine or nonemergency medicine.

Outcome measures and analysis: The primary outcome was first-attempt success; secondary outcomes included peri-intubation complications (severe hypoxemia, hemodynamic instability, and cardiac arrest). Multivariable logistic regression was used to assess the association between physician specialty and outcomes.

Main results: Among 2582 patients, 1087 (42.1%) were intubated by emergency physicians and 1495 (57.9%) by other physicians (mainly internal medicine and surgery). Intubations by emergency physicians were associated with a higher rate of first-attempt success [80.4 vs. 70.9%, adjusted odds ratio [aOR]: 1.63, 95% confidence interval (CI): 1.34-1.97]. There was also a higher odds of intubations without major complications (aOR: 1.20, 95% CI: 1.01-1.42).

Conclusion: In this study, there was a higher rate of first-attempt success in intubations performed by board-certified emergency physicians compared with other physicians working in Brazilian EDs.

Background and importance: Although advanced airway management is beneficial for patients with out-of-hospital cardiac arrest (OHCA) in certain situations, the impact of advanced airway management success or failure by the emergency medical service (EMS) crew on the clinical time course and outcomes has not yet been thoroughly evaluated.

Objectives: To evaluate the impact of EMS crew members' prehospital advanced airway management failure on patient outcomes in OHCA.

Design: Retrospective multicentre registry study.

Setting and participants: Data from an OHCA survey in a Japanese retrospective multicentre study conducted between 2019 and 2021 were reviewed.

Outcome measures and analysis: Patients who underwent advanced airway management were divided into success and failure groups. The baseline characteristics and outcomes of the two groups were evaluated. Propensity score matching was performed by creating matched success and failure groups to analyse sensitivity. The primary outcome was 30-day survival, and secondary outcomes were favourable neurological outcomes at discharge, time from on-scene EMS arrival to hospital arrival, and return of spontaneous circulation (ROSC).

Main results: Overall, 4474 patients who underwent prehospital advanced airway management were analysed. Among them, 4074 and 400 patients were in the success and failure groups, respectively. The 30-day survival rates (success vs. failure, 4.4 vs. 2.3%; P  = 0.043) and ROSC (29.9 vs. 16.8%; P  < 0.001) in the failure group were lower than those in the success group. There were no significant differences in survival rate at hospital discharge (3.6 vs. 2.0%; P  = 0.093) and favourable neurological outcomes (1.3 vs. 1.3%; P  = 0.930) between the groups. The median time from on-scene EMS arrival to hospital arrival (min) [28.0 (22.0-34.0) vs. 29.0 (25.9-35.0); P  < 0.001] in the failure group was longer than that in the success group. After propensity score matching, the results showed a similar trend.

Conclusion: Prehospital advanced airway management failure was associated with lower 30-day survival rates, ROSC, and a longer time between EMS arrival and hospital arrival. These findings suggest that failure of prehospital advanced airway management could potentially worsen the outcomes of patients with OHCA.

Background: Pediatric out-of-hospital tracheal intubation is associated with lower success rates compared with adult populations and presents distinct clinical challenges. Achieving success on the first attempt is critical, as multiple intubation attempts are associated with an increased risk of adverse events.

Objectives: The aims were to identify factors available before laryngoscopy that are independently associated with first-attempt success in pediatric out-of-hospital intubation and to evaluate the performance of a gestalt evaluation of intubation difficulty scale.

Methods: Data were extracted from a retrospective, observational, multicenter cohort study conducted in three physician-staffed mobile intensive care units (ICUs) in France. The study included patients aged 0-17 years who required out-of-hospital airway management. The primary outcome was successful intubation on the first attempt. A multivariable logistic regression model was constructed including clinically relevant variables available before laryngoscope insertion.

Results: A total of 206 pediatric patients were included in the analysis, with a median age of 6 years (interquartile range: 1-16). The overall first-attempt success rate was 59.7% [95% confidence interval (CI): (52.7-66.4)]. In the multivariable analysis, patient age [adjusted odds ratio (aOR): for 2-9 years, 2.33, 95% CI: (1.00-5.39); for 10-17 years, 3.86, 95% CI: (1.55-9.60); reference: 0-1 years] and presence of a soiled airway before laryngoscopy [aOR, 0.38, 95% CI: (0.20-0.71)] were independent predictors of successful intubation on the first attempt. The gestalt evaluation of the intubation difficulty scale yielded an area under the receiver operating characteristic curve of 0.63, 95% CI: (0.56-0.71), and it showed only a weak correlation with the Cormack-Lehane grade (Kendall tau-b = 0.36; P  < 0.001).

Conclusion: In this cohort of pediatric tracheal intubation procedures performed by physician-staffed mobile ICUs, soiled airways and younger age were associated with a lower incidence of first-attempt success. The gestalt evaluation of intubation difficulty demonstrated poor discriminative ability.

Objective: Hemorrhagic shock after severe trauma has a high mortality rate. Intubation may increase hemodynamic failure in shocked patients. Our aim was to assess the association of intubation timing with mortality and morbidity among patients with hemorrhagic shock after severe trauma.

Methods: This is a retrospective, multicenter study using data from the French Traumabase registry that includes severely injured trauma patients admitted to trauma centers. Patients were included if they were intubated, presented with hemorrhagic shock following severe trauma [≥four packed red blood cells (PRBCs) transfusions within the first 6 h of care], and underwent hemostasis surgery or interventional radiology procedure within 24 h of admission. Patients with severe trauma brain injury (abbreviated injury scale head ≥3) were excluded. The primary outcome was all-cause ICU mortality. Secondary outcomes were: time to hospital arrival, ICU and hospital lengths of stay, Simplified Acute Physiology Score II, prehospital norepinephrine use, and number of PRBCs transfusions within the first 24 h. Patients were categorized by intubation timing (prehospital intubation vs. in-hospital intubation) and matched by propensity score based on variables associated with the occurrence of prehospital intubation.

Results: Among the 840 patients included [mean age 41 (±18), 646 (74%) male], 455 (54%) had road traffic accidents, 153 (18%) falls, and 189 (23%) penetrating trauma. The median Injury Severity Score was 22 (16-34). After propensity score matching, 454 patients (227/group) were analyzed. Twenty-three patients (10%) died in the ICU in the prehospital intubation group vs. 18 (7.9%) in in-hospital intubation group [OR 1.28, 95% CI (0.69-2.37)]. Concerning secondary outcomes, prehospital intubation was associated with a higher need for norepinephrine support [130 (57%) vs. 83 (37%); OR 2.47, 95% CI (1.64-3.72)] and a longer time to hospital arrival [median within-pair absolute difference: 15 min; 95% CI (5-27)]. There was no significant difference for other secondary outcomes.

Conclusion: In this cohort of patients with hemorrhagic shock after severe trauma, prehospital intubation was not associated with a change in ICU-mortality.