European Journal of Emergency Medicine最新文献

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.

Background and importance: Clavicle fractures account for about 3% of all fractures in adults, and have reportedly good outcomes with conservative treatment for lateral and mid-shaft clavicle fractures. Whether the use of a simple two-point sling or a triangular bandage should be the optimal first choice procedure is unknown.

Objectives: The objective of this study was to compare patient satisfaction after 1 week in patients with lateral or mid-shaft clavicle fractures treated with a two-point sling vs. a triangular bandage.

Design, setting, and participants: In this single center, randomized controlled trial, patients with acute, isolated and conservatively treated clavicle fractures were included. The primary endpoint was patient satisfaction at 1 week, measured with the Dutch version of the Quebec User Evaluation of Satisfaction with Assistive Technology (D-QUEST) questionnaire. Secondary outcomes were pain and functional recovery at different time points, measured with the visual analogue scale and Disabilities of the Arm, Shoulder, and Hand scores, respectively.

Intervention: Patients were randomized for immobilization with a triangular bandage or a two-point sling.

Outcomes measure and analysis: Differences in numerical variables were calculated using the unpaired t -test or Mann-Whitney U test. Categorical variables were analyzed using the Chi-Square test. Absolute effect size and 95% confidence interval (CI) were calculated, and a minimal clinically important difference of 0.25 was defined.

Results: Between August 2020 and February 2023, 110 patients were included in this study. After excluding patients who underwent surgery or were lost to follow-up, 68 patients were analyzed. Statistically and clinically significant differences were found in patient satisfaction scores at week 1 after trauma, in favor of the two-point sling (D-QUEST scores of 2.48 (±0.48) vs. 3.20 (±0.45), absolute mean difference 0.72 (CI, 0.49-0.95). There was no significant difference in pain and disability related secondary outcomes.

Conclusions: This study identified a significant difference in patient satisfaction favoring a two-point sling compared to a triangular bandage 7 days posttrauma.

Background and importance: Vaso-occlusive crisis is the main reason for emergency department (ED) visits for patients with sickle cell disease. Therapeutic management involves multimodal analgesia, which often comprises the administration of morphine. Recently, the use of virtual reality (VR) has garnered growing interest as a nonpharmacological approach for pain modulation.

Objective: The objective of this study was to assess the impact of integrating VR on the reduction of the total dose of morphine administered during vaso-occlusive crisis.

Settings and participants: This was a prospective before-and-after study conducted in a French adult ED on patients with sickle cell disease and acute pain from vaso-occlusive crisis.

Intervention or exposure: During the first period, patients were managed according to the standard protocol, with no use of VR. During the second period, patients were able to benefit from VR sessions in addition to the usual care.

Outcome measures and analysis: The primary outcome was the total dose of morphine administered in the ED. Secondary objectives were to evaluate the feasibility, tolerance, acceptability, and effectiveness of VR in pain management, measured using a numeric rating scale.

Main results: A total of 97 patients were included in the study, 50 during the noninterventional phase and 47 during the interventional phase. The median morphine dose was 30.7 mg [interquartile range (IQR), 19.7-45.7] in the VR group and 37.7 mg (IQR, 24.7-53.3) in the control group. The median difference between the two groups was -7 mg [95% confidence interval (CI), (-18.6 to 4.6)]. In the VR group, 18.2% of patients (8 out of 44 responders) reported side effects, which included primarily dizziness (50%), followed by nausea (25%) and headaches (25%). Additionally, 83.3% (35 out of 42 responders) of patients expressed the desire to use this method again.

Conclusion: In this prospective study, the use of VR did not reduce the total morphine dose administered in the ED for patients with acute pain and vaso-occlusive crisis. However, the use of VR appeared to be effectively integrated into multimodal pain management, with a high level of patient satisfaction.

Objective: Undiagnosed HIV infection remains a major driver of viral transmission in Western countries. Whether a systematic sex-based bias exists in HIV test ordering by physicians is unknown. We aimed to analyze the frequency of HIV testing among women and men attending 11 emergency departments (EDs) in Catalonia, Spain.

Methods: We recorded the total number of ED visits and HIV tests performed, both overall and for two specific diagnoses included in an opt-in testing strategy: community-acquired pneumonia (CAP) and herpes zoster. Data on patients' sex at birth and age were retrieved from administrative records, along with hospital (large vs. medium-small, metropolitan vs. nonmetropolitan) and ED characteristics (high vs. nonhigh activity, with vs. without gynecological facilities). The primary objective was to compare HIV testing rates between women and men, overall and by diagnosis. Secondary analyses evaluated results by age strata and institutional characteristics.

Results: A total of 1.8 million patients (55% women) attended the 11 EDs over a combined period of 335 months (median: 33 months per ED). During this time, 11 250 HIV tests were ordered (38% in women), averaging 34 tests per ED per month. Women were significantly less likely to be tested than men [0.43 vs. 0.86%; odds ratio (OR): 0.50, 95% confidence interval (CI): 0.48-0.52]. Among 31 515 CAP and 2990 herpes zoster cases, women also had lower testing rates (10.6 vs. 13.5% in CAP, OR: 0.76; 6.4 vs. 11.3% in herpes zoster, OR: 0.51). Results were consistent across all age groups and hospital/ED types.

Conclusion: We identified a consistent sex-based disparity in HIV testing by emergency physicians, with women less likely to be tested than men, regardless of age or institutional setting. The causes of this bias remain unclear and warrant urgent investigation and corrective action.