European Journal of Emergency Medicine最新文献

Acute heart failure (AHF) is diagnosed in about 0.5% of all patients seen by emergency medical systems (EMS) and represents about 1% of emergency department (ED) visits. Leg swelling and shortness of breath are the most frequent patient complaints. Despite significant advancements in patient care pathways, the proper diagnosis, treatment and disposition of AHF may be further improved in emergency settings. The present document is an expert consensus document outlining key points in diagnosis, treatment and decision-making of patients being diagnosed with AHF by EMS and in the ED. Pillars of correct diagnosis include detailed clinical assessment and accurate interpretation of natriuretic peptides, while chest X-ray is still the most frequent image test used in ED, that could be substituted by ultrasonography exploration in appropriate patients. Quick identification of the most severe cases needing intensive care is mandatory, most of them characterized by hemodynamic instability, ventilatory failure or acute coronary syndrome needing intervention. Treatment could be started in prehospital settings by EMS, and loop diuretics are still the cornerstone of decongestive therapy. Measurement of diuresis and natriuresis shortly after provision of the first diuretic bolus is recommended, as it can help in detecting patients with poor diuretic response for dose augmentation or drug escalation with the addition of acetazolamide or thiazides. For selected patients, vasodilators (especially for acute cardiogenic pulmonary edema phenotype) or inotropes/vasopressors (for those with cardiogenic shock) can be needed. Oxygen therapy should be provided to patients with air-room SpO 2 below 95%, and noninvasive ventilation is an option for patients with respiratory distress. After provision of ED care, a correct decision of patient discharge or hospitalization is paramount, and risk stratification can help in this regard. Other key points of AHF management in the ED include adequate diagnosis and management of triggers of the AHF episode; to take aspects of patient frailty into account; to avoid lines, catheters, and patient overstay in the ED where possible; and to ensure a proper follow-up plan after discharge from the hospital.

Background and importance: Emergency medicine professionals face persistent challenges, including excessive workloads, shift work, and emotional stress. Job satisfaction is essential for workforce sustainability, quality of care, and retention; however, international research remains limited.

Objectives: To evaluate self-reported job satisfaction among emergency medicine professionals globally - including prehospital providers - and explore how individual and institutional factors influence it.

Design: International cross-sectional study using a structured, anonymous online survey.

Settings and participants: The survey was disseminated via international emergency medicine organizations (European Society for Emergency Medicine, International Federation for Emergency Medicine, South Asian Federation of Emergency Medicine, African Federation for Emergency Medicine, among others) over 3 weeks in April 2025. Eligible respondents included physicians, nurses, and paramedics working in prehospital and in-hospital emergency medicine settings.

Outcome measures and analysis: The primary outcome was the satisfaction score (range: 9-36), based on the nine-domain Lausanne scale. Overall job satisfaction was assessed separately using a single-item Likert scale (0-9). Descriptive and inferential statistics explored associations with demographic and organizational variables.

Main results: A total of 1112 professionals from 79 countries participated (56% female and 85.8% physicians). The mean satisfaction score was 25.37 (SD = 4.36), with a median overall satisfaction estimation of 6.77 (interquartile range = 2). High scores were reported for organisational commitment, co-worker support, and professional fulfilment. The lowest scores concerned career opportunities and work organization. Lower satisfaction was reported in high-volume emergency departments (>100 000 visits/year) and among mid-career professionals (5-20 years of experience). Intention to remain in the current role was significantly associated with higher satisfaction ( P  < 0.001).

Conclusion: The Emergency Medicine Day 2025 Survey provides one of the largest international assessments of job satisfaction in emergency medicine to date. Despite moderate-to-high satisfaction overall, challenges persist regarding career development and workload - particularly in high-pressure settings. These findings support the implementation of targeted interventions to enhance leadership, support mid-career staff, and foster resilient, well-functioning teams.

Background and importance: Although various strategies have been examined to mitigate discomfort during sampling, arterial blood gas (ABG) is a common and often painful procedure in emergency departments (EDs). Hypnotic communication, characterized by positive language/suggestions, may help reduce perceived procedural pain. Conversely, the traditional use of negative language may increase discomfort through a 'nocebo' effect.

Objective: To assess whether hypnotic communication reduces procedural pain during ABG sampling compared with neutral or nocebo communication, when delivered by emergency physicians who have not received training in hypnosis.

Design, setting, and participants: A single-center, triple-blind, randomized controlled trial with three parallel arms (hypnotic, neutral, and nocebo) was conducted from 4 April 2023 to 31 July 2024, in the ED of a Swiss Tertiary Care Hospital. All adult patients requiring ABG sampling were eligible for inclusion.

Intervention: Three standardized communication scripts were used during a standardized procedure for ABG sampling: nocebo with negative words (e.g. ' I'm going to prick '), neutral with neutral words (e.g. ' I am taking the sample '), and hypnotic with positive words, and dissociative sentences (e.g. ' What is the noise of the lights at your home?' ). Communications were audio-recorded and independently reviewed to ensure protocol adherence.

Outcomes measure and analysis: The primary outcome was the pain intensity, measured with a 0-10 numerical rating scale 3 min after the ABG sampling. Secondary outcomes included comfort and anxiety levels. Linear mixed-effects models were employed to conduct both intention-to-treat and per-protocol analyses.

Main results: A total of 216 participants (median age 72 years; 57% male) were included (hypnotic, n  = 71; nocebo, n  = 71; neutral, n  = 74). Dyspnea was the leading reason for ED consultation ( n  = 143; 66.2%). Hypnotic communication was associated with a statistically significant reduction in postprocedural pain compared with neutral communication [ β = -0.97, 95% confidence interval (CI): -1.80 to 0.14, P  = 0.02]; however, no significant differences were observed among the three groups in terms of median (interquartile range) pain scores [nocebo: 3 (1-5), neutral: 4 (2-6), hypnotic: 3 (1-5)], comfort or anxiety levels.

Conclusion: Implementing hypnotic communication in the ED during ABG procedures did not lead to clinically meaningful reductions in pain, anxiety, or discomfort.

Objective: Emergency department (ED) boarding is a major driver of overcrowding and has been associated with adverse outcomes; however, little is known about the impact of multiday boarding delays, which are common in low- and middle-income countries. Therefore, we aimed to evaluate the association between multiday boarding and in-hospital mortality in a large tertiary hospital in Brazil.

Methods: We conducted a retrospective cohort study of adult patients admitted via the ED of Hospital de Clínicas de Porto Alegre between January 2022 and December 2023, using administrative hospital data. ED boarding time was defined as the interval between the admission decision and the patient's physical departure from the ED. Multivariable logistic regression with restricted cubic splines modeled boarding time as a continuous exposure, adjusting for age, sex, and triage acuity.

Results: Among 28 743 admissions, the median boarding time was 1.8 days (interquartile range: 0.6-3.5). In-hospital mortality was 8.36%. Compared with patients in the first boarding quartile (median: 0.19 days), those in the last quartile (median: 4.92 days) had higher adjusted odds of death [odds ratio (OR): 1.15, 95% confidence interval (CI): 1.05-1.25]. At the cohort median (1.8 days), each additional day of boarding was associated with a 6% increase in the odds of in-hospital death (OR: 1.06; 95% CI: 1.02-1.09).

Conclusion: Prolonged ED boarding time was independently associated with increased in-hospital mortality, with no evidence of a safe threshold. Multiday delays represent a modifiable risk factor associated with excess mortality.

Background and importance: Early identification of imminent deliveries is crucial for guiding the decision to dispatch emergency medical team to the prehospital setting.

Objective: To study whether the use of the score predicting imminent delivery (SPID) at the emergency call center reduces the risk of prehospital delivery occurring without the presence of a physician-staffed mobile ICU team.

Design, setting, and participants: Prospective multicenter cluster randomized controlled trial in 19 call centers in France. Calls from pregnant woman in labor with at least 33 weeks of amenorrhea were eligible. The emergency call center responses included medical advice, transport to the hospital by personal means or ambulance, or dispatch of the mobile ICU team.

Intervention: In the intervention group, the use of the SPID was mandatory to guide decision-making.

Outcomes measures and analysis: The primary outcome was the rate of prehospital deliveries occurring without the initial dispatch of a mobile ICU team. The secondary endpoints included the prehospital deliveries rate without the presence of a mobile ICU team on site, call duration, satisfaction score, and maternal and neonatal mortality.

Main results: A total of 7782 pregnant women were included in the intention-to-treat analysis (3773 control and 4009 intervention), including 523 (7.0%) prehospital deliveries (6.3% intervention and 7.6% control) and a 22.3% rate of mobile ICU dispatch decision (20.8% intervention group and 23.8% control). Prehospital delivery without initial dispatch of a mobile ICU was less frequent in the intervention group compared to control: 0.95 vs. 2.01% [odds ratio (OR) 0.46; 95% confidence interval (CI), 0.31-0.70]. There was also a lower rate of prehospital delivery without the presence of a mobile ICU team on site in the intervention group: 1.92 vs. 3.34% (OR = 0.58; 95% CI, 0.42-0.82). There was no significant difference in the other secondary endpoints.

Conclusion: In this multicenter randomized controlled trial, the systematic use of the SPID was associated with a reduction of prehospital deliveries occurring without the presence of a mobile ICU team.

Background: Glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) are blood biomarkers that able to aid in the assessment of mild traumatic brain injury (mTBI) patients and reduce computed tomography (CT) overuse.

Objectives: The aim of this study was to evaluate the predictive performance of individual biomarkers and their combination (i.e. mTBI assay) in detecting clinically significant intracranial injuries in mTBI. Furthermore, the influence of older age on the predictive performance of individual biomarkers and their combination was investigated.

Methods: This prospective multicenter study was conducted in 12 European healthcare centers. Adults with suspected mTBI presenting to the emergency department (ED) of each participating healthcare center within 12 h of head trauma were enrolled. GFAP and UCH-L1 were determined in blood samples collected from each participant. Head CT was considered as reference standard for the presence of intracranial injury.

Results: The mTBI assay yielded the highest sensitivity [95.5%, 95% confidence interval (CI): 89.9-98.5] and the highest negative predictive value (NPV) value (97.3%, 95% CI: 93.9-98.9) for the exclusion of intracranial lesions in mTBI. The sensitivities and NPVs of individual biomarkers were lower compared with the mTBI assay. In adults over 65 years, the individual biomarkers and the mTBI assay displayed the weakest diagnostic performances. After optimizing cutoff values for the mTBI assay for older adults, the following diagnostic accuracy measures were obtained: sensitivity 87.7%, 95% CI: 77.2-94.5 and NPV: 94.4%, 95% CI: 89.6-97.0 ( P  < 0.001).

Conclusion: The mTBI assay yielded high sensitivity and NPV for the exclusion of significant intracranial injuries in mTBI patients presenting to the ED within 12 h from injury, performing better than individual biomarkers. A significant age-dependent influence on the predictive performances of the individual biomarkers and the mTBI assay was demonstrated.