European Journal of Emergency Medicine最新文献

Background and importance: Crowded emergency departments (EDs) and long waiting times may lead to delayed care for acute conditions and increased mortality in patients leaving without being seen by a physician (LWBS).

Objectives: The aim of this study was to characterize patients LWBS from the ED at a Swedish university hospital and report their mortality.

Design, setting, and participants: A cohort study was conducted. Data from electronic medical records of patients LWBS (exposure) were compared with those who stayed through completion of treatment. Data were gathered from 151 228 patients making 363 308 visits to the Uppsala University Hospital ED from 1 January 2010 to 30 June 2017.

Outcome measures and analysis: Short- and long-term mortality of patients LWBS were studied using Cox regression analysis. Sex, age, triage level, arrival mode, length of stay, presenting complaint, crowding, and time of day were assessed as regards effect on the probability of LWBS and as covariates in the mortality analysis.

Results: In our dataset, 9058 patient visits to the ED (2.5% of all ED visits) ended in LWBS. These patients were younger than average and had lower triage levels. No significant difference was found between males and females. The highest rates were seen in patients presenting with a psychiatric disorder (12.8%), victims of physical assault (11.7%), or alcohol/drug withdrawal (9.9%). The likelihood of LWBS was highest in the evening and lowest in the early morning. Short-term mortality at 28 days was not significantly affected by LWBS, but a 34% lower long-term mortality risk was seen for patients LWBS (hazard ratio 0.66, 95% confidence interval 0.45-0.95, P  = 0.028) in median follow-up of 3.5 years.

Conclusion: Patients LWBS were younger, had lower triage levels, and more frequently presented with psychiatric or substance use-related complaints. They had lower short- and long-term mortality compared with those who completed treatment. This observation does not imply a causal relationship but highlights differences in patient characteristics.

Background and importance: Nontraumatic abdominal pain is a common and challenging presentation in the emergency department (ED). Point-of-care ultrasound (PoCUS) offers rapid, bedside imaging, but its association with ED length of stay (LOS), resource use, and patient safety, particularly concerning unscheduled return visits, remains unclear.

Objective: To evaluate the association of early PoCUS (within 1 h) with ED LOS and safety in adults with nontraumatic abdominal pain.

Design, settings, and participants: A propensity score-weighted retrospective cohort analysis in a tertiary medical center in Taiwan (2021-2023). This study included 39 443 adult patients with nontraumatic abdominal pain (12 399 PoCUS < 1 h and 27 044 no PoCUS), excluding transfers.

Intervention or exposure: PoCUS performed by an emergency physician within 1 h of ED arrival.

Outcomes measure and analysis: Primary: ED LOS; secondary: ED costs, computed tomography (CT) use, outpatient disposition, and rate of admission after an unscheduled return visit. A key subanalysis evaluated outcomes (costs, hospital LOS, and mortality) for admissions after an unscheduled return visit. Analysis used inverse probability of treatment weighting-adjusted regression.

Main result: PoCUS performed within 1 h was associated with a 16% reduction in first ED LOS [ratio of means 0.84, 95% confidence interval (CI): 0.83-0.86] and 50% increased odds of outpatient disposition [odds ratio (OR): 1.50, 95% CI: 1.42-1.58]. 1st ED costs were slightly increased by 4% (ratio of means: 1.04, 95% CI: 1.03-1.06), and CT use was not reduced (OR: 0.98, 95% CI: 0.93-1.03). While associated with a 25% increased odds of admission after an unscheduled return visit (OR: 1.25, 95% CI: 1.02-1.53), this subgroup had 33% lower admission costs (ratio of means: 0.67, 95% CI: 0.57-0.80), 26% shorter hospital LOS (ratio of means: 0.74, 95% CI: 0.64-0.85), and 94% lower odds of ED death on return (ratio of means: 0.06, 95% CI: 0.01-0.54).

Conclusion: PoCUS performed within 1 h of ED arrival was associated with shorter ED LOS and more outpatient dispositions, without reducing CT use. However, it was also associated with an increased probability of admission following an unscheduled return visit. Future studies are needed to elucidate the causal impact of this practice on patient safety and downstream resource use.

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.