European Journal of Emergency Medicine最新文献

Establishing vascular access during cardiopulmonary resuscitation is essential for delivering guideline-recommended medications. This meta-analysis aims to compare the clinical effectiveness of initial vascular access attempts through the intraosseous route to the intravenous route in patients with out-of-hospital cardiac arrest (OHCA). A comprehensive literature search was conducted across PubMed, Cochrane, Scopus, and Web of Science, up to March 2025, for randomized controlled trials (RCTs) and propensity score-matched (PSM) observational studies comparing initial attempt intraosseous access with initial intravenous access in patients with OHCA. R Studio version 4.4.2 was used to perform statistical analysis applying a random-effect model. Trial sequential analysis (TSA) was conducted to determine the robustness of findings and estimate required information size (RIS). Four RCTs and four PSM studies involving 28 632 patients with OHCA were identified. The analysis revealed no significant differences between initial vascular access attempts via the intraosseous route compared with the intravenous route regarding survival to hospital discharge [odds ratio (OR): 0.94, 95% confidence interval (CI): 0.77-1.13, P  = 0.49], sustained return of spontaneous circulation (OR: 0.87; 95% CI: 0.74-1.02, P  = 0.09) or survival with favorable neurological outcomes (OR: 0.74, 95% CI: 0.54-1.03, P  = 0.08). Meta-regression identified initial shockable rhythm as a significant modifier of survival to hospital discharge ( P  = 0.012). TSA demonstrated the Z curve failed to reach the RIS, indicating that further studies are needed for conclusive evidence. In adults with OHCA, establishing vascular access through the intraosseous route demonstrates comparable effects to intravenous access in terms of survival and neurological outcomes. Further RCTs are needed to strengthen the evidence base and should assess long-term effects, promote protocol standardization, and enhance paramedic training.

Background: Emergency departments (EDs) are often the first point of contact for patients with sepsis, and therefore play a critical role in early recognition and treatment. However, the extent to which sepsis guidelines are implemented across EDs in Europe remains unclear, and variability in adherence may impact patient outcomes.

Objective: This study aimed to assess current sepsis management practices in European EDs, evaluate adherence to international guidelines, and identify key challenges limiting effective implementation.

Methods and design: A structured survey was developed by sepsis experts from the European Society for Emergency Medicine (EUSEM). The questionnaire included both quantitative and open-ended items and underwent iterative refinement through pilot testing to ensure clarity and relevance.

Settings and participants: The survey was distributed to EUSEM members and national emergency medicine societies across Europe. Respondents included medical directors or designated sepsis specialists, with only one response requested per ED.

Results: A total of 402 EDs from 28 European countries participated in the survey. While most EDs (72.5%) reported having a sepsis protocol in place, less than half implemented regular monitoring or structured training measures. The 1-h sepsis bundle was described as moderately to highly challenging to implement by the majority of the respondents; just over half (55%) reported completing all its elements within 1 h of ED presentation. Key barriers included high patient volumes, insufficient staffing, and lack of standardized sepsis definitions, leading to delays in recognition and treatment. The results also highlighted concerns regarding increased broad-spectrum antibiotic use following the implementation of the 1-h bundle, emphasizing the need for a balanced approach that considers antimicrobial stewardship.

Conclusion: This survey establishes a benchmark for understanding sepsis management practices in European EDs, identifying substantial variations and challenges. Areas for improvement include enhanced training to follow protocols, improved monitoring systems that measure protocol adherence, and alignment with evidence-based guidelines.

Objective: To measure the association between antithrombotic (AT) medications (anticoagulant and antiplatelet) and risk for traumatic intracranial hemorrhage (ICH) in older adults with a mild traumatic brain injury (mTBI).

Methods: We conducted a retrospective multicenter study across 103 emergency departments affiliated with a teleradiology company dedicated to emergency imaging between 2020 and 2022. Older adults (≥65 years old) with mTBI, with a head computed tomography scan, were included. Natural language processing models were used to label-free texts of emergency physician forms and radiology reports; and a multivariable logistic regression model to measure the association between AT medications and occurrence of ICH.

Results: A total of 5948 patients [median age 84.6 (74.3-89.1) years, 58.1% females] were included, of whom 781 (13.1%) had an ICH. Among them, 3177 (53.4%) patients were treated with at least one AT agent. No AT medication was associated with a higher risk for ICH: antiplatelet odds ratio 0.98 95% confidence interval (0.81-1.18), direct oral anticoagulant 0.82 (0.60-1.09), and vitamin K antagonist 0.66 (0.37-1.10). Conversely, a high-level fall [1.68 (1.15-2.4)], a Glasgow coma scale of 14 [1.83 (1.22-2.68)], a cutaneous head impact [1.5 (1.17-1.92)], vomiting [1.59 (1.18-2.14)], amnesia [1.35 (1.02-1.79)], a suspected skull vault fracture [9.3 (14.2-26.5)] or of facial bones fracture [1.34 (1.02-1.75)] were associated with a higher risk for ICH.

Conclusion: This study found no association between AT medications and an increased risk of ICH among older patients with mTBI suggesting that routine neuroimaging in this population may offer limited benefit and that additional variables should be considered in the imaging decision.

Background and importance: Acute pulmonary oedema is a frequent and potentially life-threatening emergency. Its management targets four key objectives: improving oxygenation, reducing volume overload, maintaining adequate blood pressure, and treating the underlying cause. Severe cases are mainly handled by cardiologists, emergency physicians, and intensivists, which may lead to variations in care and thus nonadherence to guidelines.

Objective: To evaluate interspecialty differences in the management of patients with severe acute pulmonary oedema and compare physicians' practices to 2021 European guidelines.

Design: A national cross-sectional survey using clinical vignettes.

Settings and participants: Four clinical vignettes, developed by a multidisciplinary scientific committee representing French cardiology, emergency medicine, and intensive care societies were distributed between June and September 2022 to physicians from the three specialties and to a panel of 20 experts.

Outcome measures and analysis: The primary outcome was adherence to European guidelines. Interspecialty differences and predictors of nonadherence were assessed using univariate and multivariate analyses.

Main results: A total of 1048 physicians responded (59% emergency physicians, 22% intensivists, and 19% cardiologists). Adherence rates were 66, 65, 69, and 76%, respectively among cardiologists, emergency physicians, intensivists, and experts. Intensivists and emergency physicians were more prone to initiate noninvasive ventilation than cardiologists (respectively 87, 82, and 71%, P  < 0.001 and P  < 0.01). Intensivists and cardiologists were more likely to intubate patients than emergency physicians (respectively 73, 65, and 43%, P  < 0.001 for both comparisons). Cardiologists more frequently administered intravenous diuretics (98%) compared with emergency physicians and intensivists (both 90%, P  = 0.002). Emergency physicians chose more frequently the correct door-to-balloon delay than cardiologists for ST-segment elevation myocardial infarction-related acute pulmonary oedema (43 versus 28%, P  = 0.003). Multivariate analysis showed lower adherence among physicians compared with experts. Adherence was also lower among physicians older than 40 years and those working in nonuniversity hospitals.

Conclusions: This nationwide survey highlights marked discrepancies between European guidelines and clinical practice in the management of acute pulmonary oedema, with substantial variation across specialties regarding initiation of oxygen therapy, invasive ventilation, nitrates, or delay for thrombolysis of an ST-segment elevation myocardial infarction.

Background and importance: Efficient triage of emergency patients is crucial for the immediate identification of critically ill individuals and enables rapid interventions to improve patient outcomes.

Design: Systematic review and meta-analysis of the diagnostic test accuracy (DTA) of the Emergency Severity Index (ESI) for identifying critically ill adult patients in the emergency department (ED).

Settings and participants: We considered all studies (case-control and cohort studies) that evaluated the DTA of the ESI in adult patients attending an ED. The outcome of a triage system is the high urgency of treatment, commonly used reference standards are short-term mortality or admission to an ICU.

Methods: We searched four bibliographic databases up to 13 February 2025. Screening, inclusion, data extraction, and assessment of methodological quality followed standard Cochrane methodology. We calculated measures of DTA for all studies against the reference standards and calculated pooled estimates using a bivariate random effects model.

Main results: We included 27 studies, representing 510 777 patients. Methodological quality according to the QUADAS-2 tool was high, except for risk of bias in patient selection, which was high for 12 (44%) studies. A total of 18 studies provided data for the reference standard short-term mortality, with an estimated pooled sensitivity of 81.8 [95% confidence interval (CI): 71.8-88.9], specificity of 70.5 (60.5-78.8), diagnostic odds ratio (DOR) of 10.8 (5.4-21.4), positive likelihood ratio of 2.77 (2.02-3.81), and negative likelihood ratio of 0.26 (0.16-0.41). For the reference standard ICU admission, based on 10 studies, pooled estimates were sensitivity of 81.5 (65.2-91.2), specificity of 81.7 (71.9-88.6), DOR of 19.7 (5.5-70.7), positive likelihood ratio of 4.45 (2.58-7.84), and negative likelihood ratio of 0.23 (0.11-0.49). Those results remained stable in the sensitivity analysis.

Conclusion: ESI showed a moderate-to-high diagnostic accuracy for identifying critically ill patients at the ED. These findings support the role of the ESI guided by a principal understanding of the limitations inherent to any triage tool.