European Journal of Emergency Medicine最新文献

Background and importance: In the cohort of patients presenting to the emergency department (ED) with acute chest pain differentiating between those at high risk of major adverse cardiac event (MACE), and those who can safely be discharged, remains a challenge. The history, ECG, age, risk factors, troponin (HEART) score, as well as several abridged versions [history, ECG, age, risk factors (HEAR), history, ECG, troponin (HET)]. are commonly used for this purpose. As with many clinical risk scores, they might be useful, but often lack proper validation. We aimed to externally validate the HEART, HEAR, and HET scores in the setting of a high-volume tertiary care ED in a healthcare system without gatekeeping functions and thus a low-risk population. We further aimed to compare the prognostic performance (discrimination and calibration) of the scores to each other.

Design: External validation study.

Settings and participants: On the basis of a-priori sample size calculations, we prospectively included consecutive adult patients presenting to the ED with acute chest pain.

Outcome measures and analysis: We assessed overall model performance, discrimination, and calibration of all scores, analyzed reclassification from the HEART score and performed decision curve analysis.

Main results: A total of 3273 patients were included, 383 (12%) suffered MACE within 30 days. Classification differed significantly between scores (HEART: 810; 25% low risk; HET: 55; 2%; HEAR: 195; 6%), as did overall performance (area under the curve: 0.85, 0.80, and 0.79, respectively; P  < 0.001). HEART score misclassified 7/810 patients (0.9%; 95% confidence interval: 0.4-1.8%) with MACE as low risk, HET 2/55 (3.6%, 0.9-13.8%), and HEAR 0/195, whereas 2087 (72%), 2837 (98%), and 2695 (93%) patients without MACE were erroneously not classified as low risk.

Conclusion: The abridged scores fell short of their results in derivation studies, identifying only very few low-risk patients, and showing inferior model performance compared with the original HEART score. Instead of developing new scores, existing scores should be recalibrated to local population characteristics, as needed.

Traumatic brain injury (TBI) is a global health burden, with an incidence of 874-1005/100 000. It is a leading cause of morbidity and mortality in all ages. TBI is a heterogeneous entity, with a variety of definitions. Treatment starts at a prehospital level and aims to prevent secondary injury. Airway management is vital to prevent hypoxia, hypercapnia, and aspiration which could contribute to secondary injuries. In some systems, it is current practice to perform endotracheal intubation in the prehospital setting to secure the airway and permit controlled ventilation, as opposed to using basic maneuvers and adjuncts with supplemental oxygen. This study aims to review the effect of prehospital tracheal intubation on mortality and functional outcome in adult and pediatric patients with severe TBI compared with patients not intubated in the prehospital setting. A digital literary search of four databases using variations of the terms 'Endotracheal Intubation', 'Laryngeal Mask Airway', and 'Traumatic Brain Injury" included reports up to 31 March 2023. Of 7242, 33 studies were included. The overall risk of bias was moderate to serious. Nine studies noted an increase in mortality associated with prehospital intubation, four studies demonstrated a significant decrease in mortality and five studies reported poorer functional outcomes using various scales. Only three reports, including the only randomized controlled trial (RCT), showed improved functional outcomes with prehospital intubation. In eight studies, the prehospital intubation cohort had significantly more severe injuries. The majority of studies showed no effect on or increased mortality, and no significant association with functional outcome in patients with severe TBI who underwent prehospital intubation. However, all but one were retrospective and with a moderate to serious risk of bias. The cause of the mortality increase is uncertain and possibly a result of more severe injuries in the prehospital intubation group. The single available RCT reported improved functional outcomes with prehospital intubation but has yet to be replicated. The current evidence for prehospital intubation is uncertain in either direction, and there is a need for new prospective research, ideally with uniform outcome measures and the application of up-to-date intubation practices in the prehospital field.