International Journal of Emergency Medicine最新文献

Background: In recent years, the Netherlands has experienced a notable increase in opioid prescriptions and associated fatalities. Emergency department (ED) patients exhibit relatively high rates of opioid use (15%) and misuse (23% of patients who present to the ED and use prescription opioids test positive for misuse). To mitigate opioid-related harm, the American College of Emergency Physicians (ACEP) advocates for the use of non-opioid analgesics and minimal opioid prescriptions. In the Netherlands, the Society for Anesthesiology has issued a guideline for appropriate opioid use, which are also relevant to EDs. However, the extent of implementation in EDs remains unclear. This study utilized an online survey to assess the implementation of opioid-prescribing guidelines in Dutch EDs. Chief medical officers from various EDs across the Netherlands were invited via email to complete questionnaires. These questionnaires gathered general information about the EDs, details on the application of opioid-prescribing guidelines, management of problematic opioid use, and specifics of the guidelines in practice.

Results: Questionnaires were completed by chief medical officers from 33 Dutch EDs, yielding a 52.4% response rate. Nineteen EDs (57.6%) used guidelines for opioid prescribing, predominantly local protocols, with only two of them (10.5%) using the national guideline. The guidelines varied in content, with 68.4% advising on specific opioids (mainly preferring oxycodone) and dosage, and in 63.2% giving advice on prescription duration (typically 3-7 days). Patient education with opioid prescriptions was specified in the guidelines at 57.9% (11/19) of EDs, with brochures provided at 17.6% (6/19) of EDs. The primary focus of patient education was on adverse effects, with addiction risks mentioned at 36.4% (4/11) EDs.

Conclusions: This study reveals significant variability and gaps in opioid prescribing guidelines across Dutch EDs. Compared to US guidelines, Dutch practices are less cautious, highlighting the need for improvement. This study underscores the necessity for a Dutch guideline tailored for EDs to manage opioid prescriptions and problematic opioid use.

Background: Systemic amyloidosis is a kind of clinical syndrome in which amyloid is deposited between the cells of various organs in the body, resulting in gradual failure of the function of the affected organs. Depending on the site of amyloid deposition, it may show various clinical symptoms of multiple system involvement.

Patient concerns: A 44-years-old female with spontaneous giant retroperitoneal hematoma was admitted to the emergency department of Peking Union Medical College Hospital in Mar 2023.

Diagnoses: She was found with a extremely X-factor deficiency and diagnosed with AL amyloidosis according to pathological findings finally.

Interventions and outcomes: She received a variety of treatments to improve her coagulation function and underwent chemotherapy for AL in the hematology department which improved her coagulation function and was discharged to her local hospital for follow-up treatment.

Conclusion: This case provides a new reference for emergency doctors in the diagnosis and treatment of acute severe hemorrhagic diseases.

Background: Pneumonia is a potentially life-threatening respiratory tract infection. Many Early Warning Scores (EWS) were developed to detect patients with high risk for adverse clinical outcomes, but few have explored the utility of these EWS for pneumonia patients in the Emergency Department (ED) setting. We aimed to compare the prognostic utility of A-DROP, NEWS2, and REMS in predicting in-hospital mortality and the requirement for mechanical ventilation among ED patients with pneumonia.

Methods: A retrospective study was conducted at the ED of Siriraj Hospital, Thailand. Adult patients diagnosed with non-COVID-19 pneumonia between June 1, 2021, and May 31, 2022, were included. We calculated and analyzed their EWS at ED arrival. The primary outcome was all-cause in-hospital mortality. The secondary outcome was mechanical ventilation.

Results: We enrolled 735 patients; 272 (37%) died at hospital discharge, and 75 (10.2%) required mechanical ventilation. A-DROP had the highest discrimination capacity for in-hospital mortality (AUROC: 0.698, 95% CI 0.659-0.737) compared to NEWS2 (AUROC 0.657; 95%CI 0.617, 0.698) and REMS (AUROC 0.637; 95%CI 0.596, 0.678). A-DROP also had superior performances than NEWS2 and REMS in terms of calibration, overall model performance, and balanced diagnostic accuracy indices at its optimal cut point (A-DROP ≥ 2). No EWS could perform well in predicting mechanical ventilation.

Conclusion: A-DROP had the highest prognostic utility for predicting in-hospital mortality in non-COVID-19 pneumonia patients in the ED compared to NEWS2 and REMS.

Introduction: Non-cancer deaths are now becoming a significant threat to the health of cancer patients. Death from stomach and duodenal ulcer is linked to cancer due to the side effects of treatment and its pathogenesis. However, guidelines for identifying cancer patients at the highest risk of death from stomach and duodenal ulcer remain unclear.

Methods: Data of all patients diagnosed with cancer between 2000 and 2021 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Data regarding the causes of death and clinicopathological features such as sex, age, race, marital status, SEER stage, and treatment procedures were extracted. We calculated standardized mortality ratios (SMRs) using the SEER*Stat software V8.4.3.

Results: Of the 6,891,191 cancer patients, 2,318 died of stomach and duodenal ulcer, a rate higher than that in the general population (SMR = 1.58, 95% CI [1.52-1.65]). Stomach and duodenal ulcer-related deaths decreased over time from 870 deaths between 2000 and 2004 to 294 deaths between 2015 and 2019. Among the 2,318 stomach and duodenal ulcer deaths, the highest numbers were observed in patients with prostate cancer (n = 389, 16.8%), and lung and bronchus cancer (n = 255, 11%). Patients with liver and intrahepatic bile duct cancers (SMR = 10.53, 95% CI [8.3-13.18]), and pancreatic cancer (SMR = 6.84, 95% CI [5.11-8.97]) had a significantly higher rate of death from stomach and duodenal ulcer than the general population.

Conclusion: Our study revealed a significantly higher risk of stomach and duodenal ulcer mortality among patients with cancer in the United States, underscoring the critical need for integrated care strategies that address both cancer and ulcer-related complications. To reduce ulcer-related mortality, we recommend the implementation of targeted prevention protocols, including routine gastrointestinal screenings for high-risk cancer patients, proactive management of ulcer risk factors, and collaboration between oncology, gastroenterology, and surgical teams.

Introduction: Traffic accidents are a major public health concern worldwide, resulting in significant injuries, fatalities, and economic costs. In urban zones, traffic accident dynamics can vary significantly due to population density, infrastructure, and emergency response capabilities. The present study was conducted to determine the time intervals of prehospital emergencies in traffic accidents by separating the 15 zones of Isfahan city, Iran.

Methods: This descriptive study was conducted in 2023. The sampling approach involved a census that included all prehospital emergency missions that occurred in the second half of 2022. A total of 7613 missions were examined. To collect the data, a checklist covering demographic characteristics and mission-specific features was utilized. The information was recorded in an Excel spreadsheet and described via the prehospital emergency information system.

Results: After analyzing 7,613 urban missions, it was determined that Zone 12 had the highest number of prehospital emergency missions in all three time periods: morning, afternoon, and evening. Therefore, all the times (reaction time, response time, scene time, transfer time, and hospitalization time) were in accordance with prehospital emergency time standards in Iran.

Conclusion: On the basis of the findings of this study, it is crucial to identify zones with greater population movement, highways, or high traffic volume and establish bases in suitable locations whenever feasible. Additionally, in zones with a greater number of missions, there should be an appropriate number of ambulances in proportion to the mission volume.

Background: Reduction of spontaneous nystagmus by fixation, a characteristic feature of peripheral nystagmus, is important for differentiating between peripheral and central vestibular disorders. In the emergency room, Frenzel goggles are recommended to observe spontaneous nystagmus for the differential diagnosis of acute vestibular syndrome. We developed a portable loupe with a Fresnel lens to observe nystagmus. The loupe does not require power supply and can be used under ceiling lights. The aim of this study was to quantitatively and objectively compare the abilities of the loupe and conventional Frenzel goggles to observe spontaneous nystagmus and to verify that the loupe can detect peripheral nystagmus that cannot be observed with the naked eye.

Methods: Visual impact susceptibility was compared between the loupe and Frenzel goggles using the slow-phase velocity of nystagmus induced by the caloric test in 15 participants. Subsequently, under lighting, the nystagmus observations under the naked eye condition and with the use of the loupe were compared. Furthermore, the visibility of nystagmus was evaluated from recorded videographic images.

Results: In observations of nystagmus induced by the caloric test, the visual impact of the loupe was not inferior to that of Frenzel goggles. The mean slow-phase velocity of nystagmus recorded with the loupe was significantly higher than that observed with the naked eye. Nystagmus weakened under bright lighting could be recovered by the loupe as fixation was blocked and the direction of the nystagmus could be defined.

Conclusions: The results showed that the loupe is helpful in observing nystagmus, which is weakly observed with the naked eye under bright light. This portable, low-cost loupe, which yields superior results, can serve as an alternative to conventional Frenzel goggles in emergency medical settings where rapid assessment is required.

Background: Over 90% of trauma deaths occur in low- and middle-income countries (LMICs). The trauma burden in Tanzania is similar to the global rate of 10% and road traffic injuries result in a 40% mortality. To understand epidemiology of trauma referrals and care we aimed to describe the patients presenting to a tertiary, referral hospital in Tanzania for trauma care, their injuries and mechanism of injury, and describe the care received.

Methods: A cross-sectional study was done at the emergency department of this tertiary referral hospital in the northwestern zone of Tanzania between March - August 2023. All patients presenting to the emergency for trauma were approached and those who could consent or assent were enrolled. Data was collected on the WHO Trauma form and injury severity was calculated with Kampala trauma score II. Data was entered into Redcap and analyzed using R statistical software. Descriptive statistics and frequency tables and charts were used to present data.

Results: At the Emergency department, 12% of the patients were categorized as trauma. Median age was 29 years (IQR 20-41 years) with a 79% male predominance. Most patients (78%) presented with major injuries resulting from road traffic accidents. There was high acuity, with 57% had Kampala trauma score < 6. The most prevalent injuries were musculoskeletal and skin. Most patients (84%) attended one prior hospital before being referred. Mwanza region contributed the highest to the trauma referrals (53%) and the most common intervention was intravenous canulation (98%).

Conclusions: Trauma-related referrals are common in the young with the majority presenting from the Mwanza region. Most patients were referred from another health facility in line the with Tanzanian referral channel. Most patients had severe injury and amongst all IV cannulation was the most prevalent lifesaving intervention at EMD.

Introduction: Thyroid storm or severe hyperthyroidism can present with various signs and symptoms. They are mostly controlled by general treatment, such as anti-thyroid drugs and other medications to control clinical features. However, in rare cases, they are more severe, and they only respond to more aggressive treatments, such as plasmapheresis and total thyroidectomy. The final histopathological features, such as the loci of differentiated thyroid carcinoma, are sometimes surprising.

Case presentation: Here, we present a 40-year-old female who presented with severe palpitation, diaphoresis, and chest pain. After taking the initial steps of treatment and stabilizing the patient, the history, physical exam, and laboratory results confirmed the diagnosis of a thyroid storm in the background of Graves' disease that is accompanied by heart failure with reduced ejection fraction (HFrEF). She was admitted to an ICU setting and received principal treatment of thyroid storm. However, the systematic treatment was not effective, and finally, plasmapheresis and total thyroidectomy were performed. Histopathologic evaluation following surgery confirmed the presence of foci of papillary thyroid carcinoma (PTC) in the background of the grave's disease. This case underscores the complexity of managing Grave's induced thyroid storm in severe cases, which might lead to plasmapheresis and total thyroidectomy. Urgent and invasive treatment may be necessary in rare cases when normally applied treatment modalities are not able to control the situation and result in life-threatening critical health conditions. In such a severe case, it can result in serious cardiovascular complications such as decompensated heart failure with a high rate of mortality.

Key clinical message: Thyroid storm, though rare, can be accompanied by severe medical conditions such as heart failure and death. In cases in which primary medical and symptomatic therapies do not work, more aggressive treatment (such as plasmapheresis and total thyroidectomy) should be considered. On the other hand, precise histopathologic evaluation of the thyroid tissue is necessary.

Background: Evidence regarding the effect of time to neurosurgical and neuroradiological intervention on outcomes in traumatic brain injury (TBI) across Asia-Pacific region is limited. This study evaluates the quality of care and outcomes for TBI patients undergoing neurosurgical and neuroradiological procedures at different timings.

Methods: Adult TBI patients who received any neurosurgical or neuroradiological interventions during the year 2015-2022 in the Pan-Asian Trauma Outcome Study database were analyzed. The time to intervention, as the main exposure, was classified into three groups (Early, Intermediate, and Delayed) using Restricted Cubic Spline (RCS) analysis. The outcomes were in-hospital mortality and unfavorable neurological outcomes. W score was utilized to compare the quality of care among exposure groups. Multivariable logistic regression analysis and interaction analysis were performed to identify the association between the exposure groups and outcomes, reported as adjusted odds ratios (AOR) with 95% confidence intervals (CI).

Results: A total of 1,780 patients were included. From the RCS analysis, patients were classified into three groups according to time to intervention: Early (< 1.9 h), Intermediate (1.9-4.1 h), and Delayed (> 4.1 h). According to the time to intervention, W score was - 8.6 in the early group, -1.1 in the intermediate group, and + 0.4 in the delayed group. Patients receiving intermediate and delayed intervention showed significantly lower mortality (AOR 0.64, 95% CI 0.47-0.86 and AOR 0.66, 95%CI 0.48-0.90, respectively).

Conclusion: Early neurosurgical and neuroradiological interventions in TBI patients in the Asia-Pacific region were associated with lower quality of care and higher mortality. The quality of care should be focused and improved during the early hours of TBI.

Aim: This study aimed to comprehensively examine the factors influencing healthcare providers' decision-making for initiation of resuscitation (IOR).

Background: In-hospital resuscitation survival hinges on timely and effective interventions. Despite guidelines, decision-making during resuscitation remains challenging, impacted by both clinical and non-clinical factors.

Methods: A mixed-methods systematic review (MMSR) was conducted, searching PubMed, Web of Science, Scopus, and Embase in May 2024. Twenty peer-reviewed studies of adult in-hospital resuscitation decision-making (≥ 18 years) were included. Data were extracted and synthesized using the Joanna Briggs Institute (JBI) convergent integrated approach.

Results: A database search yielded 4398 studies, of which 1216 were duplicates. After screening 3182 unique studies, 20 articles (five qualitative, 12 quantitative, three mixed methods) were included. Data synthesis identified three overarching themes: patient, provider, and system factors. These themes encompassed barriers and facilitators to IOR.

Conclusion: This review underscores the importance of understanding patient-related, provider-related, and system-related factors influencing IOR. By addressing these factors, healthcare organizations can improve resuscitation practices and outcomes. Future research should focus on enhancing collaboration, communication, and resource availability while considering non-medical factors in decision-making for IOR.

Relevance to clinical practice: Understanding the multifaceted barriers and facilitators identified in this study can enhance the effectiveness of resuscitation protocols and ultimately improve patient outcomes during critical care situations.