Western Journal of Emergency Medicine最新文献

Introduction: Hip fractures are a common reason for presentation to the emergency department (ED) and are associated with significant morbidity. Nerve blocks have emerged as a safe and effective tool to treat pain associated with hip fractures. In this study, we aimed to measure the frequency with which nerve blocks were performed for ED patients with hip fractures. Our secondary aims were to study the demographic and clinical characteristics of patients who received and did not receive a nerve block.

Methods: We performed a retrospective study at a single-center, urban, academic, Level I trauma center. We measured the frequency with which patients received a nerve block. We measured other demographics (age, ethnicity, insurance) and clinical data (comorbidities, Emergency Severity Index, National Emergency Department Overcrowding Scale, and hip fracture type). Lastly, we measured the types of nerve block performed, who performed the nerve block, and any associated complications.

Results: Overall, 17% (36/209) of the studied patients and 14% (36/257) of all patients with an acute hip fracture received a nerve block. Patients who were cared for by ultrasound (US) fellowship-trained physicians were more likely to receive a nerve block compared to patients cared for by non-US fellowship-trained physicians (20/35 vs 16/174; P-value < .001).

Conclusions: Nerve blocks were performed for a minority of patients presenting with an acute hip fracture. Patients who are cared for by ultrasound fellowship-trained physicians may be more likely to receive a nerve block than patients cared for by non-ultrasound fellowship-trained physicians in the emergency department.

Introduction: Out-of-hospital cardiac arrest remains a leading cause of death and significantly impacts global health outcomes. International guidelines emphasize the importance of high-quality CPR (cardiopulmonary resuscitation).

Objectives: Our goal was to compare CPR efficiency using the criteria recommended by international guidelines between two out-of-hospital cardiac arrest intervention scenarios: CPR at the incident site; and CPR during patient transport to the hospital by emergency medical services.

Methods: In each of the two scenarios, five full two-minute cycles of cardiac compression were applied to a manikin according to international guidelines. The CPR quality parameters were chest compression rate, chest compression depth recorded by the manikin, and investigator-evaluated correct hand placement on the manikin.

Results: We analyzed data from 240 CPR cycles provided by 24 healthcare professionals. The mean chest compression rate was higher (120.5±10.9/minutes vs 125.3±14.7/min, P = .001) and the mean chest compression depth was shallower (43.9±6.6 millimeters [mm] vs 37.9±7.2 mm, P = .001) in the on-the-move group. The two groups' appropriate hand placement rates were similar (92.1±5.4% vs 92.2±4.5%, P = .48) CONCLUSION: In this study, the moving ambulance simulation demonstrated that chest compressions were administered at a rate exceeding recommended guidelines and at a shallower depth than recommended, while the frequency of correct hand placement remained comparable. If the patient requires transportation from the scene of the incident, the healthcare team must be aware of the potential adverse effects on the chest compression quality.

Introduction: Pharmacogenomic-assisted prescribing of medications uses individual genetic information to identify drug-gene interactions. We aimed to assess potential pharmacogenomic drug-gene interactions in geriatric emergency department (ED) patients who sustained a fall.

Methods: This was a prospective study involving 25 older adult ED patients with fall-related injury. Data collected included current medications, demographics, and mechanism of injury. All patients provided a DNA sample, which underwent pharmacogenomic testing by an accredited genetics lab, Each patient's medications were reviewed against their pharmacogenomic report and categorized as Green (continue to use), Yellow (use with caution) or Red (stop use) based on their genetic information and published interactions by the Clinical Pharmacogenetics Implementation Consortium, Dutch Pharmacogenetics Working Group, and US Food and Drug Administration-approved drug label information. The main study outcome was pharmacogenomic drug-gene interactions.

Results: Of the 25 patients enrolled (median age, 81 years, IQR 76-85), 68% were female. Patients were taking a median of eight medications (IQR 5-11). The most common types were antihypertensives, statins, anticoagulants, and anti-platelet medications. Significant drug-gene interactions (Yellow or Red) were identified in 14/25 patients (56%; 95% CI 35-76%). Further, 6/25 (24%; 95% CI 9-45%) had one or more potentially serious (Red) interactions identified.

Conclusion: We found that in geriatric ED patients with a fall-related injury, most had a significant pharmacogenomic drug-gene interaction. DNA testing identifies these interactions and can assist with pharmacogenomic-guided medication prescribing, which may decrease adverse drug events and improve clinical outcomes.

Introduction: The emergency department (ED) serves as an entry point to the healthcare system for many patients, and the increased use of advanced imaging has resulted in identification of masses of unclear significance. We describe patients presenting to an ED who were referred to an undiagnosed mass clinic (UMC).

Methods: We performed a retrospective observational cohort study of patients ≥16 years of age presenting to Mayo Clinic in Jacksonville, Florida, from October 31, 2018-March 31, 2023, who were referred to the UMC.

Results: There were 116 patients referred to the UMC with a median of 3.5 days from ED encounter to clinic date and a median of 14.5 days from ED encounter to biopsy. Using an analytic tool in the electronic health record, we estimated that of 16,872 patients, 116 (0.69%) Mayo Clinic Florida (MCF) ED patients ≥18 years of age who received computed tomography and were discharged from the ED were referred to the UMC. Ultimately, 35 of 65 patients (53.8%) seen in the UMC received a cancer diagnosis.

Conclusion: Our study shows a viable care path from ED encounter to undiagnosed mass clinic. Further research is needed to ensure timely transitions of care for patients who are uninsured or out of network.

Introduction: Climate change has significantly impacted human health worldwide, contributing to the rise of emerging infectious diseases, allergies, pollution, natural disasters, non-communicable diseases, and malnutrition. One crucial but often overlooked area where climate change has had a notable effect is upon interpersonal violence.

Methods: Following PRISMA guidelines, we searched PubMed and Epistemonikos for studies measuring the effect of temperature on violence. Inclusion criteria encompassed peer-reviewed, English-language articles reporting an association between temperature and violence. Data extraction focused on various forms of violence including homicides, assaults, sexual assaults, suicides, intimate partner violence, riots, and civil wars, and we assessed article quality using Joanna Briggs Institute criteria.

Results: We included a total of 37 studies from 11 countries, three subcontinental regions, and two global-level analyses in this review. Of these, 46% originated from the United States. Rising ambient temperatures were significantly associated with increases in homicides (10 studies), assaults (15 studies), sexual assaults (8 studies), firearm violence (5 studies), intimate partner violence (9 studies), and suicides involving violent methods (9 studies). Conversely, no association was found between temperature and non-violent crimes. Civil wars and riots were also linked to temperature increases in all relevant studies. A meta-analysis of eight studies on violence showed that each 1°C increase in ambient temperature results in 1.64% (95% CI 1.23-2.19%) increase in violence (P<.01).

Conclusion: This review demonstrates a significant association between rising temperatures and increased worldwide incidents of violence and self-harm. These findings underscore the urgent need for public health strategies and interventions to mitigate the societal and health impacts of climate change-induced temperature increases.

Introduction: Geriatric emergency medicine (GEM) has emerged as a subspecialty of emergency medicine (EM) with seven fellowships available throughout North America and opportunities for career development in administration, clinical leadership, education, and research. Our objective in this study was to ascertain the perspectives and understanding of the subspecialty among EM trainees.

Methods: We recruited participants from four geographically diverse institutions. Three institutions were academic and had GEM faculty or divisions, and the fourth institution was a community site without geriatric-specific faculty. We conducted semi-structured interviews, adapted from a prior protocol, via teleconferencing and subsequently transcribed them. Codes were generated by two investigators and categorized into themes derived from the data.

Results: Seventeen trainees with an average age of 32.1 years across four institutions participated in the study. Three themes emerged, demonstrating that trainees' perceptions of GEM were affected by 1) education and exposure; 2) perception of geriatrics; and 3) future career considerations. Trainees with exposure to GEM had greater appreciation for the specialty, but their understanding of career opportunities was mixed. Participants acknowledged broader clinical and social considerations for older adults and in general felt that specialty training would benefit older patients. However, most participants had no personal interest in pursuing GEM, with reasons for disinterest including belief that they would only see older patients, dislike of geriatric complexity, and uncertainty about GEM as a career. Many participants identified educational opportunities for GEM, including noting that curricula include dedicated time for other subspecialties such as pediatrics but not geriatrics. Fellowship decisions were influenced by duration of training, salary, job opportunities, practice settings, and career goals.

Conclusion: Emergency medicine trainees who participated in semi-structured interviews overall viewed geriatrics as an important aspect of EM with perceptions formed from exposure and education at both the institutional and individual level, perceptions of treating older adults, and future career considerations. However, interest in pursuing GEM was overall low, and participants expressed uncertainty about the subspecialty and career options, indicating opportunity for increased awareness, education, and mentorship.

Introduction: Rib fractures are common in patients with blunt thoracic trauma, and their associated pain causes significant morbidity and mortality. Adequate analgesia is crucial to prevent rib fracture-associated pulmonary complications. However, current analgesic modalities have drawbacks, and the optimal analgesia protocol remains elusive. Intravenous (IV) lidocaine infusions have a well-established safety profile and efficacy in other patient populations and may benefit patients with traumatic rib fractures. To better understand current practices and to inform the design of a multi-centre trial, we believe that a study to determine Canadian trauma centres' current analgesic practices is warranted. This study describes the current familiarity and use of IV lidocaine infusions for management of rib fracture pain. Secondary outcomes included the identification of common Canadian analgesic protocols for rib fractures and willingness to participate in a future multi-centre trial of lidocaine for these traumatic injuries.

Methods: We distributed an online survey to 14 Canadian trauma centres. Study questions were designed to address four themes: trauma centre characteristics; pain management strategies; current use of IV lidocaine infusions; and interest in future study participation. The analysis included a frequencies analysis and a thematic analysis of descriptions.

Results: The medical directors of 12 trauma centres (85%) responded. Six of those centres (50%) experience > 450 annual trauma admissions with Injury Severity Scores > 12. Six sites (50% of respondents) have a rib-fracture analgesic protocol. Four centres (33% of respondents) frequently use IV lidocaine for rib fractures, and 10 (83% of respondents) believe further research with IV lidocaine is needed.

Conclusion: Canadian trauma centres' current practices for rib-fracture pain management are variable. Prospective work is needed to evaluate IV lidocaine as an analgesic for traumatic rib fractures.

Introduction: We assessed the prevalence of burnout syndrome among emergency physicians and advanced practice practitioners (APP) in an academic emergency department (ED) to identify demographic and lifestyle factors associated with burnout.

Methods: We administered a cross-sectional survey including the Maslach Burnout Inventory (MBI) with a demographic/lifestyle component to emergency physicians, residents, and APPs at an academic ED. We reported descriptive data and performed chi-square analysis to identify significant variables, followed by logistic regression to quantify their effects. A factor count was performed to assess for additive effects of burnout risk factors.

Results: We collected 55 surveys (60% response rate) yielding an overall burnout prevalence of 52.7%. The following had a significant association with burnout: 0-6 days off per month; fewer than two major hobbies; thoughts of quitting one's job "at least some of the time"; and spending less than four hours outdoors per week. Zero to six days off per month was associated with 4.70 times more burnout compared to ≥7 days off per month (95% confidence interval [CI] 1.24-17.82). Participants who met 3-4 vs 0-2 of the previously mentioned conditions had a 6.87 times increased burnout prevalence (95% CI 2.01-23.52).

Conclusion: This preliminary study highlights four unique factors associated with burnout. It also demonstrates that a specific number of days off may reduce burnout prevalence. Emergency department wellness efforts should consider focusing on strategically scheduling time off each month while encouraging individual habit generation and time spent outdoors to maximize burnout protection. Further research is needed to evaluate the efficacy of the proposed interventions.

Introduction: The global incidence and severity of severe heat illness is on the rise. The increasing number of summer heatwaves in Phoenix, Arizona, gave us a distinctive opportunity to better understand the impact on the clinical presentation and management of acute heatstroke. Our primary objective in this study was to describe the prehospital and emergency department (ED) clinical presentation, treatment, and outcomes of patients with acute heatstroke at a single hospital system during the summers of 2021 and 2022 in Phoenix.

Methods: This was a descriptive, retrospective observational study of heatstroke-associated adult ED presentations occurring from June 1 - August 31, 2021 and June 1 - August 31, 2022, to a single hospital system in Maricopa County.

Results: We identified 60 ED heatstroke encounters. The median environmental daily maximum (Tmax) and minimum (Tmin) were 106.0° Fahrenheit (interquartile range [IQR]) 102.0 - 109.0°F) and 84.0°F (IQR 79.0 - 88.0°F), respectively. The patients were commonly male (42, 70.0%, 95% CI 56.8 - 81.2%), White (26, 43.3%, 95% CI 30.6 - 56.8%), middle-aged (mean 52.7 years, 95% CI 48.4 - 56.9), Medicaid-insured (37, 61.7%, 95% CI 48.2 - 73.9%), and presenting via emergency medical services (60, 100%). Patients were commonly of high acuity (median Emergency Severity Index 1, IQR 1.0 - 2.0), and intubated (45, 75.0%, 95% CI 62.1-85.3%). Forty-seven (78.3%, 95% CI 65.8 - 87.9%) patients were found unresponsive outside with associated substance use (methamphetamines 22, 46.8%, 95% CI 32.1 - 61.9%; and fentanyl 14, 29.8%, 95% CI 17.3 - 44.9%). The average patient Tmax at ED presentation was 41.9°C (IQR 41.1 - 42.2). Forty-one patients (68.3%, 95% CI 55.0 - 79.7%) survived to hospital discharge or transfer, of whom 32 (82.1%, 95% CI 66.5 - 92.5%) were neurologically intact.

Conclusion: During the summers of 2021 and 2022, a significant number of heatstroke presentations were treated in a single healthcare system in Maricopa County, Arizona. A substantial number were successfully treated with cold water immersion and discharged neurologically intact. In this urban population, extreme weather exposure and associated substance use appeared to play significant roles.

Improving resident teaching skills is an expectation of training. Despite the recognized importance of resident-as-teacher (RaT) curricula, variability indicates the need for evidence-based guidelines to inform best practices. This paper outlines expert guidelines for the development, implementation, and evaluation of RaT curricula from the members of the Council of Residency Directors in Emergency Medicine Best Practices Subcommittee, based on a critical review of the literature. It is important to perform a needs assessment prior to creating and implementing a RaT curriculum. The RaT curricula should include instruction on adult learning theory, feedback, and classroom and bedside teaching techniques. Outcomes of RaT curricula should be assessed using multiple sources including direct observation and incorporate both knowledge and skill retention, as well as acquisition.