Open Access Emergency Medicine最新文献

Objective: Despite the numerous studies critiquing the Quick Sequential Organ Failure Assessment (qSOFA) score for sepsis prognosis in the emergency department (ED), there are limited known risk factors that can be missed by qSOFA.

Methods: This is a multicenter retrospective cohort study using ED data from Dr Sulaiman AL-Habib Medical Group Hospitals in Riyadh, Saudi Arabia. We assessed all suspected septic patients who came through the EDs from 1st May 2022 to 30th April 2023 with the qSOFA < 2. Among these patients, we identify those who develop critical outcomes (the requirement for vasopressors/inotropes or mortality) within 72 hours of triage. Additionally, we analyzed the potential risk factors of critical outcomes using a multivariable logistic regression model.

Results: We identified 1011 patients who presented with suspected sepsis and qSOFA < 2. Among them, 70 patients developed critical outcomes within 72 hours. In the multivariable logistic regression model, the potential risk factors for critical outcomes were age ≥65 years (adjusted OR, 3.87 [1.25, 14.9]), lactate ≥ 2.5 mmol/L with adjusted OR 2.04 [1.16, 3.54], and shock index >1 with adjusted OR 3.27 [1.13, 10.3]. There are no specific comorbidities that were independently associated with the critical outcomes.

Conclusion: The study identified potential risk factors for sepsis outcomes that qSOFA overlooks. Integration of risk factors (lactate, shock index, age) with qSOFA could enhance early sepsis recognition and improve patient outcomes. We recommend further studies to validate these risk factors.

Background: Mass casualty incidents present significant challenges to healthcare systems, necessitating effective triage and response from emergency personnel. Unfortunately, emergency medicine residents have reported discomfort with disaster preparation and lack of confidence at the prospect of responding to large-scale mass casualty incidents. Mass casualty preparation exercises are often costly, time-consuming to plan, and resource prohibitive, complicating disaster training initiatives for emergency medicine residency programs. We implemented and evaluated a novel training exercise geared toward improving resident comfort levels in utilizing the START (Simple Triage and Rapid Treatment) and JumpSTART triage algorithms that incorporated easily acquired materials and required limited faculty time commitment.

Methods: We staged two small-scale mass casualty exercises in May 2023 and December 2024 utilizing moulaged dolls and props designed to mimic a disaster scene. Dolls were equipped with QR codes linked to short vignettes including vital signs and relevant clinical information. Residents were instructed to assign a triage designation based on the information provided and input their response into Google Forms. Once submitted, participants received immediate feedback regarding the accuracy of their response, along with an explanation of why they were or were not correct.

Results: A total of thirteen residents for the first, and twelve residents for the second exercise implementation participated, completing pre- and post-intervention surveys to evaluate their comfort with mass casualty scenarios using the START triage system. Results indicated a 66% increase (first implementation) and 55% increase (second implementation) in the likelihood of residents feeling "mostly" or "very" comfortable post-exercise. Participants rated the teaching quality and instructional tools as "excellent".

Conclusion: Resident confidence in responding to mass casualty incidents improved post-exercise via the use of a cost-effective and easily replicable mass casualty triage training model, circumventing the need for costly simulation equipment and extensive faculty involvement.

Duodenal diverticular disease is a common finding in the general population and most individuals, in fact, remain asymptomatic. However, duodenal diverticular perforation is an occasional unfortunate endpoint that carries significant morbidity, and mortality rates and requires a particular attention and a wise judgement whether to liberally interfere surgically or to stay more conservative.In this writing, we describe a case of a 45-year-old male with a perforated duodenal diverticulum that presented in a stable general condition and was successfully managed conservatively, sparing the patient a particularly morbid surgical intervention. Perforated duodenal diverticula, though rare, can be managed conservatively in stable patients without signs of sepsis or generalized peritonitis. Conservative treatment, including intravenous antibiotics, bowel rest, and nasogastric suction, can be effective and avoid the morbidity associated with surgery. In our case, conservative management led to significant improvement, underscoring the importance of individualized treatment plans and close monitoring to decide on the necessity of surgical intervention.Conservative management of perforated duodenal diverticula should be considered in selected patients who fulfill the general settled criteria. Nevertheless, an individualized approach is recommended and escalating up the invasiveness of interventions may seem vital at any time during treatment.

Prehospital geriatric falls account for approximately a fifth of emergency medical services (EMS) call volumes nationwide, with a significant proportion involving head injuries and lacerations. Managing these injuries and associated hemorrhage requires substantial resource utilization, including personnel, time, and supplies. Complicating care is that many geriatric patients are maintained on long-term oral anticoagulant or antiplatelet therapy, making hemorrhage control more difficult. Failure to achieve adequate hemostasis in the field can delay critical assessments and further intervention. This case report describes the prehospital use of a novel hemostatic gel (Traumagel) in managing a complex head laceration. Traumagel achieves rapid and reliable hemostasis in complex wounds that may not be amenable to other hemostatic techniques. Deploying this gel alone or in combination with traditional methods enables emergency medical providers in the field to shift their focus to advanced patient care, allowing for earlier transport to definitive care. In this case, an elderly patient on chronic antiplatelet therapy (Clopidogrel) sustained a complex, open scalp laceration following a ground-level fall. EMS controlled a mixed venous-arterial hemorrhage unresponsive to direct pressure and traditional hemostatic interventions using Traumagel. Effective field hemostasis helped avoid trauma activation and potential operative intervention. The wound was successfully repaired in the emergency department without complication. This report underscores the importance of EMS providers integrating traditional techniques with emerging hemostatic technologies to optimize outcomes in moderate to severe trauma-related hemorrhage.

Background: Arrhythmia is a common complication among trauma patients and is frequently encountered in clinical practice. It is highly prevalent in this population and is associated with an elevated risk of adverse outcomes, including myocardial infarction, cerebrovascular events, and prolonged hospitalization.

Methods: We conducted a bibliometric analysis using CiteSpace and VOSviewer to perform both qualitative and quantitative assessments of the literature, including publication volume, contributing countries and institutions, leading authors, and keyword co-occurrence patterns.

Results: A comprehensive search of the Web of Science Core Collection database was performed for publications on trauma and arrhythmia from January 2014 to December 2024, yielding 5,840 relevant articles. The annual number of publications increased steadily, peaking in 2021 (764 articles), followed by a slight decline in 2022 (756 articles). The United States was the most productive country, accounting for 2,056 articles (35.2%). The Mayo Clinic emerged as the leading institution (107 articles), and Dr. Shinsuke Miyazaki was the most prolific author (34 articles, 0.58%). Frequently occurring keywords included atrial fibrillation, spinal cord injury, post-traumatic stress disorder, blunt chest trauma, traumatic brain injury, hip fracture, head trauma, chest trauma, pelvic fracture, and spinal cord injury. Among trauma types, spinal cord injury, traumatic brain injury, chest trauma, pelvic fracture, and post-traumatic stress disorder were most strongly associated with arrhythmia development, with atrial fibrillation being the predominant arrhythmic subtype.

Conclusion: This study represents the first bibliometric analysis to map the global research landscape of trauma-related arrhythmia. It delineates current research trends, identifies key contributors and thematic foci, and offers novel insights to guide future investigations into the mechanisms, prevention, and management of trauma-induced arrhythmias, while also forecasting emerging research hotspots.

Background: The emergency department (ED) plays a vital role in providing life-saving services in hospitals worldwide. In Jeddah province, Saudi Arabia, the Ministry of Health introduced the "Door to Disposition" key performance indicator (KPI) to enhance ED service quality by addressing overcrowding, limited bed capacity, delays in patient transfer, and complex logistical inefficiencies. However, little is known about how this initiative has affected the quality of ED care from the perspectives of patients and healthcare professionals.

Aim: To evaluate the quality of health services in the ED from the patients' and health professional's perspectives.

Methods: A qualitative design was employed using purposive sampling. Semi-structured interviews were conducted with 32 patients and 24 health professionals across 11 public hospitals (three rural and eight urban) in Jeddah between November 2023 and January 2024. Interviews were conducted face-to-face or by phone in Arabic or English, recorded with consent, and analyzed thematically.

Findings: Participants highlighted the importance of the "Door to Disposition" initiative and its valuable implementation. On the other hand, the primary reported barriers to emergency quality care provision are the absence of an effective triage system, shortage of medical practitioners, long waiting times, lack of dedicated urgent care centers, and lack of resources and logistical support. Thus, participants suggested improving emergency department services by focusing on primary and secondary care centers in terms of essential services and supplies, increasing the physical and human capacity of hospitals, establishing affiliated urgent care centers, providing effective and efficient means of communication between primary and secondary care centers, and finally, continually developing the healthcare providers capabilities.

Conclusion: The study helped to identify the barriers and facilitators encountered by patients and health professionals when accessing and utilizing emergency care in Jeddah.

Background: Road traffic injuries pose a significant public health challenge in Sub-Saharan Africa, particularly Uganda. Due to limited emergency medical services, police officers and bystanders provide inadequate prehospital care, contributing to high mortality rates of road traffic accident victims. The study evaluated the effect of an educational intervention on the knowledge and skills of police officers towards prehospital care for RTA victims in Southwestern Uganda.

Methodology: The study was conducted at Mbarara Central Police Station using a quasi-experimental design. We recruited a convenience sample of 45 participants who had served for at least 6 months and provided informed consent to participate. Data were collected using a validated structured questionnaire and checklist. Analysis was done using Stata version 17, with variables scoring a p-value of 0.001, which was considered significant utilizing a t-test.

Results: The majority (80%) of the participants were men, mean age was 41.2±11.3 years. Baseline knowledge and skills in prehospital care were low, with mean scores of 50.7%±16.8 and 34.0%±8.1 respectively. Post-intervention, there was a significant improvement in knowledge by 15.4% and skills by 46.4%, which was statistically significant (P<0.001). Improvement was most notable in the secondary survey by 67% for skills and least in the assessment for major bleeding by 18.5% for knowledge.

Conclusion and recommendations: The study found that an educational intervention greatly enhanced police officers' prehospital care skills for RTA victims, recommending regular training for Police officers as first responders.

Purpose: To investigate the association between early prophylactic anticoagulation and in-hospital mortality in ICU patients with severe acute pancreatitis.

Patients and methods: This retrospective cohort study used data from the MIMIC-IV database (v3.1), including adult ICU patients diagnosed with SAP between 2008 and 2019. Patients receiving therapeutic anticoagulation were excluded. Early prophylactic anticoagulation was defined as subcutaneous heparin or enoxaparin administered within 24 hours of ICU admission. The primary outcome was in-hospital mortality. Multivariable Cox regression models with multiple imputation and propensity score matching were used to adjust for confounding.

Results: Among 1341 eligible patients, 286 (21.3%) received early prophylactic anticoagulation. While crude in-hospital mortality was not significantly different between groups, patients receiving early anticoagulation had significantly lower in-hospital mortality (Log-rank P = 0.015). Multivariable Cox models confirmed a consistent protective association across imputed datasets (HRs ranging from 0.60 to 0.62; all P < 0.05). Subgroup analysis showed no significant interaction across age, gender, or comorbidity status. After 1:1 propensity score matching (n = 284 pairs), the mortality benefit persisted (HR = 0.51; 95% CI: 0.32-0.82; P = 0.005). Additional sensitivity analyses yielded similar results.

Conclusion: Early prophylactic anticoagulation within 24 hours of ICU admission was associated with reduced in-hospital mortality in patients with severe acute pancreatitis. These findings suggest potential benefits of early anticoagulation in this high-risk population and warrant further prospective validation.

Background: Shared decision making is a healthcare method in which health personnel and patients collaboratively evaluate different management options for medical decisions. Despite possible restraints this method encounters in the context of emergency medicine, there is a growing body of evidence. This article critically appraises the current literature and challenges to inform future research efforts.

Methods: This scoping review respects the PRISMA- and PECOS-methodologies. Qualitative- and quantitative studies were included when exposing emergency health personnel or patients to collaborative care for medical decisions with multiple reasonable management options. PubMed, CENTRAL, APA PsycINFO, Web of Science, reference lists and research group remarks served as data sources. Three researchers handled title- and abstract screening; one researcher extracted and synthesized data. Basic data on study design, publication date, country of origin, estimates for time consumption and more were extracted through standardized forms for all publications. All outcomes from the randomized clinical trials were included and reported, following the authors' conclusions. This includes effects on consultation times. Through tabular visualization, critical appraisal and author group discussions, challenges in the literature were summarized narratively. Neither risk of bias assessment nor meta-analysis were performed.

Results: Of 3954 hits, 3428 remained for the title- and abstract screening and 67 for data synthesis. Studies predominantly utilized observational designs (n=27), originated from the USA (n=50) and were published between 2011 and 2020 (n=46). The included randomized trials (n=6) report heterogeneous results on patient-reported outcome measures and resource utilization. Patient safety was reported as not affected. In three randomized trials, consultations were prolonged by 2 minutes on average. Through critical appraisal and author group discussions, six annotations on the literature on shared decision making in emergency medicine were stipulated.

Conclusion: Research on shared decision making in emergency medicine utilizes different, intertwined terminologies, originates mostly from the USA and focuses on decision aids. The few randomized trials exclude high-risk patients and suggest potential resource-saving effects without compromising patient safety. The formal increase in discussion times appears debatable.

Background: Manual ventilation is a critical skill for emergency medical service (EMS) members. However, it is challenging in terms of correct ventilation rates and tidal volumes, with potentially severe adverse effects of hypo- and hyperventilation. Measuring the quality and involving real-time feedback may be effective in optimizing of manual ventilation.

Methods: Data acquired retrospectively from a quality management project in 143 advanced emergency medical technicians were included. They performed bag ventilations on an intubated adult manikin for two minutes without any feedback system, and then another two minutes with the Real BVM Help^® device. Ventilation rates and volumes and their allocation in correct/recommended ranges were determined.

Results: With the feedback device, correctly applied ventilation rates increased by 21% (63.6% in the correct range without vs 84.6% with the feedback device; p<0.001), and ventilation volumes improved by 41% (27% in the correct range without vs 68% with the feedback device; p<0.001). Without the device, the average ventilation rate was 10.5 ±3.1/minute, compared to 9.5 ±1.9/minute with the device. Ventilation volumes amounted to 370.6 ±84 mL without Real BVM Help^®, while when using it, 415.5 ±33.1 mL was noted.

Conclusion: Our data demonstrate significant improvements in ventilation rates and volumes when using a ventilation feedback device. This manikin study suggests a ventilation feedback device being beneficial for the use by EMS members, but our findings must be further validated in real-life conditions.