Open Access Emergency Medicine最新文献

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.

Background: A simple screening tool is needed for resource-limited settings because rapid treatment is crucial in sepsis. We investigated whether a simplified score, the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG), could replace the Modified Early Warning Score (MEWS) or the quick Sequential Organ Failure Assessment (qSOFA) for sepsis screening.

Methods: We used data from a Japanese multicenter prospective observational study. This dataset included patients with suspected infection who were admitted from 35 emergency departments (cohort 1) and patients with suspected infection who were admitted to 22 intensive care units (cohort 2). The primary outcome was 28-day mortality. Secondary outcomes were ICU admission or death within 28 days and mechanical ventilation or death within 28 days in cohort 1 and diagnosis of sepsis, need for invasive support (composite of vasopressor use, mechanical ventilation, or death before day 4) in cohort 2.

Results: In cohort 1, the AUROC for rSIG was significantly higher for 28-day mortality than for MEWS but not significantly different from that of qSOFA (0.69 [95% CI 0.64-0.74] vs 0.64 [0.59-0.69] vs 0.68 [0.63-0.72]). In cohort 2, the AUROC of rSIG for 28-day mortality was similar to that of MEWS and qSOFA (0.62 [0.56-0.68] vs 0.58 [0.52-0.64] vs 0.62 [0.56-0.67]). The AUROCs for diagnosis of sepsis, ICU admission or 28-day mortality, and mechanical ventilation or 28-day mortality were similar. The AUROC for need of invasive support was significantly higher for rSIG than for MEWS. For most outcomes, rSIG ≥15 had higher sensitivity than a qSOFA ≥2 or a MEWS total ≥5 or any variable ≥3.

Conclusion: Although there are limitations in the data, rSIG predicted short-term outcomes in patients with suspected infections as well as or better than MEWS and qSOFA.

Purpose: This study aimed to explore alterations in respiratory drive in comatose patients after out-of-hospital cardiac arrest (OHCA) and their association with survival outcomes.

Patients and methods: A prospective cohort study was conducted on comatose patients with OHCA who were admitted between October 2022 and October 2024. Patients were followed until their discharge from the hospital and subsequently categorized into survivors and non-survivors. Respiratory drive was evaluated using P0.1, representing the airway occlusion pressure measured within the first 100 ms of inspiration, as displayed on the ventilator. Measurements were collected together with additional parameters at 24, 48, and 72 h following admission.

Results: The analysis involved 30 patients, with an in-hospital mortality rate of 53.3%. Over the 72-h observation period, P0.1 values were greater in survivors than in non-survivors; however, this difference was not statistically significant. During the first 24 h, survivors demonstrated significantly lower tidal volumes per predicted body weight (P = 0.034). P0.1 values ranging from 1.5 to 3.5 cmH₂O in the initial 24 h were independently associated with reduced in-hospital mortality (adjusted OR 0.043, 95% CI 0.003-0.588, P = 0.018).

Conclusion: A trend toward elevated P0.1 levels in survivors was observed. P0.1 values within the range of 1.5-3.5 cmH₂O during the first 24 h were linked to a lower mortality rate. These results indicate that P0.1 could be utilized as a prognostic indicator for comatose patients following OHCA.

Background: Nurses miss recognizingalterations in patients' conditions despite charting. This is due to a lack of knowledge and understanding of deterioration. The modified early warning score (MEWS) aids nurses in early recognition of and response to clinical deterioration. However, utilization of MEWS remains a major challenge at Mulago Hospital, where approximately 63.2% of in-hospital cardiac arrests remain unrecognized. This has resulted in a significant burden of critical illness, with a prevalence of 11.7% and mortality rate of 5.5%. Mulago Hospital-medical and surgical wards showed limited documentation of nurses' use of the MEWS. This study assessed the effect of an educational intervention on nurses' knowledge of the use of MEWS to recognize critical illnesses at the Mulago Hospital.

Methods and materials: A descriptive, quantitative, quasi-experimental one-group pretest-posttest design was employed. A convenience sample of 77 nurses from the Medical and Surgical units of Mulago National Referral Hospital participated. Nurses received face-to-face teaching on the Modified Early Warning Score (MEWS). Data were collected using a validated self-administered questionnaire, with pre-intervention data gathered two weeks before and post-intervention data one month after the training. The Wilcoxon signed-rank test was used to evaluate the effect of the intervention on nurses' knowledge of MEWS, with significance set at p < 0.05 and a 95% confidence interval.

Results: The educational intervention led to a significant improvement in nurses' knowledge of the Modified Early Warning Score (MEWS), as evidenced by a Wilcoxon signed-rank test result of Z = 7.631 (p < 0.0001). Prior to the intervention, the majority of participants (67.53%, n = 52) demonstrated a novice level of MEWS knowledge. The study sample consisted predominantly of female nurses (67.53%, n = 52), with most participants (75.32%, n = 58) aged over 30 years. The mean age was 36.78 ± 8.21 years.

Conclusion: Nurses' baseline knowledge of the nurses towards MEWS was low. Educational interventions significantly improved nurses' knowledge toward modified early warning scores in the recognition of critical illness.

Objective: Treatment of refractory ventricular fibrillation (rVF) is a clinical challenge. If rVF is still present after standard advanced life support (ALS) guideline care, including amiodaron administration, other therapeutic options might be necessary. Based on the available evidence and expertise, our Helicopter Emergency Medical Service (HEMS) team developed a local practice guide for the prolonged resuscitation of patients in rVF and implemented this as standard HEMS care in March 2022.

Methods: This database study contains all patients treated with our local practice guide during out of hospital cardiac arrest (OHCA) with rVF beyond the fifth regular ALS shock-block. This local practice HEMS treatment algorithm consisted of, among others, cessation of epinephrine and alternating administration of esmolol and norepinephrine combined with enoximone. Data were derived from the HEMS database and the treating hospitals. Primary outcome was the return of spontaneous circulation. Secondary outcome was defined as survival to hospital discharge and cerebral performance. This outcome was compared to the literature to analyze for inferiority of treatment.

Results: In a 21-month period, HEMS was 761 times deployed for OHCA. Nineteen patients were treated with the local practice guide, nine patients (47%) were admitted to hospital with return of spontaneous circulation. Median resuscitation time was 22min. Hospital survival with good neurology was achieved in 42% vs 17% as expected. Exact Clopper-Pearson and logistic regression analysis revealed non-inferiority of the local practice guide. Withholding epinephrine was achieved in 84% of patients. A total of 79% and 90% of patients received esmolol and norepinephrine/enoximone mixture, respectively. Alternative defibrillation positions were indicated in 18 patients but applied in only 6 (33%).

Conclusion: In patients with persisting VF despite prolonged advanced life support care, a multifaceted bundle of care approach shows promising results and warrants further research. Alternative drug administrations were found to be substantially easier to achieve compared to alternative defibrillation positions.

Traumatic brain injury (TBI) in the pediatric population is a major cause of morbidity and mortality. Between various etiologies of TBI, gunshot wounds occupy a unique characteristic and apprehensive place. We report a clinical case of a TBI due to a gunshot wound in Indonesia. A 4-year-old girl complained of a painful head and vomiting after sustaining a gunshot wound to the head. The patient was presented with a pediatric Glasgow Coma Scale (pGCS) score of E3V4M5 and was hemodynamically stable Multislice computerized tomography (MSCT) revealed a bullet lodged in the left temporal lobe, a subdural hematoma in the left frontoparietal-temporooccipital, an intracranial hemorrhage in the left temporoparietal region, and a midline shift to the right by 0.7 cm. The patient underwent craniotomy for subdural hematoma evacuation and bullet evacuation. Stable hemodynamics and brain relaxation conditions were achieved during surgery. Postoperative recovery in the pediatric intensive care unit (PICU) was uneventful, and the patient was discharged with improved neurological status (pGCS E4V5M6) without complications. The case highlights the successful management of a pediatric patient with traumatic brain injury due to a gunshot wound through a multidisciplinary and tailored approach focusing on hemodynamic stability, intracranial pressure management, early posttraumatic seizure, and infection prophylaxis to ensure a positive outcome. Given the scarcity of reported cases in low- and middle-income settings, this report provides valuable insights into the optimal management of pediatric gunshot-related TBIs.

Purpose: Obese trauma patients face a higher risk of mortality, prolonged ICU stays, and more complications than non-obese patients. However, some studies suggest that obesity might provide protective benefits in high-impact trauma situations through the "cushion effect". This study will examine whether obesity influences fracture occurrence, injury severity, and clinical outcomes in motor vehicle accidents (MVA).

Methods: A retrospective study of 555 adult patients who presented to a Level 1 Trauma Center following a MVA from 2010-2022. Patients with a Body Mass Index (BMI) greater than or equal to 30 kg/m² were categorized as obese (178 patients, 32.6%), and those with a BMI less than 30 kg/m² were classified as non-obese (377 patients, 67.4%). Incidence of bone fractures and injury severity were compared between both groups using injury severity score (ISS) and abbreviated injury scale (AIS). For variables significant on univariate analysis, binary logistic regression models were used to control age, gender, restraint use, and airbag deployment.

Results: The mean number of fractures (0.62 vs 0.46, p=0.096) and ISS (4.55 vs 4.51, p=0.703) were similar between the obese and non-obese groups. However, obese patients were more likely to experience upper extremity fractures (7.3% vs 3.4%, p=0.045) and lower extremity fractures (7.3% vs 2.7%, p =0.01), particularly fractures of the tibia/fibula (5.6% vs 1.6%, p=0.008). No significant differences were found in the incidence of head, thoracolumbar, or pelvic fractures between the two groups. After controlling for age, gender, restraint use, and airbag deployment, obesity remained an independent predictor of lower extremity fracture (aOR) 2.62 (95% CI: 1.01-6.56), p = 0.04).

Conclusion: Obesity is an independent predictor of lower extremity fractures following a MVA. Clinicians should acknowledge potential differences in fracture occurrence and patterns between obese and non-obese patients during triage.

Introduction: Acute aortic dissection is a rare and life-threatening condition with highly variable clinical presentations, often resulting in atypical symptoms and initial misdiagnosis. This study aimed to investigate clinical presentations and explore the associations between clinical characteristics, delayed diagnosis, and in-hospital mortality among patients with acute aortic dissection.

Methods: A retrospective chart review was performed on patients presenting with acute aortic dissection at an urban academic emergency department in Thailand between January 1, 2011, and December 31, 2020. Baseline characteristics, clinical presentations, imaging findings, delayed diagnosis (>4 h from first emergency department contact), and in-hospital mortality rates were analyzed.

Results: The study included 103 patient charts, predominately men (71 patients), with a median age of 71 years (interquartile range of 58-78 years). Abdominal pain (36.9%) and thoracic pain (24.3%) were the most common presenting symptoms. Dyspnea (11.7%), altered consciousness (4.9%), and syncope (4.9%) were the three main painless presenting atypical symptoms. Atypical presentations were not significantly associated with delayed diagnosis, which occurred in 27.2% of cases. Normotension, a history of coronary artery disease, and pleural effusion were associated with delayed diagnosis. Abnormal chest films were major risk factors for in-hospital mortality, observed in 22.3% of patients with acute aortic dissection, whereas delayed diagnosis was not directly related to such mortality.

Conclusion: The incidence of acute aortic dissection in the urban Thai population was 32.4 per 100,000 patient-years, with a range of clinical presentations. A high index of suspicion for AAD is crucial for timely diagnosis, even in patients with atypical symptoms and seemingly normal vital signs. Careful interpretation of chest radiographs is essential as abnormal chest X-ray findings are associated with a poorer prognosis.