Open Access Emergency Medicine最新文献

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.

Background: Children with epilepsy are often presented to Community Emergency Departments (CEDs) for acute treatment of status epilepticus (SE). Timely medical management is imperative to prevent morbidity and mortality, and adherence to evidence-based guidelines improves outcomes for high stakes/low frequency events. Barriers to guideline adherent management in the CED setting are understudied; in-situ simulation (ISS) can be used to identify gaps in care for events such as pediatric SE.

Objective: The primary objective was to assess for deviations from evidence-based guidelines in the management of pediatric SE. A secondary objective was to explore potential barriers to practice within the evidence-based guidelines.

Methods: We conducted a prospective observational ISS pilot study examining representative CED teams caring for a simulated child in SE. The primary outcome was overall adherence to the pediatric SE guidelines as measured by 12 metrics: 5 non-pharmacologic (for example: delays in vital sign assessment, failure to time seizure) and 7 pharmacologic (for example: incorrect benzodiazepine dose, delay in benzodiazepine administration or escalation to antiseizure medication). Additional metrics including provider knowledge (recognition of status epilepticus) and resources (antiseizure medications stocked) were analyzed as process measures. We enrolled 4 interprofessional teams at 4 participating ED sites.

Results: Overall, 0 of the 4 teams adhered to all 12 metrics. A barrier to timely administration of benzodiazepines for two of the sites came from attempting IV access repeatedly. No team referenced an up-to-date treatment algorithm based on current evidence-based guidelines.

Conclusion: Standardized ISS scenarios identified variability in adherence to the pediatric SE guideline across a pilot sample of local CEDs. Barriers to guideline-adherent care occurred at both individual and systems levels. The study was limited in scope to 4 pilot sites.

Objective: Our objective was to evaluate the amount of unnecessary Venous Blood Gas (VBG) tests initiated in the Emergency Department (ED) and to assess the effectiveness of clinical intervention, such as education, in reducing VBG tests.

Methods: 497 consecutive patients were selected between 1 August and 30 September 2019. For Phase 1, 10 volunteer nurses were randomly assigned to 50 cases each and assessed whether they would perform a VBG. A brief educational intervention was then implemented regarding specific clinical indications to perform VBGs. After the education, they were asked the same questions. For Phase 2, the entire ED team was subjected to intervention and education (Phase 2). A monthly prospective audit of VBG testing numbers in St Vincent's Melbourne Emergency Department was compared from March 2022 to December 2022.

Results: The phase 1 educational intervention saw a significant reduction in unnecessary VBG of 24% (p-value < 0.001, odd ratio of 15.8 [confidence interval (CI): 8.5-29.1]). During Phase two, a sustained reduction in absolute VBG testing in the ED was observed of 33.7% (9% adjusted reduction). This simple intervention would save around $22,000 in our ED based on an annual presentation of ~50,000.

Conclusion: Our study highlights the importance of education to support the "Choosing wisely" campaign to reduce VBG testing in EDs. By reducing the number of VBGs, we not only limit unnecessary tests for our patients, but also reduce the cost associated with frequent and unnecessary blood gas analysis.