Open Access Emergency Medicine最新文献

Purpose: This study investigates the predictive value of incorporating anemia, hyperglycemia, and left ventricular ejection fraction (LVEF) into the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality in Acute Coronary Syndrome (ACS).

Patients and methods: We conducted a single-center, cross-sectional study involving 634 ACS patients admitted to Dr. Hasan Sadikin General Hospital between 2021 and 2023. Anemia was defined as hemoglobin <13 g/dL in men and <12 g/dL in women, while hyperglycemia was indicated with random blood glucose (RBG) ≥200 mg/dL at admission. Patients with LVEF <50% were classified as having reduced LVEF. The primary outcome was in-hospital mortality. Model goodness-of-fit was assessed using R² and the Hosmer-Lemeshow's test. The predictive accuracy of the GRACE score alone and combined with these parameters were evaluated through receiver operating characteristic curve analysis, an area under the curve (AUC), and concordance (C)-statistics. Reclassification improvement was quantified using continuous net reclassification improvement (cNRI) and integrated discrimination improvement (IDI).

Results: Among 634 patients (mean age 58.10±11.08 years old; 80.3% male), anemia, hyperglycemia, and reduced LVEF were observed in 197 (31.1%), 123 (19.4%), and 364 (57.4%) patients, respectively. The in-hospital mortality rate was 6.6%. Regression analysis identified nine predictors of mortality, with anemia, hyperglycemia, and reduced LVEF confirmed as independent predictors. The GRACE score showed an AUC of 0.839 (95% confidence interval/CI 0.77-0.0.90). Incorporating anemia, hyperglycemia, and reduced LVEF increased the AUC to 0.862 (95% CI 0.81-0.91), enhancing predictive accuracy (p = 0.590). Combining these variables yielded an NRI of 0.075 (p = 0.070) and an IDI of 0.035 (p = 0.029).

Conclusion: Incorporating anemia, hyperglycemia, and reduced LVEF into the GRACE score improves its predictive capacity for in-hospital mortality in ACS patients. The modified GRACE score offers a more robust risk stratification tool for clinical practice and decision-making.

Purpose: Triage systems play a vital role in effectively prioritizing patients according to the seriousness of their condition. However, conventional emergency triage systems in pediatric care predominantly rely on subjective evaluations. Machine learning technologies have shown significant potential in various medical fields, including pediatric emergency medicine. Therefore, this study seeks to employ pediatric emergency department records to train machine learning algorithms and evaluate their effectiveness and outcomes in the triaging system. This model will improve accuracy in pediatric emergency triage by categorizing cases into three urgency levels (nonurgent, urgent, and emergency).

Patients and methods: This is a retrospective observational cohort study that used emergency patient records obtained from the Emergency Department at King Faisal Specialist Hospital & Research Centre. Using the emergency severity index (a scale of 1 to 5), various machine learning techniques were employed to build different machine learning models, such as regression, instance-based, regularization, tree-based, Bayesian, dimensionality reduction, and ensemble algorithms. The accuracy of these models was compared to reach the most accurate and precise model.

Results: A total of 38,891 pediatric emergency patient records were collected. However, due to numerous outliers and incorrectly labeled data, clinical knowledge and a confident learning algorithm were employed to preprocess the dataset, leaving 18,237 patient records. Notably, ensemble algorithms surpassed other models in all evaluation metrics, with CatBoost achieving an F-1 score of 90%. Importantly, the model never misclassified an urgent patient as nonurgent or vice versa.

Conclusion: The study successfully created a machine learning model to classify pediatric emergency department patients into three urgency levels. The model, tailored to the specific needs of pediatric patients, shows promise in improving triage accuracy and patient care in pediatric emergency departments. The implication of this model in the real-life sitting will increase the accuracy of the pediatric emergency triage and will reduce the possibilities of over or under triaging.

Background: In-hospital cardiac arrest (IHCA) is a critical emergency, occurring at rates of 1-6 events per 1000 hospital admissions, necessitating immediate and efficient resuscitation efforts. This study aims to determine the frequency, demographic characteristics, and outcomes of Code Blue activations in a tertiary teaching hospital in a low-middle-income country.

Methods: This retrospective observational study was conducted at in National Referral and Teaching Hospital in a middle income country in Asia, covering data from January 1, 2017, to December 31, 2023. The study included 2184 Code Blue activations, with data on Early Warning Scores (EWS) and palliative scores available from 2021 onwards. Statistical analyses were performed to evaluate the relationship between these scores and patient outcomes.

Results: Out of 2184 Code Blue activations, 713 cases included both EWS and palliative scores. The highest number of activations was recorded in 2019 (535 cases), and the lowest in 2021 (152 cases). Calculated incidence where 5.46 per 1000 visits. The return of spontaneous circulation (ROSC) rates ranged from 11% to 27.6%, with an average of 17.7% per year. The mean EWS and palliative scores for Code Blue activations were 9.2 (SD ± 2.3) and 7.8 (SD ± 1.9), respectively.

Discussion: The findings highlight trends in IHCA incidence, causes, and outcomes, emphasizing the importance of early identification and management of patients at risk. The study underscores the need for continuous monitoring and early intervention, particularly for patients with high EWS. Additionally, the integration of palliative care considerations into hospital protocols is crucial for improving patient outcomes and resource allocation.

Conclusion: Early warning system and palliative care scoring may predict code blue activation and if managed can reduce its number.

Introduction: Nerve injuries and resultant pain are common causes of emergency department (ED) visits in the United States. Injuries often occur either due to activity (ie sports related injury) or due to consumer products such as stairs or bedframes. We investigated the incidence of consumer product-related nerve injuries (CPNIs) in patients who presented to the ED in the United States.

Materials and methods: The National Electronic Injury Surveillance System was queried to identify patients presenting to US EDs between 2012 and 2021 with CPNIs. The cohort was categorized by age: 1) 0-17-year-olds, 2) 18-64-year-olds, 3) and 65+ year-olds. The primary outcomes were the type of injury and the location of injury.

Results: A total of 14,410 CPNIs were reported. There was an increase in yearly CPNIs (β = 4763, (95% confidence interval 1940-7586); P = 0.004). The majority (11,547/14,410, 80.1%) of injuries were among adults. Elderly females encountered more CPNIs than males (52.5% vs 47.8%, P = 0.002). Stairs were most involved in nerve injuries among adults (8.21%) and children (3.96%) whereas beds or bedframe injuries were most frequent (12.0%) among the elderly. Sciatica was the most common diagnosis (≥60%) followed by radiculopathy (≥20%) in adults >18 years of age. Among adults aged 18 to 29, the upper trunk, lower arm, and wrist was more frequently involved, while these areas were less commonly involved in adults aged 40 to 49. Compared to adults, the pediatric and elderly patients presented with more traumatic spinal cord injuries.

Conclusion: Sciatica, radiculopathy, and traumatic spinal cord injury were the most common diagnoses following CPNIs. Children and the elderly tended to present with more severe CPNIs than the general adult population. Further investigations exploring interventions to lower the burden of CPNIs, improve consumer product safety, and reduce potentially chronic and debilitating injuries are necessary.

Background: One of the most serious complications of coronary artery stenting is restenosis and in-stent thrombosis; their prevalence can reach 20-25%. Stent thrombosis can be acute (up to 24 hours), subacute (24 hours to 30 days), late (30 days to 1 year), and very late (> 1 year after previous stenting). In the patients with COVID-19 in intensive care units, the proportion of those with elevated troponin levels reached 25%.

Objective: Evaluation of the association between COVID-19 and the development of in-stent thrombosis and restenosis of the coronary arteries based on the analysis of clinical cases and case series.

Materials and methods: We searched the PubMed and Scopus databases for relevant case reports and case series of stent restenosis and in-stent thrombosis associated with coronavirus infection (CVI) published between 2020 and the present. Thirty-eight full-text publications were screened and manually checked for analysis. We found 10 publications describing cases of thrombosis and restenosis of stents associated with coronavirus infection, of which only 2 were case series. In total, we analyzed 22 cases.

Results: In the structure of in-stent restenosis and thrombosis, 59.1% were very late, 9.1% were late; 18.2% were considered subacute events, and 13.6% were acute events. All cases were angiographically confirmed. The main location of restenosis or thrombosis was the left coronary artery (LAD) (51.1%), thrombosis of the right coronary artery (RCA) occurred in 27.3%, and location in circumflex artery was in 22.7%. All patients had COVID-19 confirmed by a PCR test or the presence of immunoglobulins G and M. In fourteen patients (54.5%), an X-ray examination showed the presence of bilateral polysegmental infiltration.

Conclusion: Analysis of publications demonstrates the association between restenosis and in-stent thrombosis in patients with coronary arteries disease (CAD) and coronavirus infection.

Background: Lactate has long been recognized as a key prognostic biomarker in sepsis. Similarly, the prognostic role of the neutrophil-to-lymphocyte ratio (NLR) has been investigated in various conditions, including sepsis. Previous studies have explored the optimal NLR cutoff to differentiate sepsis survivors from nonsurvivors, predict bacteremia, diagnose sepsis, and assess mortality. This study compares the prognostic value of lactate and NLR in septic patients.

Methods: This prospective cohort study included 874 adult septic or septic shock patients presenting to a tertiary care center's Emergency Department between September 2018 and February 2021. The primary outcome was to compare the prognostic value of NLR and lactate regarding in-hospital mortality. Secondary outcomes compared their prognostic value in different septic subgroups.

Results: Stepwise logistic regression showed NLR was not associated with in-hospital mortality (OR=1.003, p=0.544), while lactate was significantly associated with in-hospital mortality (OR=1.188, p<0.0001). There was no significant difference in the AUCs of NLR and lactate (0.552 vs 0.591, p=0.22). Lactate outperformed NLR in patients with albumin <30, those <65 years old, and those with sepsis from a urinary tract infection. No significant differences were found in AUCs between lactate and NLR in patients with septic shock, Lactate<2, Lactate≥2, diabetes, malignancy, chronic kidney diseases, other sources of infection, albumin ≥30 and age ≥ 65.

Conclusion: In this study, lactate but not NLR was associated with in-hospital mortality. There was no significant difference in the AUCs between lactate and NLR among sepsis patients and among most of the subgroups. However, lactate outperformed NLR in the following subgroups: albumin<30 g/L, patients <65 years old and patients with sepsis due to a urinary tract infection. Our results advocate for the continued use of serum lactate rather than NLR, despite its limitations, as a predictor of mortality among septic patients and the different subgroups in this study.

Introduction: Emergency department overcrowding is a universal problem. It is associated not only with poor clinical outcomes but also with a decrease in patient satisfaction, especially in patients with low complexity emergencies or triage 4 and 5, who tend to have a longer waiting time.

Objective: This study aims to determine whether the implementation of a care strategy for patients with low complexity emergencies called "The special Line" in the emergency department of a third level academic institution in Colombia, has a positive impact on the level of satisfaction with the care received by the patient and the number of people who leave without being seen.

Methods: This is a retrospective analytical observational study that looks at the effect on the rate of patients who leave without being seen and the net promoter score (NPS) of the entire emergency department of establishing a protocol for the care of patients with low complexity emergencies.

Results: Of a total of 22,743 patients divided into the two comparison groups, it was found that after the implementation of the care protocol, a non-significant reduction in the median rate of patients without care from 2.35% to 1.85% was documented, as well as a significant improvement in the median value of the NPS from 44 to 53, p: 0.001.

Conclusion: The implementation of a protocol for the care of patients with low-complexity emergencies demonstrated a significant improvement in the experience of care for all users in the emergency service, additionally, indirectly influencing the leave without being seen of the entire emergency service.

Purpose: We describe emergency medical services (EMS) protocols for pain management in the United States to elucidate systemic variability in protocols. We describe types of pain medications included in protocols, routes of administration, indications for use, standing orders for dosing, and use in pediatric patients.

Methods: We performed a review of all publicly accessible EMS protocols from the website http://www.emsprotocols.org, supplemented with internet searches. Data were abstracted into a data collection form from June 2021 to January 2022. We developed categories of responses to summarize the data, using frequencies and proportions to describe outcome measures.

Results: We reviewed 104 EMS protocols, spanning 43 states. The most common pain management medications include fentanyl (94.2%), morphine (70.2%), ketamine (61.5%), ketorolac (40.4%), oral acetaminophen (36.5%), oral ibuprofen (22.1%), and nitrous oxide (19.2%). The most common route of administration across all protocols and medications is intravenous. Severe pain, without a specified level, is the most common indication for fentanyl (65.3%), morphine (61.6%), ketorolac (50.0%), and nitrous oxide (40.0%). Musculoskeletal injuries and burns are the most common indications for morphine, 15.1% and 19.2% of protocols, respectively. The majority of protocols dictate the weight-based dosing of fentanyl (74.5%), morphine (64.4%), ketamine (87.3%), oral acetaminophen (56.8%), and oral ibuprofen (59.1%). However, 97.6% and 100.0% of protocols dictate a fixed dose of ketorolac and nitrous oxide, respectively. Fentanyl, morphine, oral acetaminophen, and oral ibuprofen can be administered to pediatric patients based on standing orders among >90.0% of protocols. However, only 46.2% and 75.0% of protocols allow the use of ketorolac and nitrous oxide in pediatric patients, respectively.

Conclusion: We found variability in EMS pain management protocols including the types of allowed medications, routes of administration, dosing, and indications for use. Further studies may assess whether standardized protocols across EMS systems could improve patient safety and quality of care.