Open Access Emergency Medicine最新文献

The proportion of older adults is increasing worldwide. Frailty assessment in prehospital care was suggested to improve triage decisions and paramedics' judgment. This study aimed to assess the scope and nature of available evidence around frailty identification in prehospital care. A systematic search of the literature was performed using MEDLINE, SCOPUS, CINHAL, and Web of Science to identify relevant articles published from January 2022 downwards. A list of indexed terms and their associated alternatives were pre-determined. Of the 71 identified and reviewed articles after removing duplicates, six articles were included in the review. Due to the heterogeneity of the included articles, the findings were described narratively. The findings of this review showed that the available evidence is limited and heterogenic. Two themes emerged from the findings of the included articles: 1) Paramedics' Perceptions about Frailty Assessment in Prehospital Care and 2) Frailty Scores for Application in Prehospital Care. Paramedics recognised frailty assessment in pre-hospital care to be feasible and important. They highlighted the need for a simple and clear frailty score that could be used and mentioned to other healthcare professionals when handing over patients. Six frailty scores were reported to be used in prehospital care. The evidence around each frailty score is very limited. Overall, frailty assessment in prehospital care was shown to be important and feasible. Different frailty scores have been assessed for use in prehospital care. Further research investigating frailty identification in prehospital care is needed.

Background: Patients with severe vasodilation accompanied by refractory hypotension despite high doses of vasopressors were associated with a high mortality rate. The Ang-2 for the Treatment of High-Output Shock (ATHOS) 3 trial demonstrated that angiotensin 2 (Ang-2) could effectively increase MAP and blood pressure in vasodilatory shock patients. This systematic review aims to summarize the impact of Ang-2 for the treatment of vasodilatory shock on clinical outcomes, including length of stay, MAP level (before and after), and mortality also Ang-2 dose needed.

Methods: A systematic search in PubMed, Sage, ScienceDirect, Scopus and Gray literature was conducted to obtain studies about the use of Ang-2 in vasodilatory shock patients.

Results: In all of the studies that we obtained, there were different results regarding mortality in patients with vasodilatory shock with Ang-2. Mortality was significantly lower when Ang-2 was administered to patients with elevated renin. The initial dose of Ang-2 can be started at 10-20 ng/kg/min, but there is no agreement on the maximum dose. Ang-2 may be considered a third-line vasopressor if the targeted MAP has not been achieved after administration of norepinephrine >200 ng/kg/min for more than 6 hours. Although not statistically significant, the use of Ang-2 can reduce the length of stay in the ICU and in the hospital when compared to patients without Ang-2 therapy, in addition to reducing the dose of vasopressor.

Conclusion: Overall, the use of Ang-2 has potential to be a regimen for patients with vasodilatory shock. Further study is needed to obtain more data.

Background: Beginning January 26th, 2022, the National Board of Medical Examiners transitioned scoring of the United States Medical Licensing Examination (USMLE) Step 1 from a 3-digit score to pass/fail. In the past, the Step 1 score has been weighted heavily by program directors (PDs) as one of the most important metrics when assessing medical student's competitiveness.

Objective: The objective of this study was to evaluate the perceptions of emergency medicine (EM) PDs on the transition to a pass/fail USMLE Step 1 exam, and to elicit the opinions of EM PDs on the USMLE examinations' ability to predict resident performance.

Methods: A survey consisting of ranking and multiple-choice questions was sent to EM PDs. The multiple-choice questions were asked to determine EM PDs level of confidence in the ability of Step 1 and Step 2 Clinical Knowledge (CK) to predict a student's ability to succeed in residency. The ranking questions focused on assessing each program's current resident selection practices in comparison to expected selection criteria changes following a transition to pass/fail Step 1. R studio and MATLAB were used for statistical analysis, and a P value <0.05 was considered significant.

Results: The survey was completed by 57 (20.21%) EM PDs. When asked if Step 1 and Step 2 CK are accurate predictors of a resident's ability to perform clinically within EM, only 10.5% of PDs answered 'yes' to Step 1 being predictive, compared to 31.6% for Step 2 CK. Regarding selection criteria, the top quartile of attributes (standardized letters of evaluation [1st], away rotations [2nd], clerkship grades [3rd] and Step 2 CK score [4th]) remained the same following the transition.

Conclusion: Our results indicate that the top quartile of attributes might remain the same, despite most PDs agreeing that Step 2 CK is a better predictor of a resident's performance.

Introduction: Annually, approximately 4% of the entire adult population of Denmark participate in certified basic life support (BLS) courses. It is still unknown whether increases in BLS course participation in a geographical area increase bystander cardiopulmonary resuscitation (CPR) or survival from out-of-hospital cardiac arrest (OHCA). The aim of the study was to examine the geographical association between BLS course participation, bystander CPR, and 30-day survival from OHCA.

Methods: This nationwide register-based cohort study includes all OHCAs from the Danish Cardiac Arrest Register. Data concerning BLS course participation were supplied by the major Danish BLS course providers. A total of 704,234 individuals with BLS course certificates and 15,097 OHCA were included from the period 2016-2019. Associations were examined using logistic regression and Bayesian conditional autoregressive analyses conducted at municipality level.

Results: A 5% increase in BLS course certificates at municipality level was significantly associated with an increased likelihood of bystander CPR prior to ambulance arrival with an adjusted odds ratio (OR) of 1.34 (credible intervals: 1.02;1.76). The same trends were observed for OHCAs in out-of-office hours (4pm-08am) with a significant OR of 1.43 (credible intervals: 1.09;1.89). Local clusters with low rate of BLS course participation and bystander CPR were identified.

Conclusion: This study found a positive effect of mass education in BLS on bystander CPR rates. Even a 5% increase in BLS course participation at municipal level significantly increased the likelihood of bystander CPR. The effect was even more profound in out-of-office hours with an increase in bystander CPR rate at OHCA.

Herein the authors call attention to the importance of ophthalmic evaluation in the setting of multi-trauma, particularly with facial and orbital fractures. In institutions such as ours, a tertiary general hospital, where such fractures are initially managed by a non-ophthalmic team such as trauma or maxillofacial surgeons, we would advocate for prompt referral to the ophthalmology team for assessment as described by our case of a choroidal rupture in the setting of multi-trauma.

Lemierre syndrome (LS) is a rare, life-threatening complication of oropharyngeal infections associated with septicemia and internal jugular thrombosis. Internal jugular vein thrombosis is an uncommon disease associated with central vein catheterization, intravenous drug abuse, hypercoagulability, trauma to the neck, infection, ovarian hyperstimulation syndrome (OHSS), and systemic infections. Here, we highlight a case of a 62-year-old women who presented progressively worsening neck swelling for three weeks, shortness of breath, and fever for four days. Her sepsis due to Ludwig's angina was accompanied by septic pulmonary embolism and internal jugular vein thrombosis in keeping with a diagnosis of Lemierre syndrome. For this presentation of Lemierre syndrome, the treating physicians recommended surgical excision and drainage, followed by intravenous antibiotics and subcutaneous anticoagulation to treat septic emboli of the lungs and internal jugular veins. Sadly, after being informed about the procedure, the patient refused to consent, and four days later, she passed away. It is essential to remember that early detection and aggressive treatment may significantly impact prognosis and outcome.

Background and aims: A sudden increase in blood pressure without serious, life-threatening symptoms or indications of immediate target organ damage is referred to as "hypertensive urgency." This case study revealed the rare direct cause of epistaxis and the direct cause of hypertensive urgency in an elderly man due to antihypertensive medication noncompliance.

Case presentation: A black male farmer, age 63, was brought to the emergency room on June 1st, 2022, with chief complaints of breathing difficulties, epistaxis, and disorientation. The patient was hospitalized after exhibiting symptoms of breathlessness, malaise, nausea, and vomiting. Magnetic resonance imaging, an echocardiogram, and a computed tomography scan of the brain are all clear. For the treatment of epistaxis, he received 1g of tranexamic acid intravenously three times a day for two days. He received intravenous labetalol, which was effective in treating his hypertensive urgency and rebound hypertension, utilizing repeated dosages of 5-20 mg. The patient's intravenous labetalol and previous enalapril were switched to captopril 25 mg orally three times a day for one month after starting drugs per os.

Discussion: The patient's hypertensive urgency is directly caused by forgetting to take his blood pressure medication and by not adhering to his previous antihypertensive drugs as prescribed. In this study, the patient's hypertension had been uncontrolled for the previous six months despite his treatment plan. Unaware that he had missed two doses of his antihypertensive medication, he was admitted to the emergency room with progressive anterior nose bleeding that persisted for four hours. The patient's elevated arterial blood pressure is what's causing the patient's nose to bleed.

Background: School cardiopulmonary resuscitation (CPR) training has not been previously implemented nor studied in the Arabian Peninsula, and this is due to the challenges that this training imposes. This study aims to determine high school teacher perspectives, willingness, and barriers as related to CPR student training in high schools.

Methods: An anonymous, voluntary, cross-sectional electronic questionnaire, primarily based on the theory of planned behavior (TPB) was distributed to high school principals and teachers from 20 local (public and private) high schools between October and December 2021. The questionnaire was a 4-part (demographics, willingness, barriers, implementation approach), 23-variable tool.

Results: Eighty-four out of 88 participants were included in the analysis from 20 high schools. The overall willingness to teach CPR to students was 4.2 ± 0.9, and this willingness was significantly associated with being a female (p = 0.019), being a teacher (p = 0.036), having a family history of cardiovascular disease (p = 0.007), previous school CPR campaigns (p = 0.02), and all TPB factors: attitude (p = 0.001), subjective norms (p = 0.011), and perceived behaviour control (p = 0.007). As for perceived barriers, there was moderate concern regarding the absence of the Good Samaritan law (3.8 ± 1.1) and CoVID-19 transmission (3.5 ± 1.3). High school teaching staff recommended formal legislation of CPR training from the Ministry of Education (MoE) and favoured CPR training delivery by healthcare professionals. However, they were willing to conduct CPR training themselves with regular training, material integration into the curriculum, and online teaching material access.

Conclusion: High school teachers are willing to teach students CPR. They need MoE legislation, appropriate training, online material, and a standardized database. Teaching staff also recommend specific training session settings. CoVID-19 and Good Samaritan law are moderate barriers. A number of factors influence teaching staff willingness to conduct CPR training. From this analysis, we recommend piloting CPR training in Kuwait high schools with consideration to the identified influential factors and barriers.

Intravenous (IV) fluid resuscitation is a key component of the initial resuscitation of septic shock, with international consensus guidelines suggesting the administration of at least 30mL/kg of isotonic crystalloid fluid. The rationale is to restore circulating fluid volume and optimise stroke volume. It is acknowledged that there is a paucity of high-level evidence to support this strategy, with most studies being observational or retrospective in design. In the past decade, evidence has emerged that a large positive fluid balance is associated with worse outcomes among patients with septic shock in intensive care who have already received initial resuscitation. Randomised trials undertaken in low-income countries have found increased mortality among patients with sepsis and hypoperfusion administered a larger fluid volume as part of initial resuscitation, however, translating these findings to other settings is not possible. This uncertainty has led to variation in practice with some advocating a more conservative fluid strategy coupled with the earlier introduction of vasopressors for haemodynamic support. This question is the subject of several ongoing clinical trials. This article summarises the current state of the evidence for IV fluid resuscitation in septic shock and provides guidance for practitioners in the face of our evolving understanding of this important area.

Objective: We aimed to evaluate the National Early Warning Score‒Lactate (NEWS‒L) and NEWS to predict 24-hour mortality as the primary outcome. The secondary outcomes were to predict 48-hour, 28-day, and in-hospital mortality rates, and the need for critical care in patient with suspicion of sepsis at the emergency department (ED).

Methods: A prospective observational study was performed in patients aged ≥18 years diagnosed with sepsis in the ED from March to November 2021. Area under the receiver operating characteristic curve (AUROC) analyses determined the predictive values of NEWS and NEWS‒L for 24-hour mortality.

Results: Ninety-two patients were enrolled (mean age 68 years, 48 [52.2%] males). Three (3.2%) patients died within 24 hours and 34 (36.9%) patients needed critical care during the ED stay. The median (interquartile range) NEWS and NEWS-L results were higher in the 24-hour non-survivors versus survivors: 12 (10.5, 12.5) versus 8 (6, 9) (p = 0.024) and 18.7 (15.2, 19.1) versus 10.6 (8.9, 13) (p = 0.036), respectively. The adjusted odds ratio (aOR) was 1.22 for the primary outcome as the NEWS-L increased by 1 unit without statistical significance (p = 0.228). The aOR values for the secondary outcomes ranged from 1.34 to 1.67 with statistical significance. A NEWS-L of 11 and a NEWS of 12 predicted 24-hour mortality with sensitivities/specificities of 100%/56% and 67%/91%, respectively. The AUROC values of NEWS-L for mortality at 24 hours, 48 hours, 28 days, and in-hospital patients, and the need for critical care were 0.860, 0.905, 0.813, 0.839, and 0.837, respectively.

Conclusion: NEWS-L is an accurate predictor for 24-hour mortality in septic patients in the ED. NEWS‒L performed better than NEWS for each outcome. NEWS‒L demonstrated good to excellent performance and was accurate in predicting sepsis related to adverse outcomes.