American Journal of Emergency Medicine最新文献

Background: This study investigated insertion patterns, insertion success rates and survival outcomes of out-of-hospital cardiac arrest (OHCA) according to vascular access route using data from an OHCA registry in the state of Queensland, Australia.

Methods: Included were adult medical OHCA who received a resuscitation attempt from Queensland Ambulance Service (QAS) paramedics and had vascular access attempted intra-arrest between January 2018 and December 2024. Insertion patterns and initial attempt success rates were described. The association between route of vascular access and survival outcomes was investigated with multivariable logistic regression analysis after a match using propensity score.

Results: 9854 patients were included. IV was initially attempted in 93.3% of patients, and IO 6.7%. Initial attempt success rate was higher with IO than IV (94.2 versus 68.5%, p < 0.001). After propensity score matching in patients with successful initial access attempt, the IO route had lower return of spontaneous circulation (ROSC) rates, however similar survival to discharge and survival to 30 days rates, compared to the IV route. In patients with successful vascular access regardless of the route and outcome of the initial attempts, the IO route was associated with reduced odds of all survival outcomes.

Conclusions: QAS paramedics are competent with vascular access with high initial attempt success rates for both IV and IO routes. IO may be associated with reduced odds of ROSC on hospital arrival in patients with successful initial access attempt. This study supports current recommendations preferring IV over IO as the primary vascular access route in adult OHCA.

Background: Pediatric out-of-hospital cardiac arrest (OHCA) carries high mortality, with post-arrest coagulopathy contributing to poor outcomes. However, pediatric-specific prognostic tools remain limited. We evaluated the prognostic value of early coagulation parameters among children who survived the first 24 h after return of spontaneous circulation (ROSC).

Methods: This single-center retrospective cohort study included pediatric OHCA patients (<18 years) who achieved ROSC and survived beyond 24 h between January 2000 and June 2024. Laboratory parameters-including activated partial thromboplastin time (aPTT), international normalized ratio (INR), and lactate-were collected within one hour of emergency department (ED) arrival. A three-tier risk stratification system was developed with bootstrap validation. The primary outcome was 28-day mortality.

Results: Among 70 patients, the 28-day mortality rate was 51.4% (36/70). Non-survivors had longer ROSC time (45.1 vs. 24.1 min, p < 0.001) with worse coagulopathy. The Three-Tier Rule stratified patients into low-risk (24.1% mortality), intermediate-risk (50.0%), and high-risk (87.0%) groups (p for trend <0.001). The Clinical Model (four Utstein variables) achieved an area under the curve (AUC) of 0.817, which improved to 0.869 (95% CI: 0.781-0.957) when incorporating the aPTT-based risk group (Full Model). Compared to the International Society on Thrombosis and Haemostasis (ISTH) DIC score, the Three-Tier Rule demonstrated higher sensitivity (55.6% vs. 34.5%), comparable specificity (91.2% vs. 92.9%), and complete data availability (100% vs. 81.4%).

Conclusion: Among pediatric OHCA patients who survive the first 24 h, admission aPTT may serve as a practical marker for early risk stratification. These exploratory findings warrant multicenter validation.

Objective: Metoclopramide is widely used to treat nausea, vomiting, and headache. However, it may cause extrapyramidal symptoms (EPS) such as akathisia. Continuous intravenous (IV) infusion has been proposed as a safer alternative to bolus injection. This study aimed to compare the risk of EPS and effectiveness between continuous and bolus IV metoclopramide administration.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing continuous vs. bolus IV administration of metoclopramide. Databases searched included CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, and ICTRP (inception to January 2025). The primary analysis was restricted to trials conducted in the emergency department (ED), with secondary analyses including all clinical settings. Primary outcome was the occurrence of EPS. Secondary outcomes included nausea severity; headache severity; occurrence of akathisia. Pooled estimates were calculated using random-effects models (standardized mean differences [SMDs], risk ratios [RRs]).

Results: Among 5878 randomized controlled trials screened, seven trials (924 patients) were included in the meta-analysis. Across five ED trials, continuous infusion was associated with a lower risk of EPS (RR: 0.34; 95% CI: 0.15 to 0.79; I² = 75.1%), with EPS outcomes in ED trials being defined as akathisia. Two trials assessed nausea severity (SMD: 0.10; 95% CI: -0.13 to 0.32; I² = 0%). One trial assessed headache severity (SMD 0.17; 95% CI: -0.18 to 0.53).

Conclusion: In the emergency department, continuous intravenous metoclopramide was associated with a lower risk of EPS without clear differences in symptom control, suggesting that continuous infusion may be a reasonable approach in clinical practice.

Introduction: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide, with rising incidence in the United States. Diagnosis can be particularly challenging in the emergency department (ED), where time-sensitive decisions are required and maternal physiologic adaptations may obscure early warning signs. Emergency physicians must be equipped to recognize subtle presentations, initiate resuscitation, and coordinate care across specialties.

Objective: This review highlights the pearls and pitfalls of PPH, including presentation, diagnosis, and management in the ED based on current evidence.

Discussion: PPH presents variably, and patients can deteriorate rapidly, with pregnancy-related physiologic changes often masking early signs of blood loss. Emergency physicians should consider this diagnosis in appropriate clinical scenarios, recognizing that hypotension is a late finding and subtle symptoms may represent early hemorrhage. Initial evaluation begins with resuscitation, followed by identifying the etiology using the "4 Ts" framework: tone (uterine atony), tissue (retained placenta), trauma (tears, lacerations, uterine inversion), and thrombin (coagulation abnormalities). Pelvic examination is essential, with laboratory studies and ultrasound serving as adjuncts to confirm retained tissue, uterine rupture, or intra-abdominal bleeding. Timely recognition and targeted intervention are critical to preventing morbidity and mortality.

Conclusion: Emergency physicians must remain prepared to rapidly identify and treat PPH, as early recognition and intervention are vital to survival. Applying the "4 Ts" framework and engaging a multidisciplinary team are keys to reducing morbidity and mortality in this high-risk condition.

Objective: The objective of this study was to evaluate the impact of operator training level, specifically comparing Emergency Medicine (EM) attending physicians and residents, on the analgesic efficacy of ultrasound-guided nerve blocks (UGNBs) performed in the emergency department (ED).

Methods: This is a secondary analysis of the National Ultrasound-Guided Nerve (NURVE) Block Registry, involving 11 U.S. EDs from January 1, 2022, to December 31, 2023. Adult patients undergoing UGNBs for acute pain or procedural analgesia were included, totaling 1595 procedures after exclusion of incomplete post-procedural pain scores. The primary outcome was percent pain reduction, with >50% defined as clinically meaningful and > 75% as substantial analgesia. Subgroup analyses were performed by operator experience and block type.

Results: Attendings achieved clinically meaningful pain reduction in 80.7% of cases versus 63.4% for residents, and substantial reduction in 68.1% vs 47.7% respectively (p < 0.001). This difference persisted at the highest experience level (>20 prior blocks: 82.3% vs 71.0%, p = 0.0007) and was observed across block types, reaching significance for erector spinae plane blocks (79.6% vs 63.6%, p = 0.01). Complications were rare (0.13%), with both events in resident-performed blocks.

Conclusion: UGNBs performed by attendings were associated with greater analgesic success compared with those by residents, yet both groups achieved high rates of clinically meaningful pain reduction with very low complication rates. These results underscore the role of experience in UGNB efficacy while supporting the safety and effectiveness of supervised resident performance in the ED.