American Journal of Emergency Medicine最新文献

Introduction: Survival alone may not fully reflect the quality of emergency and critical care. Neurological outcomes provide an important measure of recovery among critically ill patients treated in the emergency department (ED).

Objective: To identify patient- and emergency care system-related factors associated with neurological outcomes following ED admission.

Methods: This prospective cohort study was conducted across seven tertiary hospitals in six central provinces of Thailand between December 2023 and May 2024. Critically ill adult patients (≥18 years) admitted to the ED were enrolled. A favorable neurological outcome was defined as a Cerebral Performance Category (CPC) score of 1 or 2. Data were analyzed using a population-averaged Generalized Estimating Equation (GEE) model to account for repeated outcome measurements.

Results: Among 442 critically ill adult patients admitted to the ED, the mean age was 66.8 ± 15.0 years, 230 (52.0%) were female, and 254 (57.7%) were classified as Emergency Severity Index (ESI) level 2. At 30 days, 393 patients (96.4%) achieved favorable neurological outcomes. Increasing age (OR 0.95; 95% CI: 0.92-0.97), and a high risk of pre-cardiac arrest signs (OR 0.15; 95% CI 0.03-0.83) were associated with lower odds of favorable neurological outcomes. In contrast, higher emergency nursing competency (OR 2.78; 95% CI: 1.11-6.96) and adherence to clinical practice guidelines for early warning signs monitoring patients' status (OR 2.76; 95% CI: 1.10-6.94) were independently associated with higher odds of favorable neurological outcomes.

Conclusion: Both patient characteristics and emergency care system factors were associated with neurological outcomes following ED admission. Enhancing emergency nursing competency and adherence to clinical practice guidelines may improve neurological recovery among critically ill patients.

Purpose: Myasthenia gravis (MG) pathophysiology and drug-drug interactions with cholinesterase inhibitors can make patients both relatively sensitive and resistant to neuromuscular blocking agents (NMBAs). NMBA dose adjustments in MG patients undergoing rapid sequence intubation (RSI) are described in anesthesia literature but not outside of the operating room (OR). This study sought to characterize NMBA use in MG patients undergoing RSI outside of the OR.

Methods: Retrospective, observational, multicenter study of MG patients undergoing RSI outside of the OR from January 2011-September 2023. Patient demographics, NMBA used and dose, and post-intubation monitoring were collected. Data are reported descriptively.

Results: Forty-four cases were included; median age 74 years (IQR 59.8-81.0), 31.8% receiving pyridostigmine, 88.6% intubated for respiratory failure, 81.8% received rocuronium. Only 11 cases (25%) had an NMBA dose adjustment. No cases experienced inadequate paralysis. Of the 24 cases (54.5%) with monitoring within the expected NMBA recovery timeframe, 75% had documented recovery. Of these, only one case had an NMBA dose adjustment. Five cases (11.4%) experienced possible prolonged paralysis based on study definitions; one case with NMBA dose adjustment.

Conclusions: Most cases did not receive an NMBA dose adjustment for MG. There were limited neurologic and neuromuscular assessments available post-intubation. Cases of possible prolonged paralysis were identified. The necessity of adjusting NMBA doses in MG patients undergoing RSI remains unclear and warrants further study. Clinicians should be aware of the potential for unpredictable NMBA response in MG and need for timely monitoring and sedation and analgesia in the immediate post-intubation period.

Conium maculatum poisoning presents a critical medical emergency that is characterized by rapid clinical deterioration. This invasive plant, native to Europe, Western Asia, and North Africa, poses significant public health risks due to its striking resemblance to edible species such as parsley and wild carrot. The plant's toxic piperidine alkaloids induce a biphasic toxidrome: initial nicotinic overstimulation manifesting as autonomic hyperactivity, progressing to potentially fatal respiratory depression through neuromuscular paralysis. The clinical picture of Conium maculatum poisoning can vary greatly with symptom profiles ranging from respiratory depression to cardiac arrhythmia and even erythematous skin reactions. Clinical outcomes depend heavily on early recognition of the characteristic symptom progression and immediate supportive intervention. This study emphasizes the critical need for increased clinical vigilance when evaluating potential plant poisonings, especially in endemic regions of Conium maculatum. Moreover, it highlights the diverse presentation profiles in Conium maculatum poisoning, as seen in this case series, where four cases were characterized by different presentations, some of which possessed unique features including cardiac arrest and an erythematous rash.

Background: The pre-hospital phase is a critical factor affecting the prognosis of patients with traumatic intracranial hemorrhage (TICH). Early recognition, rapid transport, and optimized pre-hospital management can significantly influence patient outcomes.

Objective: To compare the impact of "traditional pre-optimized workflow" versus "post-optimization workflow" pre-hospital transport models on scene-to-CT time, scene-to-surgery time, and complication rates in TICH patients.

Methods: This retrospective cohort study analyzed patients treated by the pre-hospital emergency system between January 2023 and June 2025. Patients were divided into a control group (traditional workflow, January 2023 - February 2024) and an optimization group (post-implementation of standardized triage, direct imaging access, and wireless remote command, March 2024-June 2025). Primary outcomes were scene-to-CT time and scene-to-surgery time. Secondary outcomes included early complications (hypotension, hypoxemia, rebleeding, and transport-related hypothermia). Advanced hypothesis testing analyses included multivariable logistic regression and Cox Proportional Hazards models.

Results: The study included 223 TICH patients. The optimization group showed significantly reduced scene-to-CT time [from 52 (IQR 44-63) to 37 (IQR 31-45) minutes, p < 0.001] and scene-to-surgery time [from 89 (IQR 76-108) to 67 (IQR 56-82) minutes, p < 0.001]. Cox regression analysis indicated that the optimization group had a significantly higher likelihood of receiving definitive treatment (adjusted HR 2.14, 95% CI 1.58-2.90). Treatment-related complications decreased significantly, with hypothermia rates reducing from 21 (18.6%) to 8 (7.3%) and hypoxemia from 17 (15.0%) to 6 (5.5%). Multivariable logistic regression confirmed that workflow optimization was independently associated with reduced odds of complications (adjusted OR 0.44, 95% CI 0.24-0.79).

Conclusion: Pre-hospital workflow optimization, specifically incorporating rapid dispatch protocols, direct transport to neurosurgical-capable facilities, wireless telemedicine consultation, and standardized point-of-care resuscitation, significantly reduced the time from scene to surgery and improved rescue efficiency while decreasing complication rates in TICH patients. These improvements suggest that systematic integration of evidence-based pre-hospital interventions represents a feasible and essential strategy for regional trauma networks.