American Journal of Emergency Medicine最新文献

Background: The "Golden Hour" represents the critical period following traumatic injury when timely definitive care is essential for survival. Although most U.S. residents live within 60 min of a Level I or II trauma center, rural populations face greater challenges in accessing such care. This study evaluated trauma transfer patterns and outcomes in Montana and neighboring rural regions.

Methods: A 10-year retrospective review (2012-2022) was conducted at a rural Level I trauma center. Patients were excluded if they lacked a documented injury time, had an Injury Severity Score (ISS) of 75, or transfer times exceeding 48 h. The remaining 4213 trauma activations were categorized as direct scene admissions (n = 2221) or interfacility transfers (n = 1992). Multivariate logistic regression identified mortality predictors.

Results: Transfer patients had longer hospital (6.0 vs. 3.0 days; p < 0.0001) and ICU stays (4.6 vs. 3.7 days; p = 0.0045) and higher unadjusted mortality (5.0% vs. 3.0%; p < 0.0001). However, transfer status was not an independent predictor of mortality after adjustment. Mortality was significantly associated with ISS, age, hospital length of stay, and shock index. Mean transfer time was 7 h and mean distance was 188 miles. Most transfers (81.4%) originated from small or isolated rural towns with limited surgical coverage and greater reliance on advanced practice providers (p < 0.0001).

Conclusions: Rural trauma patients experience significant delays in access to definitive care. Enhancing resources and trauma training for rural providers, particularly advanced practice providers, may mitigate outcome disparities across geographically underserved regions. Further regional studies are needed to reduce time to definitive care.

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.

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.

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.

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.