American Journal of Emergency Medicine最新文献

A middle-aged woman presented with nausea and vomiting after consumption of dinner. Her son experienced similar symptoms after sharing the meal. The patient had a history of syncope and had been treated with a dual-chamber pacemaker years prior to the incident. While being treated by emergency medical services (EMS), the patient developed pulseless wide complex tachycardia. EMS performed cardiopulmonary resuscitation (CPR) and several defibrillation attempts. After being referred to our intensive care unit (ICU), initial workup revealed no evidence of structural heart disease, coronary artery disease, or electrolyte imbalances. The patient was treated with multiple defibrillations, including double-sequence defibrillation, antiarrhythmic drugs, and continuous Veno-Venous hemodialysis in the following hours. Due to similar symptoms in both the patient and her son following food intake, multiple body fluids were sampled for toxicological screening. The results revealed evidence of acute aconitine poisoning. Despite undergoing CPR for approximately 45 min, the patient stabilized over the following days and ultimately showed no significant neurological deficiencies. The legal review of the case concluded that the poisoning had occurred in a homicidal context.

Background: Previous studies have shown poison centers (PCs) reduce healthcare costs, often by preventing unnecessary emergency care visits. An updated cost-savings estimate has not been recently conducted.

Methods: This was a retrospective study analyzing caller survey data for a three-state American PC, gathered from 2021 to 2024. The PC's annual budget is $3.3 million (M). Eligible cases included public callers whose poisoning question was managed on-site and later completed a post-call telephone survey, including the question, "What would you have done if the poison center was not available to you?" Emergency care costs were estimated using three variables to reflect costs rather than charges. Ambulance transport costs and physician professional fee reimbursements for emergency department (ED) evaluation and management (E&M) codes were calculated from the U.S. Centers for Medicare and Medicaid Services published data. Facility fees from the associated E&M codes were calculated based on a general reimbursement rate of 33% of charges from our PC's affiliated safety-net hospital. E&M codes 99284 and 99285 (levels of service [LOS] 4 and 5, respectively) were used to calculate a cost-savings range.

Results: Among 1670 respondents to the survey (overall completion rate, 24%), 1346 (81%) would have immediately sought care; n = 916 [55%] of which would immediately call a healthcare professional while n = 430 [26%] would call 911 or go to the ED. Extrapolating survey results to our entire caller population, the estimated annual cost-savings from avoided emergency care visits for each state were as follows: Minnesota, $29.4 to 48.0 M; North Dakota, $5.0 to 5.7 M; South Dakota, $5.1 M to 7.5 M, for a benefit-to-cost ratio of $12.07 to $18.55:1. When factoring in our annual budget, this results in an annual net savings of $36.5 to 58.0 M for our three-state region. Sensitivity analysis, assuming all ED visits reimbursed at LOS 4 and that ambulance transports occurred less frequently and were less costly per transport, still demonstrated robust cost-savings, with a benefit-to-cost ratio of $6.22-6.88:1.

Conclusions: Using standard reimbursement data, we demonstrated our poison center likely saves our three-state region more than six times its annual budget solely from preventing unnecessary emergency care visits.

Introduction: Most emergency departments (EDs) have low pediatric annual volume, which is associated with worse clinical outcomes. The demographic characteristics of who presents to low- vs. high-volume EDs is not well understood.

Methods: We performed a retrospective, cross-sectional study of patients aged 0-18 years using the 2022 National Emergency Department Sample. We divided pediatric volume based on known standards: low volume, <1800 visits; medium volume, 1800-4999 visits; medium-high volume, 5000-9999 visits, and high volume, ≥10,000 visits. We calculated survey-weighted frequencies of patient-level demographic and ED-level characteristics, reporting proportions and 95% confidence intervals, as well as proportion differences.

Results: The sample included 6,094,603 ED pediatric visits (population estimate: 26,443,822 ED visits). Low-volume compared to high-volume EDs were less likely to treat infants <1 year (proportion difference - 5.5%, 95% CI -6.2, -4.7%) and younger children aged 1-5 years (proportion difference - 7.8%, 95% CI -8.9, -6.7%). Low-volume compared to high-volume EDs saw higher proportions of children of non-Hispanic Native American (proportion difference 1.0%, 95% CI 0.1, 2.0%) and White race and ethnicity (proportion difference 33.2%, 95% CI 28.4, 38.0%). Low-volume EDs were more often rural (69%).

Discussion: This national cross-sectional study of US EDs found pediatric patient population differences in age and race and ethnicity based on annual pediatric ED volume. This study reports contemporary data on differences in patient populations presenting to EDs based on pediatric patient volume which is important to inform national and institutional policies to apply focused interventions to improve quality of care in EDs with different pediatric volumes.

Objective: Selective non-operative management (SNOM) is increasingly used for hemodynamically stable patients with abdominal gunshot wounds (GSW). Although peritoneal signs traditionally mandate emergency laparotomy, the clinical value in the era of computed tomography (CT) remains unclear. This study evaluated the clinical value of peritoneal signs and the adjunctive use of CT for identifying patients requiring therapeutic laparotomy.

Methods: We conducted a retrospective cohort study of patients with abdominal GSW admitted to a Level I trauma center between 2016 and 2023. Patients with systolic blood pressure < 90 mmHg, Glasgow Coma Scale<9 or intubation in the emergency department were excluded. Patients were categorized by the presence of peritoneal signs upon arrival. Clinical data, CT, and operative findings were reviewed. The primary outcome was intra-abdominal injuries requiring therapeutic laparotomy.

Results: Among 308 patients, 57 (18.5%) had peritoneal signs. Of those, 50 (89.3%) had therapeutic laparotomy. Peritoneal signs alone demonstrated sensitivity of 36.8% and specificity of 95.9% (95% confidence interval [CI]: 28.7-45.4 and 91.7-98.3, respectively). Among 251 patients without peritoneal signs, 95 underwent laparotomy based on CT findings, with 85 (89.5%) having therapeutic laparotomy. Only two of 157 patients managed non-operatively after CT required laparotomy following clinical observation. Combining peritoneal signs with CT findings yielded sensitivity of 99.3% and specificity of 87.8% (95% CI: 96.0-100.0 and 81.8-92.4, respectively).

Conclusions: Peritoneal signs alone had high specificity but limited sensitivity for detecting intra-abdominal injuries requiring therapeutic laparotomy. With selective CT use, our results supported the safety of SNOM in hemodynamically stable patients with abdominal GSW.

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: 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.