American Journal of Emergency Medicine最新文献

Objectives: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) frequently result in emergency department (ED) visits, necessitating accurate risk stratification. The aim of this study was to evaluate and compare the prognostic utility of the DECAF score and serum procalcitonin levels in predicting clinical outcomes in patients with AECOPD.

Methods: This retrospective cohort study encompassed AECOPD patients presenting to the ED over a three-year period who had serum procalcitonin levels measured. The primary outcome was one-month mortality, with secondary outcomes including ED re-admission, hospitalization, and intensive care unit (ICU) admission. Receiver operating characteristic (ROC) curve analysis was employed to assess the prognostic performance of DECAF score and procalcitonin, and differences between areas under the curve (AUC) were compared.

Results: A total of 130 patients were analyzed, comprising 105 survivors and 25 non-survivors. The median DECAF score was significantly higher in non-survivors [4 (IQR: 3-4)] compared to survivors [3 (IQR: 2-4)] (p < 0.001). Similarly, median procalcitonin levels were elevated in non-survivors [0.26 ng/mL (IQR: 0.11-2.77)] relative to survivors [0.08 ng/mL (IQR: 0.04-0.21)] (p < 0.001). The AUC for the DECAF score was 0.758 (95 % CI: 0.673-0.842), while that for procalcitonin was 0.764 (95 % CI: 0.668-0.860). The difference between AUCs was 0.006 (95 % CI: -0.140 to 0.127), (p = 0.927). The negative predictive value (NPV) was 90.6 % for the 4-point DECAF score and 96.2 % for a 0.075 ng/mL procalcitonin cut-off. Notably, when used in combination, the NPV reached 100 % (95 % CI: 89.1-100).

Conclusions: The DECAF score and serum procalcitonin levels both exhibit robust prognostic capabilities in excluding adverse outcomes in AECOPD patients, with their predictive accuracy enhanced when used in tandem.

Background: The study of the inclusion of new variables in already existing early warning scores is a growing field. The aim of this work was to determine how capnometry measurements, in the form of end-tidal CO2 (ETCO2) and the perfusion index (PI), could improve the National Early Warning Score (NEWS2).

Methods: A secondary, prospective, multicenter, cohort study was undertaken in adult patients with unselected acute diseases who needed continuous monitoring in the emergency department (ED), involving two tertiary hospitals in Spain from October 1, 2022, to June 30, 2023. The primary outcome was 30-day all-cause in-hospital mortality. Demographics and vital signs necessary for NEWS2, ETCO2 and PI were collected.

Results: A total of 687 patients were included in the study. The median age was 79 years (IQR: 69-86), and 36.7 % were females, with an in-hospital mortality rate of 6.7 %. The NEWS2 score was 7 points for nonsurvivors and 4 points for survivors (p < 0.001). The EtCO2 levels were 30 mmHg (26-35) and 23  mmHg (16-30), and the PI levels were 4.7% (2.2-8.1) and 2.5 % (0.98-4.4) for survivors and nonsurvivors, respectively (both p < 0.001). The discrimination capacity of NEWS2 was AUC = 0.769 (95 % CI: 0.707-0.831), that of EtCO2 + PI was AUC = 0.737 (95 % CI: 0.66-0.814), and that of NEWS2 + ETCO2 + PI was AUC = 0.804 (95 % CI: 0.745-0.863).

Conclusions: The present study findings indicate that the PI and ETCO2 improved the ability of the NEWS2 to predict 30-day in-hospital mortality. The novel association of the NEWS2 with the PI and ETCO2 should be considered since it could improve the identification of patients at risk of clinical worsening.

Introduction: Patients with heart failure exacerbation can present in a variety of ways, including sympathetic crashing acute pulmonary edema (SCAPE). Emergency physicians play a key role in the diagnosis and management of this condition.

Objective: This narrative review evaluates key evidence-based updates concerning the diagnosis and management of SCAPE for the emergency clinician.

Discussion: SCAPE is a subset of acute heart failure, defined as a patient with sudden, severe pulmonary edema and hypertension, resulting respiratory distress, and hypoxemia. This is associated with significantly elevated afterload with fluid maldistribution into the pulmonary system. Evaluation and resuscitation should occur concurrently. Laboratory assessment, electrocardiogram, and imaging should be obtained. Point-of-care ultrasound is a rapid and reliable means of confirming pulmonary edema. Management focuses on respiratory support and vasodilator administration. Noninvasive positive pressure ventilation (NIPPV) with oxygen support is associated with reduced need for intubation, improved survival, and improved respiratory indices. If the patient does not improve or decompensates on NIPPV, endotracheal intubation is recommended. Rapid reduction in afterload is necessary, with the first-line medication including nitroglycerin. High-dose bolus nitroglycerin is safe and effective, followed by an infusion. If hypertension is refractory to NIPPV and high-dose nitroglycerin, other agents may be administered including clevidipine or nicardipine. Angiotensin-converting enzyme inhibitors such as enalaprilat are an option in those with normal renal function and resistant hypertension. Diuretics may be administered in those with evidence of systemic volume overload (e.g., cardiomegaly, peripheral edema, weight gain), but should not be routinely administered in patients with SCAPE in the absence of fluid overload. Caution is recommended in utilizing opioids and beta blockers in those with SCAPE.

Conclusion: An understanding of the current literature concerning SCAPE can assist emergency clinicians and improve the care of these patients.

Introduction: Droperidol is a dopamine-2 receptor antagonist in the class of butyrophenone antipsychotics with antiemetic, sedative, analgesic, and anxiolytic properties. In the postoperative setting, droperidol provides an opioid sparing effect and decreases nausea/vomiting. Another butyrophenone antipsychotic, haloperidol, has been shown to reduce morphine milliequivalents (MME) administered when used for abdominal pain in the emergency department (ED). The purpose of this study is to evaluate if the use of droperidol for undifferentiated abdominal pain reduces the amount of MME administered in the ED.

Methods: This retrospective, single-center study included patients ≥18 years old who presented to the ED for undifferentiated abdominal pain. Patients must have had two separate encounters for abdominal pain, one encounter where they received droperidol and one encounter where they did not receive droperidol but did receive an opioid. The primary outcome was the difference in MME administered between the two separate patient encounters. Secondary outcomes included utilization rates of rescue antiemetics, rescue analgesics, admission to the hospital, hospital length of stay, and adverse effects (including arrhythmias and extrapyramidal symptoms).

Results: Fifty patients with self-matched encounters were evaluated. A majority of the patients were female (33/50, 66 %) with a median age of 38 years old. All doses of droperidol were intravenous and the majority of patients received a dose of 2.5 mg (34/50, 68 %; range 1.25-5 mg). Non-droperidol encounters received significantly more MME compared to droperidol encounters (19.4 MME [IQR 12-30] vs 10 MME [IQR 0-20], p-value 0.0002). There were no statistically significant differences between the secondary outcomes.

Conclusion: Among patients presenting to the ED for abdominal pain, droperidol administration resulted in a significant reduction in MME administration. Future research should include prospective studies, comparison of droperidol to haloperidol, and investigate droperidol use beyond the ED for these encounters.