American Journal of Emergency Medicine最新文献

Objective

This study sought to externally validate and compare proposed methods for stratifying sepsis risk at emergency department (ED) triage.

Methods

This nested case/control study enrolled ED patients from four hospitals in Utah and evaluated the performance of previously-published sepsis risk scores amenable to use at ED triage based on their area under the precision-recall curve (AUPRC, which balances positive predictive value and sensitivity) and area under the receiver operator characteristic curve (AUROC, which balances sensitivity and specificity). Score performance for predicting whether patients met Sepsis-3 criteria in the ED was compared to patients' assigned ED triage score (Canadian Triage Acuity Score [CTAS]) with adjustment for multiple comparisons.

Results

Among 2000 case/control patients, 981 met Sepsis-3 criteria on final adjudication. The best performing sepsis risk scores were the Predict Sepsis version #3 (AUPRC 0.183, 95 % CI 0.148–0.256; AUROC 0.859, 95 % CI 0.843–0.875) and Borelli scores (AUPRC 0.127, 95 % CI 0.107–0.160, AUROC 0.845, 95 % CI 0.829–0.862), which significantly outperformed CTAS (AUPRC 0.038, 95 % CI 0.035–0.042, AUROC 0.650, 95 % CI 0.628–0.671, p < 0.001 for all AUPRC and AUROC comparisons). The Predict Sepsis and Borelli scores exhibited sensitivity of 0.670 and 0.678 and specificity of 0.902 and 0.834, respectively, at their recommended cutoff values and outperformed Systemic Inflammatory Response Syndrome (SIRS) criteria (AUPRC 0.083, 95 % CI 0.070–0.102, p = 0.052 and p = 0.078, respectively; AUROC 0.775, 95 % CI 0.756–0.795, p < 0.001 for both scores).

Conclusions

The Predict Sepsis and Borelli scores exhibited improved performance including increased specificity and positive predictive values for sepsis identification at ED triage compared to CTAS and SIRS criteria.

Introduction

Ectopic pregnancy is a serious condition that can have significant morbidity and mortality.

Objective

This review highlights the pearls and pitfalls of ectopic pregnancy, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

Discussion

Ectopic pregnancy is a pregnancy that implants outside the normal uterine cavity. It most commonly presents with vaginal bleeding, abdominal or pelvic pain, and amenorrhea. Risk factors for ectopic pregnancy include abnormalities of the fallopian tube, prior ectopic pregnancy, and age over 35 years, but a significant number of patients with confirmed ectopic pregnancy will not have an identifiable risk factor. In patients with suspected ectopic pregnancy, evaluation includes quantitative serum hCG, blood type, and ultrasound. Ultrasound is necessary regardless of the hCG level. If the patient is hemodynamically unstable, resuscitation with blood products and early consultation of obstetrics/gynecology is necessary. Patients with confirmed ectopic pregnancy but who are otherwise stable may be managed medically or surgically. If a yolk sac or fetal pole is not seen in the uterus on ultrasound, this is considered a pregnancy of unknown location (PUL), which may represent an early, failed, or ectopic pregnancy. Stable patients with a PUL who can reliably follow up are managed with close specialist follow up and repeat 48 h HCG level. These patients need to have an hCG level repeated every 48 h until diagnosed with a viable pregnancy, failed pregnancy, or ectopic pregnancy.

Conclusions

Knowledge of the latest advances in managing ectopic pregnancy will help clinicians more quickly and accurately diagnose patients presenting with this potentially fatal condition.

Objectives

To better understand the clinical and radiological characteristics of Cerebral Venous Thrombosis (CVT), we conducted a study focusing on the assessment of neurological outcomes and factors associated with poor prognosis in patients with CVT.

Methods

This prospective, observational study took place over two years (July 2020 to June 2022) in a tertiary care teaching hospital in South India, encompassing adults aged 18 years and over. Key data points included demographic information, symptomatology, physical and neurological examinations, neuroimaging findings, hospital interventions, and neurological outcomes at discharge and at a six-week telephonic follow-up.

Results

A total of 140 patients with CVT, median age 34 years, were studied. 61.4 % were males. The most common symptoms and signs were headaches (70.7 %) and papilledema (60.7 %). Hemorrhagic infarct was the most prevalent finding on the non-contrast computed tomography (NCCT) of the brain, involving 39.4 % of patients. The most commonly affected sinus was the superior sagittal sinus. Risk factors most often observed were alcoholism (45 %), smoking (21.4 %), anemia (27.1 %), oral contraceptive pill usage (12.1 %), and hypertension (12.1 %). Deep vein thrombosis or pulmonary embolism was present in 5 % of the patients. The mean hospital stay was 13.9 days, with 6.4 % of patients requiring endotracheal intubation at presentation and 22.9 % during their stay. The observed in-hospital mortality rate was 17.9 %, increasing to 22.4 % at the six-week follow-up. Morbidity (mRS 3–5) was 24.3 % at discharge, decreasing to 8.2 % at six-week follow-up. Favorable outcomes were reported in 57.9 % of cases at discharge, rising to 69.4 % at six weeks.

Conclusions

Our study underscores the importance of recognizing cardinal symptoms and diverse risk factors of CVT, including alcoholism and anemia. Majority of CVT occurrences were observed in males aged 18–29. Critical determinants of heightened morbidity and mortality were identified, including lower GCS scores and the necessity for advanced interventions. Notably, majority of patients presented favorable neurological outcomes at six-week follow-up.

Background

Gabapentinoids increasingly utilized for neuropathic pain, possibly to curb opioid prescribing. At the same time, data suggest subsequent increases in misuse and overdose of gabapentinoids, often in mixed overdoses. We sought to determine national trends and characteristics of gabapentinoid prescribing, including co-use with opioids, from the emergency department (ED).

Methods

This is a retrospective review of the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2012 to 2021. Our primary outcome was the trend in ED visits in which gabapentinoids were prescribed at discharge. Secondarily, we identified trends in gabapentinoid and opioid co-prescribing and gabapentin and pregabalin prescribing at ED discharge. We examined demographic data and used descriptive statistics, Shapiro Wilke's test, Pearson's Spearman's rho (SR) or Pearson's correlation coefficient (PC) as applicable. Neural networks were used to identify the most important predictors of opioid utilization during the same visit.

Results

Between 2012 and 2021, there were an estimated 7,242,694 (0.53% of all ED visits) visits in which gabapentinoids were prescribed at ED discharge. Prescriptions increased from a total of 138,479 (0.1%) in 2012 to 893,495 (0.63%) in 2021 (PC: 0.85, p < 0.001). Opioids were co-prescribed in 27.2% of all visits in which gabapentinoids were prescribed, with no change over time (PC: −0.47, p = 0.09). Pregabalin prescription increased linearly over time (PC: 0.64, p = 0.02).

The most important predictors of opioid administration or co-prescribing were whether an alternative provider (e.g., consult or nurse practitioner) saw the patient (100%), insurance (94.4%), age (75.9%), and region (75.2%).

Conclusion

Despite an association of misuse and overdose, often associated with opioids, gabapentinoids were increasingly prescribed at ED discharge. While these agents may be safer alternatives to opioids, misuse may be an associated consequence of increased prescribing, which warrants further investigation.

Introduction

Airway management is a key intervention during the resuscitation of critically ill trauma patients. Emergency surgical airway (ESA) placement is taught as a backup option when endotracheal intubation (ETI) fails. We sought to (1) describe the incidence of the emergency department (ED) ESA, (2) compare ESA versus ETI-only recipients, and (3) determine which factors were associated with receipt of an ESA.

Methods

We searched within the Trauma Quality Improvement Program datasets from 2017 to 2022 for all emergency department surgical airway placement and/or endotracheal intubations recipients. We compared ESA versus ETI-only recipients.

Results

From 2017 to 2022, there were 6,477,759 within the datasets, of which 238,128 met inclusion for this analysis. Within that, there were 236,292 ETIs, 2264 ESAs, with 428 (<1 %) having documentation of both. Of the ESAs performed, there were 82 documented in children <15 years of age with the youngest being 1 year of age. The ETI-only group had a lower proportion serious injuries to the head/neck (52 % versus 59 %), face (2 % versus 8 %), and skin (3 % versus 6 %). However, the ETI-only group had a higher proportion of serious injuries to the abdomen (15 % versus 9 %) and the extremities (19 % versus 12 %). Survival at 24-h was higher in the ETI-only group (83 % versus 76 %) as well as survival to discharge (70 % versus 67 %). In the subanaysis of children <15 years (n = 82), 34 % occurred in the 1–4 years age group, 35 % in the 5–9 years age group, and 30 % in the 10–14 years age group. In our multivariable logistic regression analysis, serious injuries to the head/neck (odds ratio [OR] 1.37, 95 % CI 1.23–1.54), face (OR 3.41, 2.83–4.11), thorax (OR 1.19, 1.06–1.33), and skin (OR 1.53, 1.15–2.05) were all associated with receipt of cricothyrotomy. Firearm (OR 3.62, 3.18–4.12), stabbing (2.85, 2.09–3.89), and other (OR 2.85, 2.09–3.89) were associated with receipt of ESA when using collision as the reference variable.

Conclusions

ESA placement is a rarely performed procedure but frequently used as a primary airway intervention in this dataset. Penetrating mechanisms, and injuries to face were most associated with ESA placement. Our findings reinforce the need to maintain this critical airway skill for trauma management.