Academic Emergency Medicine最新文献

Background: Morbidity and mortality in cardiogenic pulmonary edema have been reduced by noninvasive positive-pressure airway maneuvers. The value of continuous positive airway pressure (CPAP) for the treatment of high-altitude pulmonary edema (HAPE) is uncertain. The purpose of this study was to evaluate the efficacy and speed of CPAP for HAPE resolution.

Methods: A prospective, investigator-initiated, multicenter, randomized, double-blind controlled trial of high-flow oxygen with CPAP versus sham CPAP with high-flow oxygen (oxygen-only group) was conducted. Sixty-four dyspneic adults with maximum oxygen saturation < 85%, recent arrival at high altitude, and noncardiogenic pulmonary edema on chest radiography were randomized to receive CPAP treatment plus usual care or usual care (oxygen-only) delivered through a sham CPAP mask. The primary endpoint was the clinical resolution of HAPE.

Results: HAPE resolution in the CPAP plus high FiO₂ group and the high flow oxygen alone group was similar. However, this finding should be interpreted cautiously due to this study being slightly underpowered. There was no significant difference in time to resolution (CPAP ~158 min vs. oxygen ~178 min, p = 0.297). Both therapies were effective, with a mean time to resolution of HAPE of approximately 2.5 to 3 h. No treatment-related adverse outcomes, intubations, or mortality were observed in either group.

Conclusion: Both CPAP with high-flow oxygen and high-flow oxygen alone are highly effective for the treatment of HAPE. CPAP conferred no improvement in the time to resolution of HAPE. High-flow oxygen therapy requires significantly less resource utilization for similar benefits in the treatment of HAPE.

Trial registration: ClinicalTrials.gov identifier: NCT04186598.

Objective: We quantified the magnitude of systolic blood pressure (SBP) adverse effects associated with intravenous furosemide (IVFu), compared to other factors, during treatment for acute decompensated heart failure (ADHF).

Methods: Continuous BP monitoring (598.2 person-hours, 91,210 observations) before and after IVFu was performed in a prospective multicenter ADHF cohort (n = 253). Multivariable-adjusted mixed effects regression was used to determine the amount of SBP reduction and the risk of hypotension attributable to IVFu administration, as opposed to confounders (e.g., non-IVFu treatments and baseline patient characteristics).

Results: Median SBP was 124 mmHg (IQR: 105-149) at baseline. Hypotension occurred in 5515 observations (6.0%). The multivariable models explained 79.6% and 58.1% of variance in SBP and risk of hypotension, respectively. Only 1.4% of variance in SBP and 1.7% of hypotension risk were related to IVFu, with the remainder accounted for by confounders. After multivariable adjustment, SBP dropped -11.9 mmHg on average after 80 mg IVFu, reaching a nadir at 147 min (-15.2 mmHg) and partial return to baseline by 6 h (-8.5 mmHg). IVFu-related risk of hypotension after multivariable adjustment depended predominantly on baseline SBP and dose. Risk of hypotension associated with 80 mg IVFu was ≤ 2% with baseline SBP ≥ 120 mmHg. For 40 mg, IVFu-associated hypotensive risk was ≤ 2% with SBPs of 90-100 mmHg, and < 1% with SBP ≥ 110 mmHg. IVFu-associated risk of hypotension returned to zero at 6 h after administration, regardless of dose.

Conclusions: Blood pressure reductions after IVFu during ADHF treatment are modest, and hypotension is rare and transient. Most variance in SBP during ADHF treatment is due to other factors.

Background: Patients with chronic pain frequently visit the emergency department (ED) due to accessibility of care, but the impact is underestimated. This study examines the prevalence and characteristics of patients who visited the ED for chronic pain at an urban safety-net hospital.

Methods: A systematic sampling strategy was used to survey adult ED patients between June and August 2024. We categorized participants who visited the ED as having (1) chronic pain, (2) acute pain, or (3) nonpain conditions. The study collected data on self-reported demographics and health access information, and hospital records on ED wait time, length of stay, insurance, and arrival time. Chi-square tests and regression models compared differences across groups.

Results: Of the 602 participants (64% Medicaid, 78% Hispanic/Latino), 18% visited the ED for chronic pain. This group of participants was more likely to report worse health status, visiting the ED as a usual place for care, despite being more likely to have seen a health care provider within a week before their ED visit. Furthermore, they had a longer ED length of stay and were more likely to arrive after business hours (4:30 pm) and perceive their ED visit as an emergency compared to those who visited the ED for acute pain and nonpain conditions. There is no difference in ED workup, specialty service involvement, and consultation.

Discussion: Chronic pain is highly prevalent in a safety-net ED patient population. Patients with chronic pain present to the ED because they feel the condition is emergent. The lack of different ED treatment strategies highlights that perhaps ED providers have a general approach to painful conditions regardless of chronicity. Health systems need to better assess the burden of chronic pain in the ED and develop programs to help manage such patients in an effective and efficient manner.

Objectives: We aimed to identify the most diagnostically challenging features in first-trimester point-of-care ultrasound (FT-POCUS) images. We also sought to determine the physician image review behaviors associated with increased diagnostic accuracy.

Methods: We conducted a multicenter prospective cross-sectional study in a convenience sample of emergency physicians in the United States and Canada. The web-based intervention included 400 FT-POCUS cases acquired via the transabdominal or transvaginal approach. Participants reviewed FT-POCUS cases to identify pregnancy-related imaging findings. We captured clickstream-level data with each case encounter, including the correctness of a participant's response and physician image review behaviors.

Results: We enrolled 317 participants, who collectively generated 16,295 case interpretations. The most diagnostically challenging imaging findings included eccentrically located gestational sac and endometrial collection/heterogeneous uterine material (p < 0.001 for all comparisons). Participants who reported "definite" certainty, as opposed to "probable," demonstrated a significantly higher odds of getting the diagnosis of intrauterine pregnancy (IUP) present or absent correct (OR = 4.48; 95% CI 4.00, 5.01) and a lower odds of time spent reviewing cases (OR = 0.46; 95% CI 0.40, 0.51). Those who reviewed a higher proportion of available views per case were more likely to accurately identify a fetal heartbeat (OR = 1.51; 95% 1.34, 1.69), multiple IUPs (OR = 1.33; 95% CI 1.10, 1.61), and adnexal structures (OR = 1.11; 95% CI 1.04, 1.17), but less likely to correctly identify an IUP (OR = 0.93; 95% CI 0.88, 0.99) and endometrial fluid collection/heterogeneous uterine material (OR = 0.96; 95% CI 0.92, 0.99).

Conclusions: Emergency physicians interpreting FT-POCUS images encountered specific diagnostic challenges that may increase risks to patient safety. We found that higher diagnostic confidence correlated with greater diagnostic accuracy and efficiency. Reviewing a larger proportion of available images improved diagnostic accuracy for some findings, but not for others.

Objective: To determine if the utilization of an Electronic Health Record-integrated clinical pathway increased the provision of recommended medical and forensic care to adult sexual assault survivors in the ED.

Methods: This was a retrospective chart review of 552 adult survivors of sexual assault who received care at a health care system in the Northeast between January 1, 2020, and December 31, 2022. Our six outcomes were the proportion of patients who were offered a consultation with a sexual assault advocate, the proportion of patients who had the sexual assault forensic evidence kit collected, pregnancy test ordered, emergency contraception ordered, HIV post-exposure prophylaxis ordered, and sexually transmitted infection prophylaxis ordered. Primary analysis compared the impact of the pathway on outcomes before and after the implementation. Secondary analysis included the impact on outcomes of pathway use compared to non-pathway use after implementation.

Results: The pathway was used in 128 (51%) patient encounters after it was implemented. Offering consultation with a sexual assault advocate and ordering HIV post-exposure prophylaxis improved post-implementation compared to pre-implementation. In the post-implementation period, there was an improvement in recommended medical and forensic care across all outcomes, including offering an advocate, collecting forensic evidence, ordering STI prophylaxis, HIV PEP, pregnancy tests, and emergency contraception. Patients were less likely to have a SAFE kit collected if the pathway was not used compared to pre-implementation.

Conclusions: Pathway usage led to improved medical and forensic care of sexual assault survivors. Implementation of Electronic Health Record-integrated clinical pathways requires active use of the pathway rather than indirect learning from the presence of the pathway.

Background: Alcohol withdrawal syndrome (AWS) significantly contributes to ED resource utilization. While phenobarbital is increasingly used as an alternative to benzodiazepines, data comparing their impact on ED utilization remain limited. We evaluated whether phenobarbital monotherapy improves ED operational outcomes compared to benzodiazepines or combination therapy.

Methods: We conducted a single-center, retrospective cohort study of 1178 adults at a regional academic medical center from January 1, 2020, to December 31, 2023. Patients ≥ 18 years old who were treated with intravenous (IV) phenobarbital, IV benzodiazepines, or both for AWS in the ED were included. The primary outcome was hospital admission. Secondary outcomes included ED length of stay, return visits within 72 h of index visit, and 30-day hospital readmission. A formalized data abstraction process was utilized. Analyses used chi-squared or Kruskal-Wallis tests and logistic regression to estimate odds ratios with 95% confidence intervals.

Results: Of 777 eligible encounters, 459 (59.1%) resulted in admission. Admission rates were 74.0% for benzodiazepine-only encounters, followed by combination therapy (62.4%), and lowest for phenobarbital-only (52.1%; OR 0.44, 95% CI 0.30-0.66, p < 0.0001). Among discharged patients (318 encounters), median ED LOS was shortest in the phenobarbital-only group (5.8 h), versus 7.6 h for benzodiazepine-only and 10.3 h for combination therapy (p < 0.0001). Logistic regression analysis revealed treatment with phenobarbital alone was independently associated with discharge, while increasing age, increasing heart rate, and treatment with benzodiazepines alone were independently associated with hospitalization.

Conclusions: Phenobarbital monotherapy for AWS was associated with lower admission rates, shorter ED LOS, and fewer IV medication administrations compared to benzodiazepine-based regimens. Return visit rates were similar across all groups. These findings are exploratory, underscoring the need for prospective studies to confirm these associations.

Objective: Cluster-randomized trials (also called group-randomized trials) are increasingly common in emergency care research. In such trials, groups of participants are allocated to different interventions based on naturally occurring "clusters," such as clinics, hospitals, or emergency medical services agencies. In this methodological review, we introduced key terminology and features of cluster-randomized trials, described common rationales for cluster-randomization and its most common limitations, and offered brief advice for conducting and critically appraising cluster-randomized trials in emergency care research.

Results: Researchers elect to use cluster-randomization when individual participant randomization is not preferred or not possible. Common reasons include a desire to limit contamination between study groups, logistical convenience relating to trial administration or study procedures, or the use of an intervention that is naturally group-oriented, such as an educational intervention or clinical decision support tool that is directed toward influencing clinician behaviors. Although cluster-randomization has advantages in these contexts, this approach also comes with some notable weaknesses, such as inflated sample size requirements, greater difficulty in blinding participants and researchers, and an increased risk of baseline imbalances between comparator groups. When reading and critically appraising cluster-randomized trials, emergency clinicians should consider whether researchers have appropriately justified group over individual randomization, accounted for different levels of clustering and the degree of correlation between participants within clusters (intracluster correlation), and appropriately consented various levels of participants to study participation.

Conclusions: Cluster-randomized trials are frequently used in emergency care research, especially as researchers are increasingly evaluating educational or electronic health record interventions that are naturally group-oriented or have a high risk of contamination. After reading this review, emergency medicine clinicians and researchers will have a foundational understanding of key cluster trial features and will be able to assess the quality and limitations of emerging evidence.