Journal of the American College of Emergency Physicians open最新文献

Objectives: Cardiac arrest patients with a shockable rhythm are more likely to survive an out-of-hospital cardiac arrest (OHCA) compared with a nonshockable rhythm. An electrocardiogram (ECG) is the most common way to identify a shockable rhythm, but it can miss patients with clinically significant ventricular fibrillation (vfib). We sought to determine the percentage of nonshockable OHCA patients that demonstrated vfib on echo.

Methods: Secondary analysis of echo images recorded from a prior study from our group, Real-Time Evaluation and Assessment for Sonography-Outcomes Network (REASON), a multicenter, observational study of OHCA patients presenting to the emergency department with nonshockable rhythms. Using ECG and echocardiogram images recorded during the initial cardiopulmonary resuscitation (CPR) pause, 2 independent emergency physicians determined the presence of vfib. Two experienced emergency physicians (R.G. and T.G.) reviewed echo images with adjudication by a third if necessary. ECG interpretation was unblinded to patient information. The primary outcome was the proportion of patients in occult vfib.

Results: During the first CPR pause, reviewers noted occult vfib in 22/685 (3.2%; 95% CI, 2.1%-4.8%) subjects. Patients with ECG vfib (n = 55) were defibrillated immediately during the first pause in CPR, but no patients with occult vfib during the first pause in CPR were defibrillated. Subsequently, 50% (11 of 22) of occult vfib patients were defibrillated when ECG vfib was recognized during an ensuing pause in CPR.

Conclusion: One in 33 OHCAs with a nonshockable ECG rhythm exhibits VF on echocardiogram. Patients presenting to the emergency department in a presumed nonshockable rhythm following OHCA may benefit from prompt defibrillation if personnel recognize occult vfib on echo.

Objectives: Given the support for methicillin-resistant Staphylococcus aureus (MRSA) antimicrobial stewardship in the 2021 Surviving Sepsis Campaign Guidelines, we sought to measure the use of vancomycin in the emergency department (ED) in the years preceding these recommendations.

Methods: A retrospective cohort study was conducted of all patients aged ≥ 18 years presenting to 5 emergency departments within a university-based health system who were given intravenous (IV) vancomycin during their ED index visit. The primary outcome assessed the proportion of patients with MRSA-positive blood cultures who received IV vancomycin in the ED. We also measured associations between clinical attributes associated with any MRSA infection.

Results: Of the 20,212 unique ED visits for patients who received IV vancomycin, 63% (n = 12,755) had at least 1 MRSA risk factor. Only 2.4% (n = 494) and 14.1% (n = 2850) of patients receiving IV vancomycin in the ED were found to have MRSA bacteremia or any MRSA-positive culture, respectively. A total of 3160 patients met Sepsis-3 criteria and received IV vancomycin, though 65% (n = 2064) had no MRSA risk factors. For any patient with culture-proven MRSA, 63.8% (n = 315) and 43.4% (n = 1236) received an MRSA antimicrobial in the ED. MRSA risk factors were not associated with MRSA bacteremia (≥1 MRSA risk factor: odds ratio, 1.3, 95% CI, 0.9-1.8) or an MRSA-positive culture of any type (odds ratio, 0.9, 95% CI, 0.7-1.1).

Conclusion: Within our hospital system, MRSA was an infrequent cause of bacteremia for patients presenting to the ED with sepsis or septic shock. Although vancomycin is frequently used in the ED, many patients with culture-proven MRSA did not receive MRSA antimicrobials. Notably, one-third of patients with culture-proven MRSA had no MRSA risk factors. MRSA risk factors were not predictive of culture-proven MRSA, thus highlighting the complexity of antimicrobial stewardship in the ED without validated clinical decision rules.

Clinical documentation in the United States has grown longer and more difficult to read, a phenomenon described as "note bloat." This issue is especially pronounced in emergency medicine, where high diagnostic uncertainty and brief evaluations demand focused, efficient chart review to inform decision-making. Note bloat arises from multiple factors: efforts to enhance billing, mitigate malpractice risk, and leverage electronic health record tools that improve speed and completeness. We discuss best practices based on available evidence and expert opinion to improve note clarity and concision. Recent E/M coding reforms aim to streamline documentation by prioritizing medical decision-making over details of historical and physical examination, though implementation varies. New technologies such as generative artificial intelligence present opportunities and challenges for documentation practices. Addressing note bloat will require ongoing effort from clinical leadership, electronic health record vendors, and professional organizations.

Objectives: Guidelines recommend emergent coronary angiography (CAG) for out-of-hospital cardiac arrest (OHCA) patients with ST-segment elevation (STE) and selective angiography for those without STE. However, real-world data reporting coronary artery status in OHCA patients without STE are scarce, especially in an Asian population. This study evaluated the coronary artery status and associated outcomes in Asian OHCA patients without STE, comparing the results with those of patients with STE.

Methods: This retrospective study enrolled 345 OHCA survivors with presumed cardiogenic cause who underwent CAG. Based on electrocardiographic evidence of STE following return of spontaneous circulation, the patients were segmented into an STE group (n = 150) and a non-STE group (n = 195). The CAG findings and percutaneous intervention details for the non-STE group were compared with those of the STE group. Chi-squared tests were applied for categorical variables, whereas Mann-Whitney U tests were applied for continuous variables.

Results: Compared with the STE group, the non-STE group had a lower but still high prevalence of coronary artery stenosis (69.7% vs 91.3%, P < .001) and multivessel involvement (50.8% vs 68.0%, P = .001), especially in the left anterior descending coronary artery (56.9% vs 79.3%, P < .001). No differences in survival-to-discharge and neurological outcomes were observed.

Conclusion: In OHCA survivors with presumed acute coronary syndrome, there was a high prevalence of coronary artery stenosis and multivessel involvement in patients without STE. Moreover, patients without STE had comparable survival-to-discharge and neurological outcomes with patients with STE.

Objectives: Ventilation of bearded patients using the standard face mask (FM) is often difficult, particularly in field settings and mass casualty events. The current study compares the effectiveness of a novel Bag-Valve-Guedel Adaptor (BVGA) with the standard FM when applied to anesthetized patients by anesthesiology trainees with limited experience.

Methods: Male patients scheduled for elective surgery (American Society of Anesthesiology physical score 1-2) were recruited for this prospective, randomized, cross-over trial. Beard length was categorized as <0.5 cm (none/stubble), 0.5 to 1 cm, 1 to 5 cm, or ≥5 cm. Anesthetized patients were ventilated by anesthesiology trainees using the BVGA and an FM. The main outcome included end-tidal CO₂, expiratory tidal volume (tidal volume of predicted body weight), and user evaluation (comfort, physical demand, and tiredness). The role of the level of expertise was evaluated by comparing data from the present study with those of a previous study performed by attending anesthesiologists.

Results: Forty men (mean ± SD, age, 37 ± 17 years; body mass index, 25 ± 3 kg/m²), of whom 30 had beards, were enrolled. For the BVGA, ventilation parameters were found to be superior to the FM (BVGA vs FM: end-tidal CO₂ [mm Hg], 34.3 ± 4.9 vs 26.6 ± 5.8, P < .001; expiratory tidal volume [mL/kg predicted body weight], 7.9 ± 2.5 vs 6.3 ± 2.8, P = .003). The BVGA was graded as more comfortable and less physically demanding by 96% to 100% of trainees. The level of expertise of the anesthesiologist (trainee vs attending [additional n = 61 patients]) and the presence of a beard were found to be significant factors for ventilation with the FM but not with the BVGA.

Conclusion: The BVGA provides more effective and convenient ventilation than the FM for ventilation even when applied by anesthesia trainees. Its use can be of particular value in bearded subjects or in a setting where the use of supraglottic airway devices is limited.