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

Objectives: We developed a mobile web application to help identify nontraumatic abdominal patient-reported symptoms (PRS) in patients who visited the emergency department (ED). Patients can use this during waiting times to facilitate patient history-taking by the physician. The study aimed to evaluate the feasibility and acceptability of PRS usage in the ED by patients.

Methods: A mixed-methods study was conducted at the ED of an academic tertiary hospital in Seoul, Korea. Adult patients aged ≤65 years presenting with abdominal symptoms were enrolled. We assessed PRS completion, time, and help required. Patient surveys and semi-structured interviews with patients and physicians were used to evaluate feasibility and acceptability.

Results: A total of 30 patient surveys were analyzed, and in-depth interviews were conducted with 6 patients and 6 doctors. All participants completed the PRS in an average of 7.6 (SD, 5.0) minutes. Sixteen patients (53.3%) needed help with content, and 15 (50.0%) required technical assistance. The PRS was rated as acceptable based on the diffusion of innovation theory, with an average of 3.9 (SD, 0.76) out of 5. Patients reported that the PRS helped them communicate symptoms clearly but raised concerns about its usability for older patients or those in pain.

Conclusion: In our pilot study, the PRS was feasible to use but required improvements in usability. Patients were acceptable to PRS use in the ED.

Objectives: To examine the efficacy of 4-factor prothrombin complex concentrate (4F-PCC) compared with plasma in vitamin K antagonist (VKA)-treated patients with gastrointestinal (GI) bleeding or requiring a GI surgical/invasive procedure.

Methods: A retrospective analysis was conducted on a subset of data from 2 prospective phase 3b randomized controlled trials of 4F-PCC or plasma for VKA reversal. Data from patients receiving VKA who experienced acute major GI bleeding or needed a GI surgical/invasive procedure within 24 hours were included in the analysis. Hemostatic efficacy, international normalized ratio (INR), and vitamin K-dependent coagulation factor (VKDF) restoration were analyzed.

Results: In total, 171 patients were included in the analysis. Overall, hemostatic efficacy was rated excellent and good in 68 of 83 (81.9%) and 66 of 88 (75.0%) patients in the 4F-PCC and plasma treatment groups, respectively (odds ratio [OR], 1.52; 95% CI, 0.72-3.20). At 0.5 hours after infusion, 68.2% of patients treated with 4F-PCC achieved an INR of ≤1.3 compared with 0.0% of patients treated with plasma (68% difference; 95% CI, 57-79). Time to INR restoration from the start of infusion was significantly shorter for 4F-PCC than plasma (45 vs 1326 minutes, respectively; OR, 0.10; 95% CI, 0.07-0.14). All VKDF levels were significantly higher in the 4F-PCC group vs the plasma group within 3 hours from the start of infusion (all P < .002). Additional blood product use in the acute major bleeding study was comparable between both groups.

Conclusion: 4F-PCC was associated with a nearly immediate decrease in INR and rapid VKDF restoration compared with plasma in patients experiencing acute major GI bleeding or in need of GI surgery/invasive procedure. Yet, hemostatic efficacy was similar between the 2 groups, and therefore, larger studies might be needed to better understand patient outcomes.

Objectives: All traditional dental clinics were closed from March to May 2020 due to the COVID-19 shutdown, potentially causing additional strain on hospital emergency departments (EDs) to care for patients with dental conditions. We evaluated the impact of pandemic-associated dental office closures on the share of dental conditions managed in EDs among children on Medicaid.

Methods: We quantified the change in the dental-related ED burden among publicly insured children before, during, and after pandemic dental office closures across NY using 2018-2020 New York State (NY) Medicaid claims data among children under age 19 using a difference-in-differences approach.

Results: After controlling for seasonality, dental practice closures in 2020 in NY led to a 2.31 percentage point increase in the share of dental conditions seen in EDs (P < .01) among children on Medicaid, representing a 62% increase over 2019 levels. This was sustained even after reopening in May 2020 (1.26 percentage point increase in the reopening phase, P < .01). The increases in the dental-related ED burden during dental office closures were due to the increased use of EDs for dental conditions.

Conclusion: Lack of access to dental care during a time of significant health care system strain was associated with an increased burden on EDs from dental conditions among publicly insured children. Health care systems should consider alternatives to referral programs to dental offices to ensure publicly insured children do not fall through the dental safety net, such as by providing limited dental services on-site or incorporating urgent dental care clinics within hospitals.

Artificial intelligence (AI) is increasingly being utilized to augment the practice of emergency medicine due to rapid technological advances and breakthroughs. AI applications have been used to enhance triage systems, predict disease-specific risk, estimate staffing needs, forecast patient decompensation, and interpret imaging findings in the emergency department setting. This article aims to help readers without formal training become informed end-users of AI in emergency medicine. The authors will briefly discuss the principles and key terminology of AI, the reasons for its rising popularity, its potential applications in the emergency department setting, and its limitations. Additionally, resources for further self-studying will also be provided.

Objectives: Trauma-induced coagulopathy (TIC) carries significant risks, including increased mortality. Traditional TIC definitions rely on laboratories that result slowly and do not highlight therapeutic targets. We hypothesized that a TIC score, based on thromboelastography (TEG) and rotational thromboelastometry (ROTEM), collectively termed viscoelastic hemostatic assays, is associated with in-hospital mortality and packed red blood cell (pRBC) transfusion.

Methods: This retrospective cohort study used a database of adult patients undergoing institutional massive transfusion at seven level 1 trauma centers (2013-2018). A "TIC score" was developed, with 1 point assigned for abnormal TEG R-time (≥ 9 min) or ROTEM clot time (≥ 80 sec), ɑ-angle (< 65^o), or maximum amplitude (< 55 mm). TIC+ patients (TIC score 1-3) were compared with TIC- patients (TIC score 0). TIC Score composition and abnormal cutoff values were adjusted to investigate optimal weighting and thresholds. Multiple logistic and negative binomial regression was used to control confounders while evaluating the association between abnormal TIC values, in-hospital mortality, and 24-hour pRBC transfusion.

Results: Of 1499 patients in the final analysis, 591 (39.4%) were TIC+. Each 1-point increase in TIC score was associated with a 53% increase in the odds of mortality (odds ratio [OR], 1.53, 95% CI, 1.33-1.76, P < .001) and a 25% increase in pRBC transfusion volumes (incidence rate ratio, 1.25, 95% CI, 1.16-1.34, P < .001). Abnormal maximum amplitude was associated with both mortality (OR 1.50, 95% CI, 1.03-2.19, P = .034) and pRBC transfusion volumes (P < .001), whereas abnormal ɑ-angle was associated with mortality (OR, 1.59, 95% CI, 1.09-2.32, P = .015). The unequal weighting of TIC score components and adjustments to normal/abnormal cutoff thresholds were maintained but did not improve the model's predictive power.

Conclusion: A viscoelastic hemostatic assay-based TIC score is independently associated with mortality and pRBC transfusion volumes. This association persists with unequal weighting and adjustment of normal/abnormal cutoff thresholds of TEG components.

Following the military's advancement of prehospital blood into the field, civilian prehospital blood programs are becoming more prevalent. However, there are significant differences between civilian and military prehospital operations that should be considered. Civilian prehospital systems also vary widely in terms of resources, transport times, and patient types. Given these variations and the logistical challenges associated with establishing a prehospital blood program, careful consideration of the state of the science is warranted. Although blood is the preferred fluid for patients in hemorrhagic shock, there have only been a few high-quality studies that have examined the efficacy of administering blood in the prehospital setting. Given the conflicting results of these studies, individual medical directors must determine whether the risk-benefit analysis for their system warrants establishing such a resource-intensive operation. Efforts to establish a prehospital blood program should not supersede attempts to optimize the fundamental components of trauma operations and management.

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.