Archives of Academic Emergency Medicine最新文献

Introduction: Sepsis-associated acute kidney injury (SA-AKI) is a frequent complication in critically ill patients and is associated with increased mortality. This study aimed to evaluate the prognostic value of the lactate/albumin ratio (LAR) and other albumin-based biomarkers in predicting SA-AKI.

Methods: A retrospective observational study was conducted on 564 patients with sepsis, divided into two groups based on the presence (n = 298) or absence (n = 266) of AKI. Clinical characteristics, laboratory parameters, and disease severity scores (SOFA, APACHE II, NEWS, NEWS-Lactate) were compared between groups. The predictive performance of each marker in detecting SA-AKI was assessed using receiver operating characteristic (ROC) curve analysis.

Results: Patients with SA-AKI had significantly higher levels of lactate (p = 0.001), procalcitonin (PCT) (p = 0.001), urea (p = 0.019), creatinine (p = 0.004), and lower albumin (p = 0.001) concentrations upon admission. The LAR demonstrated the highest discriminative performance among all tested markers, with an area under the curve (AUC) of 0.800 (95% confidence interval (CI): 0.765-0.835), sensitivity of 70.5% (95% CI: 64.9 - 75.6), and specificity of 70.3% (95% CI: 64.4 - 75.7) at a cut-off value of 0.101. NEWS-Lactate also showed good prognostic ability (AUC = 0.772, 95% CI: 0.734-0.809), sensitivity of 71.1% (95% CI: 65.6 - 76.2), and specificity of 63.2% (95% CI: 57.1 - 69.0) at a cut-off value of 7.11. Other indices, including serum creatinine/albumin ratio (sCAR), blood urea nitrogen/albumin ratio (BAR), and procalcitonin/albumin ratio (PAR), and procalcitonin (PCT) × lactate, yielded moderate AUCs. While NEWS alone showed limited predictive value (AUC = 0.508), both SOFA and APACHE II scores were significantly higher in the SA-AKI group.

Conclusion: It seems that, the LAR and NEWS-Lactate are promising biomarkers for early detection of SA-AKI and may outperform conventional severity scores and standalone laboratory parameters.

Introduction: Termination of resuscitation (TOR) rules in out of hospital cardiac arrest (OHCA) varies across different healthcare settings and populations. This study aimed to externally validate ten TOR rules for predicting death before hospital admission among OHCA patients.

Methods: A retrospective prognostic accuracy study analyzed 379 non-trauma OHCA patients (≥18 years) in Bangkok who were either treated by the emergency medical services (EMS) of Ramathibodi Hospital or transported to Ramathibodi's emergency department by another EMS provider (January 2010 - March 2023). The predictive performance of ten TOR rules (AHA-BLS, AHA-ALS, Korean Cardiac Arrest Research Consortium (KoCARC) rules I, II, and III, Goto's rule, Shihabashi's rule, the New Model I, Helsinki's, and Petrie's rule) in predicting death before hospital admission as well as false positive rates (FPRs) of rules at various resuscitation times were calculated and reported with 95% confidence interval (CI).

Results: Among 379 OHCA patients, 308 (81.27%) died before hospital admission and 71 (18.73%) survived to discharge. The New model I demonstrated the most conservative predictive performance with sensitivity of 96.7% (95% CI: 93.0-98.8), NPV of 91.5% (95% CI: 82.5-96.8), and area under the curve (AUC) of 0.74 (95% CI: 0.70-0.79). The KoCARC III showed FPR of 2.8%. Based on the initial presenting criteria, the FPR varied at different resuscitation time points, with increasing FPR over 30 minutes. Among all rules, Helsinki's and AHA-BLS showed the highest FPRs (1.14 - 21.13 and 1.14 - 23.94, respectively) while the KoCARC TOR rules III demonstrated the most conservative consistency in maintaining a low FPR (0-2.82%) throughout time.

Conclusion: The KoCARC III demonstrated relatively high safety for TOR decisions in Bangkok's OHCA population, with the lowest FPR, and high sensitivity and NPV. TOR rules showed higher FPRs compared to previous studies. These findings should be interpreted with caution due to the retrospective design, potential selection bias, and EMS protocol changes over the 10-year study period.

Introduction: Traumatic Brain Injury (TBI) is one of the leading causes of mortality and severe disability worldwide. This study aimed to develop and optimize machine learning (ML) algorithms to predict abnormal brain computed tomography (CT) scans in patients with mild TBI.

Methods: In this retrospective analyses, the outcome was dichotomized into normal or abnormal CT scans, and univariate analyses were employed for feature selection. Then SMOTE was applied to address class imbalance. The dataset was split 80:20 for training/testing, and multiple ML algorithms were evaluated using accuracy, F1-score, and area under the receiver operating characteristic curve (AUC-ROC). SHAP analysis was used to interpret feature contributions.

Results: The data included 424 patients with an average age of 40.3 ± 19.1 years (76.65% male). Abnormal brain CT scan findings were more common in older males, patients with lower Glasgow Coma Scale (GCS) scores, suspected fractures, hematomas, and visible injuries above the clavicle. Among the ML models, XGBoost performed best (AUC 0.9611, accuracy 0.8937), followed by Random Forest, while Naive Bayes showed high recall but poor specificity. SHAP analysis highlighted that lower GCS scores, decreased SpO2 levels, and tachypnea were strong predictors of abnormal brain CT findings.

Conclusion: XGBoost and Random Forest achieved high predictive accuracy, sensitivity, and specificity. GCS, SpO2, and respiratory rate were key predictors. These models may reduce unnecessary CT scans and optimize resource use. Further multicenter validation is needed to confirm their clinical utility.

Introduction: By enabling direct consultation with neurologists, Real-Time Telemedical Oversight (ReTMO) can facilitate rapid stroke assessment and decision-making. This study aimed to assess the efficacy of prehospital stroke management before and after ReTMO implementation.

Methods: A single-center retrospective before-and-after study was conducted at Ramathibodi Hospital, Bangkok, Thailand, from January 2020 to December 2024. In March 2022, a structured prehospital stroke protocol was integrated with the ReTMO system in this hospital. We evaluated its impact by comparing stroke patients transported by emergency medical services (EMS) before and after protocol implementation. Neurological outcomes at hospital discharge were analyzed using multivariable ordinal logistic regression. In contrast, door-to-treatment times in the emergency department (ED) and hospital length of stay were assessed using multivariable Gaussian regression.

Results: The study included 91 prehospital stroke patients, with 36 in the pre-protocol group and 55 in the post-protocol group. Implementation of the structured prehospital stroke protocol was associated with a significant reduction in door-to-computed tomography (CT) scan time by 10.47 (95% confidence interval (CI): -17.62 to -3.3) minutes and door-to-laboratory result time by 15.90 (95% CI: -30.48 to -1.33) minutes. Additionally, adjusted ordinal logistic regression analysis demonstrated a significant improvement in neurological outcomes at hospital discharge (odds ratio (OR) = 0.14, 95% CI: 0.02-0.99, P = 0.049). However, reductions in ED stroke treatment time and hospital length of stay were not statistically significant.

Conclusions: Implementing ReTMO alongside a structured prehospital stroke protocol significantly reduced in-hospital delays in door-to-CT and door-to-laboratory result times while also improving neurological outcomes at hospital discharge.

Introduction: Reducing the compression rotation interval from 2 to 1 minute is expected to improve cardiopulmonary resuscitation (CPR) quality. This meta-analysis aimed to assess the effect of altering the compression rotation interval on key CPR quality parameters, including compression depth, rate, and rescuer fatigue.

Methods: We systematically searched MEDLINE, EMBASE, Scopus, Google Scholar, Web of Science, and the Cochrane Controlled Register of Trials from their inception to May 15, 2025. We searched for randomized controlled trials, simulation studies, and crossover studies that compared 1-min and 2-min compression rotation times. The assessed outcomes included compression depth, rate, correctness, and rescuer fatigue, which were reported as the standard mean difference (SMD) with a 95% confidence interval (95% CI).

Results: One randomized controlled trial and seven randomized crossover studies, involving 668 rescuers in total, using manikins, were included. The 1-min rotation group exhibited significantly greater compression depth, with an increase of 2.06 mm (SMD = 2.06, 95% CI: 0.44-3.68, p < 0.001). This group demonstrated lower levels of fatigue, as indicated by a significant reduction on the visual analog scale for fatigue (SMD = -1.27, 95% CI: -2.24 to -0.30, p < 0.001). However, there were no significant differences in the compression rate or percentage of compressions that achieved adequate depth.

Conclusion: It seems that altering the chest compression rotation interval from 2 min to 1 min improves the compression depth and reduces rescuer fatigue. However, parameters, such as the compression rate and compression adequacy, remained unchanged. Notably, all the studies were conducted on manikins, thus necessitating further research to assess the applicability of these changes in real-world clinical settings.

Introduction: Intoxication-related unconsciousness is a frequent and challenging condition in emergency medicine, where rapid interventions are critical to improve patient outcomes. This study aimed to evaluate the efficacy of methylphenidate in improving consciousness levels of intoxicated patients.

Methods: In this double-blind clinical trial, intoxicated patients over 18 years of age with the Glasgow Coma Score (GCS) 13 and below were studied. 51 people were included in the intervention group and received methylphenidate, while 50 were in the control group and received placebo. Consciousness levels were measured using the Reed score before and at 12, 24, 36, and 48 hours post-intervention and compared between groups using SPSS software version 21.

Results: 101 patients with the mean age of 34± 14.26 (range: 17-81) years were studied (55.4% male). 74.5% of the people in the intervention group achieved the most alert state (a REED score of zero) after 48 hours, compared to only 32% in the control group. The intervention group had significantly lower average Reed scale (0.33) compared to the control group (0.76) 48 hours after the treatment (p = 0.001). Using Methylphenidate in treatment of intoxicated patients showed effect size of 0.703 (95% confidence interval (CI): 0.299-1.104), number needed to treat of 2.17 (95%CI: 1.48 - 3.34), absolute risk reduction of 46% (95%CI: 0.29 -0.67), and relative risk reduction of 57% (95%CI: 0.37 - 0.72).

Conclusion: It seems that, the use of methylphenidate in patients with intoxication can reduce the time it takes for their consciousness to return to a normal level. Since benzodiazepines are the leading cause of poisoning, this study suggests that methylphenidate could be beneficial in cases of benzodiazepine poisoning to aid in cognitive recovery.

Introduction: One of the main contributing factors of emergency department (ED) crowding is ED patient boarding. This study aimed to assess the factors influencing length of stay (LOS) in intensive care unit (ICU) and in-hospital mortality (IHM) among ICU-admitted ED boarded cases.

Methods: A retrospective cohort study was conducted on adult patients at a tertiary care hospital in Lebanon who required ICU admission and stayed for 6+ hours in the ED during one year. The independent predictive factors of LOS in ICU and IHM were studied using multivariable logistic regression analysis.

Results: Out of 583 patients (mean age 69.5 years; 61.6% male), 12.8% died in hospital. 25.5% had a prolonged ICU stay (≥7 days) with a median LOS of 3 days. Prolonged ICU LOS was associated with previous cancer diagnosis (adjusted odds ratio (aOR)=1.66), prehospital bedridden status (>5 days, aOR=4.41), ED vasopressor use (aOR=1.86), extended ED boarding (aOR=1.03), IHM (aOR=3.37), and not being married (aOR=2.0). IHM was associated with abnormal Modified Shock Index at ED triage (aOR=7.35), ED mechanical ventilation use (aOR=6.07), ED triage Shock Index ≥1.3 (aOR=18.25), and long ICU stay (aOR=7.48). ED-triage Saturation of Peripheral Oxygen (SPO₂) level was negatively associated with IHM (aOR=0.89).

Conclusion: It seems that, ED boarding of ICU patients is associated with an increase in ICU LOS, which is associated with an increase in IHM. Hospitals should allocate resources to reduce ED boarding and improve outcomes for critically ill patients.

Introduction: Smart glasses with an augmented reality workflow have emerged as a new tool for triage in mass casualty incidents (MCIs). This study aimed to investigate the accuracy and time efficiency of smart glasses in MCIs triage.

Methods: A retrospective field exercise study was conducted in November 2024 at EMS Srinagarind Hospital, Thailand. All participants performed self-assessments and used smart glasses for triage sieve. Data were recorded in terms of accuracy and time required for triage.

Results: A total of 108 participants were enrolled, with a mean age of 33.4 years, of whom 57.4% were female. The smart glasses group achieved the highest accuracy in triage level 1, with 98.3% compared to 79.3% in the self-assessment group (P < 0.001). The smart glasses group also completed triage significantly faster than the self-assessment group, with a time of 23.5 versus 72.4 seconds for triage level 1 and 31.3 versus 89.1 seconds for level 2.

Conclusion: The use of smart glasses with an augmented reality workflow for triage sieve in MCIs is beneficial, improving both accuracy and evaluation time for patients in triage levels 1 and 2.

Introduction: Combining multiple drugs for intubation raises concerns such as increased side effects, medication errors, nursing workload, and costs. Ketamine, with its anesthetic and analgesic properties, shows promise as a sedative agent for post-intubation care. This study aimed to evaluate the efficacy and safety of ketamine infusion as the sole sedative for critically ill intubated patients.

Methods: Following PRISMA 2020 guidelines, we conducted a systematic review by searching Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Google Scholar up to May 10, 2024. We included studies assessing ketamine use for post-intubation sedation in critically ill adults or children. Study quality was assessed using the Newcastle-Ottawa scale, and meta-analysis was performed using a random-effects model.

Results: The systematic review included 7 studies, with 4 studies included in the meta-analysis. There was no significant difference in mortality (OR = 1.52; 95% CI: 0.49-4.70, p = 0.46; I2 = 83%) or length of hospital stay (MD = 6.42; 95% CI: -1.42-14.26, p = 0.11; I2 = 84%) between the ketamine only and other groups. The most common adverse events in the ketamine infusion group were atrial fibrillation and agitation.

Conclusion: Single-agent ketamine infusion is effective and safe for critically ill intubated patients. No significant differences were found in mortality or hospital stay between ketamine only and other groups. Atrial fibrillation and agitation were the most common adverse effects.

Introduction: An accurate emergency department (ED) diagnosis is critically important for providing proper treatment during the so-called "Golden Hour." This study aimed to evaluate the agreement between admitting and discharge diagnoses in ED.

Method: This retrospective cross-sectional study was conducted over the course of 6 months in the emergency department (ED) of a tertiary care center. The main aim of the study was to evaluate the agreement between admission and hospital discharge diagnoses. The patients were categorized into two groups based on whether the admitting and discharge diagnoses were matched or mismatched. The reasons for diagnostic discrepancies, as well as their impact on patient outcomes, were assessed.

Results: A total of 6812 cases with mean age of 43.2 ± 17.9 (range: 1-95 years) years were included (59.30% male). The admitting and discharge diagnoses were matched in 5585 (81.99%) cases and mismatched in 1227 (18.01%) cases (7.2% were completely unmatched). The proportion of mismatched diagnoses did not differ significantly between males and females (p = 0.0977). Mismatched diagnoses were significantly more common in 0-15 years age group (37.86%), and the lowest proportion was seen in patients aged 15-65 years (9.65%) (p < 0.001). The most frequent reason for diagnostic discrepancy was "writing chronic disease as discharge diagnosis (relabeling)," (37.08%). Other contributing factors included radiological tests after hospital admission (20.37%), physical examination findings (18.1%), additional laboratory tests (15.81%), and other causes (8.57%). A change in diagnosis impacted the clinical outcomes of 103 (8.39%) patients.

Conclusion: Diagnostic agreement between ED and discharge diagnoses was observed in 81.99% of cases, with a 7.2% complete mismatch rate. The most frequent causes were discharge relabeling and delayed investigations. These discrepancies had measurable impacts on management, hospital stay, and mortality.