Annals of emergency medicine最新文献

Study objective: Tranexamic acid (TXA) can be used after trauma to prevent bleeding. Our goal was to examine the influence of TXA on morbidity and mortality for children with severe traumatic brain injury (TBI).

Methods: We identified children aged <18 years with a severe TBI (Glasgow Coma Scale score less than 8) presenting to 1 of the 291 hospitals contributing to the Japanese Trauma Data Bank between 2019 and 2023. The primary outcome was inhospital death, and the secondary outcome was poor neurologic outcome defined with Glasgow Outcome Scale (GOS) score of 1 to 3 at hospital discharge. Our primary exposure was any TXA administered in the hospital. Using propensity score-based inverse probability weighting, we used logistic regression to measure the association between TXA administration and death as well as poor neurologic outcome.

Results: Of the 342 included patients, 30 (14%) died, and 102/225 (45%) had a GOS score less than 4 at discharge. After inverse propensity weighting, TXA administration was not associated with either mortality (adjusted odds ratio [aOR] 1.25, 95% confidence interval [CI] 0.61 to 2.54) or poor neurologic outcome (aOR 0.86, 95% CI 0.47 to 1.56).

Conclusions: TXA administration was not associated with either death or poor neurologic outcome. Prospective clinical trials of TXA usage in children with severe TBI are needed.

Study objective: Identify high-risk clinical characteristics for a serious cause of vertigo in patients presenting to the emergency department (ED).

Methods: Multicentre prospective cohort study over 3 years at three university-affiliated tertiary care EDs. Participants were patients presenting with vertigo, dizziness or imbalance. Main outcome measurement was an adjudicated serious diagnosis defined as stroke, transient ischemic attack, vertebral artery dissection or brain tumour.

Results: A total of 2,078 of 2,618 potentially eligible patients (79.4%) were enrolled (mean age 77.1 years; 59% women). Serious events occurred in 111 (5.3%) patients. We used logistic regression to create a 7-item prediction model: male, age over 65, hypertension, diabetes, motor/sensory deficits, cerebellar signs/symptoms and benign paroxysmal positional vertigo diagnosis (C-statistic 0.96, 95% confidence interval [CI] 0.92 to 0.98). The risk of a serious diagnosis ranged from 0% for a score of <5, 2.1% for a score of 5 to 8, and 41% for a score >8. Sensitivity for a serious diagnosis was 100% (95% CI, 97.1% to 100%) and specificity 72.1% (95% CI, 70.1% to 74%) for a score <5.

Conclusion: The Sudbury Vertigo Risk Score identifies the risk of a serious diagnosis as a cause of a patient's vertigo and if validated could assist physicians in guiding further investigation, consultation, and treatment decisions, improving resource utilization and reducing missed diagnoses.

Study objective: Cardiopulmonary resuscitation (CPR) is critical for out-of-hospital cardiac arrest patients but is prone to rapid changes and errors. Effective teamwork and leadership are essential for high-quality CPR. We aimed to introduce the Airway-Circulation-Leadership-Support (A-C-L-S) teamwork model in the emergency department (ED) to address these challenges.

Methods: The study comprised 2 phases. The development phase involved reviewing CPR videos, categorizing problems, and formulating strategies using the Systems Engineering Initiative for Patient Safety model. Resuscitation tasks were organized into A-C-L-S domains using hierarchical task analysis. Equipment and environmental deficits were optimized ergonomically with a pit-crew style arrangement. Mnemonics enhanced teamwork and leadership. The evaluation phase assessed postimplementation ED resuscitation team performance, focusing on adherence, timeliness, and quality of A-C-L-S tasks.

Results: The development phase produced a structured teamwork model, assigning tasks, tools, mnemonics, and positions based on A-C-L-S domains. The A-team manages the airway and optimizes end-tidal CO₂ levels; the C-team focuses on high-quality chest compressions and defibrillation. Leadership coordinates resuscitation efforts using goal-directed mnemonics (DABCD²E³), whereas the S-team handles medications, timekeeping, and recording. The evaluation phase showed improvements in adherence and timeliness of A-C-L-S tasks, with sustained increases in chest compression fraction before mechanical CPR, from 67.2% preimplementation to 83.0% postimplementation, 89.1% after 1 year, and 86.1% after 2 years. Overall, chest compression fraction also improved from 81.7% to 88.6%, peaking at 92.2% after 1 year and maintaining 90.8% after 2 years.

Conclusion: The A-C-L-S teamwork model is feasible, applicable, and effective. Further research is needed to assess its influence on patient outcomes.

Study objective: Interhospital transfer is often required in the care of patients with hemorrhagic stroke. Guidelines recommend a door-in-door-out (DIDO) time of ≤120 minutes at the transferring emergency department (ED); however, it is unknown whether DIDO times are related to clinical outcomes of hemorrhagic stroke.

Methods: Retrospective, observational cohort study using US registry data from Get With The Guidelines-Stroke participating hospitals. Patients include those aged ≥18 years with intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) who were transferred from the ED to a Get With The Guidelines participating receiving hospital from January 1, 2019, to July 31, 2022. The primary outcome was ordinal discharge modified Rankin scale (mRS) score and secondary outcomes included dichotomous discharge mRS, ability to ambulate independently at discharge, and inhospital mortality at the receiving hospital.

Results: In all, 19,708 ICH and 7,757 patients with SAH were included. For patients with ICH, an increasing DIDO time was associated with greater odds of mRS 0 to 3 versus 4 to 6 at discharge in the unadjusted analyses (DIDO 91 to 180 minutes, odds ratio [OR] 1.15 [1.04 to 1.27]; DIDO 181 to 270 minutes, OR 1.51 [1.33, 1.71]; DIDO >270 minutes, OR 1.83 [1.58, 2.11]; versus DIDO ≤90 minutes). In the adjusted analyses, no associations were observed. Similar results were seen for mRS at discharge in patients with SAH. In both patients with ICH and SAH, longer DIDO times were associated with greater odds of independent ambulation at discharge and lower odds of inhospital mortality in the unadjusted analyses. After adjustment, the effect sizes of these associations were reduced, with some of the results based on quartiles becoming statistically nonsignificant.

Conclusion: These findings suggest that EDs currently expedite the transfer of the sickest patients; however, prospective studies and more granular data are needed to understand the impact of early treatment and timing of transfer for patients with hemorrhagic stroke.

Study objective: The osmol gap can help detect and manage those with toxic alcohol exposure, and it is altered by all alcohols including ethanol. The optimal correction for ethanol that would allow accurate detection of an alternative alcohol is unclear.

Methods: We conducted a prospective cohort study to assess baseline variations in osmol gap, and then to assess the validity of 2 commonly used coefficients (correction factors) for ethanol. Twenty-two healthy volunteers received a body mass-based dose of oral ethanol that targeted an estimated peak blood ethanol concentration >200 mg/dL. We measured laboratory values prior to ethanol administration and at 2, 4, and 6 hours after ingestion. We considered an osmol gap >10 or <-10 abnormal and an osmol gap of >10 after correction as a false positive.

Results: Four of the 22 subjects (18%) had an osmol gap >10 at baseline. Following ethanol ingestion and across 66 timepoints (N=66), there were 14 abnormal osmol gap tests (21%) when corrected with an ethanol coefficient of 4.6, and 31 (47%) abnormal tests when corrected using the Purssell ethanol coefficient of 3.7. The mean difference between the baseline and the post-ethanol corrected osmol gap was lower with the molecular weight correction factor of 4.6 compared with the Purssell correction factor of 3.7 (0.2 versus 11.0; P<.001).

Conclusion: Our data show that the osmol gap is occasionally elevated absent ingestion of any alcohol, and using an ethanol correction coefficient of 4.6 produced a better clinical osmol gap input albeit still with some variation.

Study objective: To cover pediatric emergency physicians' off-hours, third-year pediatric residents in Israel are trained for unsupervised administration of emergency department (ED) dissociative and deep sedation. We assessed the frequency of critical sedation events associated with resident-performed sedations.

Methods: We conducted a retrospective chart review on all patients receiving intravenous sedation across 10 pediatric EDs between January 2018 and September 2022. We defined a critical sedation event as one or more of the following: chest compressions, tracheal intubation, neuromuscular blockers, vasopressors, atropine for bradycardia, aspiration syndrome, death, or unplanned hospital admission due to sedation. We liaised with the Ministry of Health's reporting department and ED directors to verify complete identification of all sentinel events.

Results: Pediatric residents and pediatric emergency physicians performed 12,733 and 10,845 sedations, respectively, most frequently for fracture reduction (44.4%) and laceration repair (25.6%). Patients' mean (SD) age was 6.9 (4.4) years. Residents and emergency physicians administered ketamine or propofol alone in 6,473 and 3,465 cases, respectively, with drug combinations for the remainder. We identified 6 critical sedation events, of which 3 were resident-performed sedations. The frequency of critical sedation events among pediatric residents and emergency physicians was 0.024% (95% CI, 0.005% to 0.069%) and 0.028% (95% CI, 0.006% to 0.080%), respectively.

Conclusion: We observed a low frequency of critical sedation events in this large sample of dissociative and deep sedations performed by pediatric residents and pediatric emergency physicians. Our findings suggest that ED sedation by unsupervised, trained pediatric residents is a safe practice in Israel.

Study objective: Nontraumatic, incidental findings on computed tomography (CT) may be discovered after blunt abdominal trauma in children; however, the rate and importance of these findings are not well known. The objective of this study was to determine the prevalence and types of incidental CT findings among injured children undergoing abdominal/pelvic CT.

Methods: This was a planned secondary analysis of a multicenter prospective cohort study of children (<18 years) who underwent abdominal/pelvic CT after blunt trauma. We abstracted radiology reports for nontraumatic findings. We assessed and classified findings by their clinical urgency.

Results: Of 7,581 children enrolled, 2,500 (33%) underwent abdominal/pelvic CT. The mean patient age was 10.1±4.8 years, and 1,446 (58%) were boys. A total of 988 (39.5%, 95% CI 37.6 to 41.5%) children had 1,552 incidental findings with a mean patient age of 10.6±4.8 years, of whom 59% were boys. Fifty-five (3.5%) incidental findings were considered to need immediate evaluation/treatment, and 84 (5.4%) were considered to require outpatient follow-up within 4 weeks. Most incidental findings, however, were considered less urgent regarding follow-up: 552 (36%) were routine, 574 (37%) were considered to have a potential need, and 287 (18%) did not need follow-up.

Conclusions: Forty percent of children undergoing CT scanning after abdominal trauma have incidental findings, few of which are clinically important and require timely follow-up. CT scans should be obtained only when necessary, and clinicians must be prepared to address incidental findings and ensure proper management.