Annals of emergency medicine最新文献

Although aortoenteric fistula is traditionally associated with aortic aneurysms or grafts, modern multimodal oncologic therapies have introduced a new paradigm of aortic injury in native vessels. We describe a rare case of treatment-related aortoenteric fistula arising from a nonaneurysmal aorta in a 56-year-old woman with fallopian tube carcinoma. Her history included para-aortic lymph node excision, pelvic radiation, and recent bevacizumab therapy. Although these factors may act synergistically, bevacizumab represents a potential primary driver of vascular wall compromise. The patient presented with weakness and intermittent melena representing multiple herald bleeds but subsequently suffered a sudden inhospital cardiac arrest. Emergent computed tomography obtained prior to endoscopic evaluation revealed an aortoduodenal fistula despite a nonaneurysmal aorta, prompting successful endovascular aortic repair. This case illustrates that a nonaneurysmal caliber does not rule out aortoenteric fistula in patients with this specific risk profile. This report highlights one of the few documented cases of such vascular pathology following this specific combination of therapies. For unstable oncology patients with gastrointestinal bleeding and recent antiangiogenic therapy, emergency physicians should broaden the diagnostic workup to include early vascular imaging and enlist vascular specialists alongside standard endoscopic evaluation.

Study objective: Assess how emergency department (ED) mistriage is associated with timeliness of ED care and patient outcomes.

Methods: This was a retrospective cohort study of ED encounters from 2016 to 2020, across 21 EDs. Using operational measures of triage accuracy, we assessed how assigned Emergency Severity Index (ESI) matched downstream intensity of care and resource use. Patients with a mismatch between ESI assignment and downstream resource use were classified as undertriaged high-acuity or overtriaged low acuity, whereas those with no mismatch were classified as true low-, mid-, or high-acuity. The primary outcome was delay in care; secondary outcomes included ED length of stay, intensive care unit admission (ICU), and short-term mortality.

Results: Among 5,315,081 adult ED encounters, mean age was 51.7 years, 2,962,827 (56%) were women, and 590,566 (11.1%), 800,966 (15.1%), 2,336,012 (44.0%), 1,137,444 (21.4%), and 450,093 (8.5%) were Asian, Black, Non-Hispanic White, Hispanic, and other, unknown or multi-race, respectively. Undertriaged high-acuity patients had higher comorbidity burdens, high-risk medication use, and recent health care use compared with true mid- and high-acuity patients. In adjusted analyses, mistriage, both under- and overtriage, was associated with small delays in care. Undertriaged high-acuity patients had an 8-minute delay in care compared with true high-acuity patients. Overtriaged low-acuity patients had a 3-minute delay in care and a 42-minute longer total ED length of stay compared with true low-acuity patients.

Conclusion: Mistriage was associated with small delays in care. Early identification of critically ill patients remains a triage priority, and the use of patient history data may help support accurate triage.

Study objective: The National Prehospital Pediatric Readiness Project aims to optimize pediatric out-of-hospital care by emergency medical services (EMS). The current report details the findings of the first national assessment of pediatric readiness among US EMS agencies.

Methods: We performed a cross-sectional study of data collected from 911-responding EMS agencies in the United States via a scored web-based survey developed based on national guidelines for out-of-hospital care. The survey contained 207 questions across 8 domains of out-of-hospital readiness: education, equipment, safety, family-centered care, pediatric coordination, interaction with systems, policies, and quality improvment. The primary outcome was the Prehospital Pediatric Readiness Score (range 0-100); secondary outcomes were median domain scores and the effect of a pediatric emergency care coordinator on scores.

Results: Overall, 6,989/15,293 (46%) agencies responded; 2,661 (38%) reported having a pediatric emergency care coordinator. Median Prehospital Pediatric Readiness Score was 65.5 (interquartile range [IQR] 50.9 to 78.8). Domain scores were highest for equipment (median 12.0, IQR [12 to 12], range 0 to 12), policies (11.5, IQR [10 to 12], range 0 to 13), and safety (11.5, IQR [7 to 14], range 0 to 14) and lowest for family-centered care (5.8, IQR [2 to 8], range 0 to 10), quality improvement (5.7, IQR [3 to 9], range 0 to 12), and interactions with systems (4.9, IQR [3 to 7], range 0 to 10). Presence of a pediatric emergency care coordinator was associated with a perfect score in all domains.

Conclusion: A national assessment of EMS agencies revealed strengths and gaps in pediatric readiness. Pediatric emergency care coordinators are associated with higher readiness scores. Future work should address barriers to pediatric readiness and the effect of higher readiness on patient outcomes.