Academic Emergency Medicine最新文献

{"title":"Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule.","authors":"Cosby G Arnold, Paul Ishimine, Kevan A McCarten-Gibbs, Kenneth Yen, Nisa Atigapramoj, Mohamed Badawy, Irma T Ugalde, Pradip P Chaudhari, Jeffrey S Upperman, Nathan Kuppermann, James F Holmes","doi":"10.1111/acem.15084","DOIUrl":"https://doi.org/10.1111/acem.15084","url":null,"abstract":"<p><strong>Objective: </strong>The Pediatric Emergency Care Applied Research Network (PECARN) derived and externally validated a clinical prediction rule to identify children with blunt torso trauma at low risk for intraabdominal injuries undergoing acute intervention (IAI^AI). Little is known about the risk for IAI^AI when only one or two prediction rule variables are positive. We sought to determine the risk for IAI^AI when either one or two PECARN intraabdominal injury rule variables are positive.</p><p><strong>Methods: </strong>We performed a planned secondary analysis of a prospective, multicenter study that included 7542 children (<18 years old) with blunt torso trauma evaluated in six emergency departments from December 2016 to August 2021. Patients with only one or two PECARN rule variables positive were included. The outcome was IAI^AI (IAI undergoing therapeutic laparotomy, angiographic embolization, blood transfusion, or two or more nights of intravenous fluids).</p><p><strong>Results: </strong>Among the 7542 children enrolled, 2986 (39.6%, 95% confidence interval [CI] 38.5%-40.7%) had one or two PECARN variables positive and were included. Of this subpopulation, 227 (7.6%, 95% CI 6.7%-8.6%) had intraabdominal injuries. In the 1639 patients with only one rule variable positive, 21 (1.3%, 95% CI 0.8%-2.0%) had IAI^AI. In the 1347 patients with two rule variables positive, 27 (2.0%, 95% CI 1.3%-2.9%) had IAI^AI. Risk for IAI^AI for each variable was highest for Glasgow Coma Scale (GCS) score <14 (16/291, 5.5%, 95% CI 3.2%-8.8%) and abdominal wall trauma (three of 321, 0.9%, 95% CI 0.2%-2.7%). Risk for IAI^AI when two variables were present was highest when decreased breath sounds (three of 44, 6.8%, 95% CI 1.4%-18.7%) and GCS <14 (10/207, 4.8%, 95% CI 2.3%-8.7%) were present with one other variable.</p><p><strong>Conclusions: </strong>Few children with blunt torso trauma and one or two PECARN predictor variables present have IAI^AI. Those with GCS score <14, however, are at highest risk for IAI^AI.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":3.4,"publicationDate":"2025-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142969160","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Balancing risks and priorities: Achieving right care in diagnosing pulmonary embolism during pregnancy.","authors":"Pierre-Marie Roy, Thomas Moumneh","doi":"10.1111/acem.15082","DOIUrl":"https://doi.org/10.1111/acem.15082","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":3.4,"publicationDate":"2025-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142969156","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Optimal timing for epinephrine administration in adult patients with out-of-hospital cardiac arrest: A retrospective observational study.","authors":"Kenta Sakamoto, Hideto Yasuda, Yutaro Shinzato, Yuki Kishihara, Shunsuke Amagasa, Masahiro Kashiura, Takashi Moriya","doi":"10.1111/acem.15089","DOIUrl":"https://doi.org/10.1111/acem.15089","url":null,"abstract":"<p><strong>Background: </strong>This study aimed to clarify the appropriate timing for epinephrine administration in adults with out-of-hospital cardiac arrest (OHCA), particularly those cases with nonshockable rhythms, by addressing resuscitation time bias.</p><p><strong>Methods: </strong>We performed a retrospective observational study utilizing a multicenter OHCA registry involving 95 hospitals in Japan between June 2014 and December 2020. We included patients with OHCA and nonshockable rhythms who received epinephrine during resuscitation. The primary and secondary outcomes were favorable 30-day neurological status and survival, respectively. A favorable neurological outcome was defined as a cerebral performance category score of 1 or 2. The time from emergency medical service (EMS) personnel contact to epinephrine administration was categorized in 5-min intervals. We used the Fine-Gray regression to calculate the time-dependent propensity score in each group. After risk set matching, we employed a generalized estimating equation (GEE) to adjust for within-patient clustering.</p><p><strong>Results: </strong>A total of 36,756 patients were included in the analysis. When involving timing variables and GEE, epinephrine administration significantly affected favorable 30-day neurological status at 1-5 and 6-10 min, with risk ratios (RR; 95% confidence intervals [CIs]) of 9.36 (1.19-73.7) and 3.67 (1.89-7.14), respectively. Epinephrine administration significantly affected 30-day survival at 1-5, 6-10, 11-15, and 16-20 min, with RRs (95% CIs) of 2.33 (1.41-3.85), 2.09 (1.65-2.65), 1.64 (1.32-2.05), or 1.70 (1.29-2.25), respectively.</p><p><strong>Conclusions: </strong>Epinephrine administration within 10 min of EMS personnel contact may be associated with favorable neurological outcomes in patients with OHCA and nonshockable rhythms.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":3.4,"publicationDate":"2025-01-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142963539","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical decision instruments for predicting mortality in patients with cirrhosis seeking emergency department care.","authors":"Swetha Parvataneni, Michelle Haugh, Yara Sarkis, Brittany Baker, Lauren D Nephew, Marwan S Ghabril, Raj Vuppalanchi, Eric S Orman, Naga P Chalasani, Archita P Desai, Nicholas Eric Harrison","doi":"10.1111/acem.15088","DOIUrl":"10.1111/acem.15088","url":null,"abstract":"<p><strong>Objective: </strong>Clinical decision instruments (CDIs) could be useful to aid risk stratification and disposition of emergency department (ED) patients with cirrhosis. Our primary objective was to derive and internally validate a novel Cirrhosis Risk Instrument for Stratifying Post-Emergency department mortality (CRISPE) for the outcomes of 14- and 30-day post-ED mortality. Secondarily, we externally validated the existing Model for End-Stage Liver Disease (MELD) scores for explicit use in ED patients and prediction of the same outcomes.</p><p><strong>Methods: </strong>A cohort of 2093 adults with cirrhosis, at 16 sites in a statewide health system, was analyzed for 119 candidate variables available at ED disposition. LASSO with 10-fold cross-validation was used in variable selection for 14-day (CRISPE-14) and 30-day (CRISPE-30) logistic regression models. Area under the receiver operating characteristic curve (AUROC) was calculated for each variant of the CRISPE and MELD scores and compared via Delong's test. Predictions were compared to actual ED disposition for predictive value and reclassification statistics.</p><p><strong>Results: </strong>Median (interquartile range [IQR]) characteristics of the cohort were age 62 (53-70) years and MELD 3.0 13.0 (8.0-20.0). Mortality was 4.3% and 8.5% at 14 and 30 days, respectively. CRISPE-14 and CRISPE-30 outperformed each MELD variant, achieving AUROC of 0.824 (95% CI: 0.781-0.866) and 0.829 (0.796-0.861), respectively. MELD 3.0 AUROCs were 0.724 (0.667-0.781) and 0.715 (0.672-0.781), respectively. Compared to ED disposition, CRISPE-14, CRISPE-30, and MELD 3.0 significantly improved positive and negative predictive value and net reclassification index at multiple cutoffs. Applying CRISPE-30 (cutoff 4.5) favorably reclassified one net ED disposition for mortality for every 12 patients, while MELD 3.0 net reclassified one disposition per 84 patients.</p><p><strong>Conclusions: </strong>CDIs may be useful in risk-stratifying ED patients with cirrhosis and aiding disposition decision making. The novel CRISPE CDI showed powerful performance and requires external validation, while the existing MELD 3.0 score has moderate performance and is now externally-validated in an ED population for short-term mortality.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":3.4,"publicationDate":"2025-01-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142942423","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Emergency department-initiated oral naltrexone for patients with moderate to severe alcohol use disorder: A pilot feasibility study.","authors":"Ethan Cowan, Clare O'Brien-Lambert, Erick Eiting, Bull Edwards, Jacqueline Ryder, Yvette Calderon, Edwin Salsitz","doi":"10.1111/acem.15059","DOIUrl":"https://doi.org/10.1111/acem.15059","url":null,"abstract":"<p><strong>Objectives: </strong>Alcohol use disorder (AUD) is the most common substance use disorder in the United States. Despite availability of four FDA-approved medications, fewer than 10% of patients are prescribed medication. This study aimed to evaluate the impact and feasibility of emergency department (ED)-initiated oral naltrexone in patients with moderate to severe AUD.</p><p><strong>Methods: </strong>This was a prospective, single-arm, open-label, nonrandomized clinical trial conducted a single ED. Consenting participants were adults with moderate to severe AUD who were provided a single 50-mg dose of oral naltrexone, a 14-day starter pack of naltrexone, and referral for treatment. Follow-up was conducted at 14 and 30 days post-ED visit. The primary outcome was engagement in formal addiction treatment. Secondary outcomes included alcohol consumption, craving, quality-of-life measures, satisfaction, and safety.</p><p><strong>Results: </strong>Of 761 patients screened, 21 enrolled and received at least one dose of naltrexone. At 14 days, 29% were engaged in treatment, increasing to 33% at 30 days. There was a decrease in the mean (±SD) number of drinks per day from 5.20 (±4.67) at baseline to 2.23 (±4.35) during the follow-up period (p = 0.078). There was a decrease in alcohol craving scores, with median scores dropping from 19 at baseline to 8.27 during the follow-up period (p < 0.001). Quality-of-life measures improved, with a statistically significant increase in the reported number of healthy days (p = 0.006) and decrease in depressive symptoms (p < 0.001). Reported side effects were mild and satisfaction with the screening process was high.</p><p><strong>Conclusions: </strong>ED-initiated oral naltrexone is feasible and acceptable for patients with moderate to severe AUD. While engagement in treatment was moderate, significant reductions in alcohol craving and improvements in quality of life suggest potential benefits. Further research is warranted to confirm these findings.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":3.4,"publicationDate":"2025-01-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142942424","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Exploring diagnostic stewardship in the emergency department evaluation of pediatric abdominal pain in a statewide quality collaborative.","authors":"Alexander T Janke, Kenneth A Michelson, Keith E Kocher, Kristian Seiler, Michelle L Macy, Michele Nypaver, Prashant V Mahajan, Rajan Arora, Courtney W Mangus","doi":"10.1111/acem.15075","DOIUrl":"https://doi.org/10.1111/acem.15075","url":null,"abstract":"<p><strong>Background: </strong>Diagnostic stewardship is the effort to optimize diagnostic testing to reduce errors while avoiding overtesting and overtreatment. Abdominal pain and appendicitis in children are essential use cases. Delayed diagnosis of appendicitis can be dangerous and even life-threatening, but overtesting is harmful.</p><p><strong>Methods: </strong>We conducted a retrospective cohort study of children aged 5-17 years presenting with abdominal pain to 26 EDs within the Michigan Emergency Department Improvement Collaborative (MEDIC) from May 1, 2016, to February 29, 2024. We defined two outcome measures summarized by ED. First, we describe the cross-sectional imaging:appendicitis visits ratio, defined as the count of ED visits resulting in any cross-sectional imaging (CT or MRI) divided by the count of ED visits with a diagnosis of appendicitis. Second, we describe the delayed diagnosis rate, defined by an ED visit for abdominal pain resulting in a discharge and subsequent return visit with a diagnosis of appendicitis within 7 days.</p><p><strong>Results: </strong>The sample included 120,112 pediatric visits for abdominal pain at 26 EDs; 4967 (4.1%) were diagnosed with appendicitis. The cross-sectional imaging:appendicitis visits ratio varied by site, from as low as 0.2 (95% confidence interval [CI] 0.1-0.2) at a pediatric site to as high as 7.9 (95% CI 4.8-16.4) at an urban ED. The proportion of pediatric ED visits for abdominal pain that resulted in an identified delayed diagnosis of appendicitis was 0.1% (141/120,112). All but four sites had fewer than 10 cases of delayed diagnosis across the study period.</p><p><strong>Conclusions: </strong>In this retrospective cohort study of 120,000+ ED visits for pediatric abdominal pain, we found that the ratio of visits with cross-sectional imaging to diagnosed cases of appendicitis varied widely across EDs. Delayed diagnosis of appendicitis was uncommon. Adherence to best practices and improved imaging quality may hold promise to improve diagnostic stewardship for children with abdominal pain across EDs.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":3.4,"publicationDate":"2025-01-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142930083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Decreased racial disparities in sepsis mortality after an order set-driven initiative: An analysis of 8151 patients.","authors":"Maria L Fernandez Olivera, Carl Pafford, Thomas Lardaro, Steven K Roumpf, Michele Saysana, Benton R Hunter","doi":"10.1111/acem.15083","DOIUrl":"https://doi.org/10.1111/acem.15083","url":null,"abstract":"<p><strong>Background: </strong>Sepsis is a leading cause of hospital mortality and there is evidence that outcomes vary by patient demographics including race and gender. Our objectives were to determine whether the introduction of a standardized sepsis order set was associated with (1) changes in overall mortality or early antibiotic administration or (2) changes in outcome disparities based on race or gender.</p><p><strong>Methods: </strong>Patients seen in the emergency department and admitted to the hospital with a diagnosis code of sepsis were identified and divided into a preintervention cohort seen during the 18 months prior to the initiation of a new sepsis order set and an intervention cohort seen during the 18 months after a quality initiative driven by introducing the order set. Associations between time period, race, gender, and mortality were assessed using univariate and multivariate logistic regression models. Other outcomes included early antibiotic administration (<3 h from arrival).</p><p><strong>Results: </strong>Overall mortality was unchanged during the intervention period (7.8% vs. 7.2%) in both univariate (relative risk [RR] 1.08, 95% confidence interval [CI] 0.93-1.26) and multivariate logistic regression (RR 1.11, 95% CI 0.93-1.28) models. Although male gender tended to have higher mortality, there was no statistically significant association between gender and mortality in either cohort. In the multivariable model, Black race was associated with increased risk of death in the preintervention period (RR 1.41, 95% CI 1.02-1.94), but this association was not present in the intervention period. Patients of color also saw significantly more improvement in early antibiotic administration during the intervention period than White patients.</p><p><strong>Conclusions: </strong>An order set-driven sepsis initiative was not associated with overall improved mortality but was associated with decreased racial disparities in sepsis mortality and early antibiotics.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":3.4,"publicationDate":"2025-01-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142930053","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Trends in dexamethasone treatment for asthma in U.S. emergency departments.","authors":"Daniel J Shapiro, Eric R Coon, Sunitha V Kaiser, Jacqueline Grupp-Phelan, Adam L Hersh, Naomi S Bardach","doi":"10.1111/acem.14997","DOIUrl":"10.1111/acem.14997","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"91-93"},"PeriodicalIF":3.4,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142046078","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Response to Letter to the Editor.","authors":"Elin Moltubak, Kalle Landerholm, Marie Blomberg, Roland E Andersson","doi":"10.1111/acem.15036","DOIUrl":"10.1111/acem.15036","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"106"},"PeriodicalIF":3.4,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142455481","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"SQuID (subcutaneous insulin in diabetic ketoacidosis) II: Clinical and operational effectiveness.","authors":"Richard T Griffey, Ryan M Schneider, Margo Girardi, Gina LaRossa, Julianne Yeary, Michael Lehmkuhl, Laura Frawley, Rachel Ancona, Taylor Kaser, Dan Suarez, Paulina Cruz-Bravo","doi":"10.1111/acem.15020","DOIUrl":"10.1111/acem.15020","url":null,"abstract":"<p><strong>Objective: </strong>We previously demonstrated safe treatment of low- to moderate-severity (LTM) diabetic ketoacidosis (DKA) using the SQuID protocol (subcutaneous insulin in DKA) in a non-intensive care unit (ICU) observation setting, with decreased emergency department length of stay (EDLOS). Here, we expand eligibility to include sicker patients and admission to a regular medical floor and collected more detailed clinical data in a near-real-time fashion.</p><p><strong>Methods: </strong>This is a real-world, prospective, observational cohort study in an urban academic hospital (March 4, 2023-March 4, 2024). LTM DKA patients were treated with IV insulin (floor or ICU) or on SQuID. We compare fidelity (time to glargine and dextrose-containing fluids), safety (rescue dextrose for hypoglycemia), effectiveness (time to anion gap closure, time on protocol), and operational efficiency (time to bed request, EDLOS, and ICU admission rate since implementation of the protocol).</p><p><strong>Results: </strong>Of 84 patients with LTM DKA, 62 (74%) of were treated with SQuID and 22 (26%) with IV insulin. Fidelity was high in both groups. Rescue dextrose was required in five (8%) versus four (18%) patients, respectively (difference 9%, -31% to 10%). Compared to the IV insulin group, time to anion gap was 1.4 h shorter (95% CI -3.4 to 0.2 h) and time on protocol was 10.4 h shorter (95% CI -22.3 to -5.0 h) in SQuID patients. Median EDLOS was lower in the SQuID cohort 9.8 h (IQR 6.0-13.6) than the IV floor cohort 18.3 h (IQR 13.4-22.0 h), but longer than the overall IV insulin cohort. Since inception of SQuID, ICU admission rate in LTM DKA has decreased from 54% to under 21%.</p><p><strong>Conclusions: </strong>In this single-center study, we observed excellent fidelity, equivalent or superior safety, and clinical and operational effectiveness with SQuID compared to IV insulin. The SQuID protocol has become the de facto default pathway for treatment of LTM DKA. Since inception of SQuID, ICU admissions in LTM DKA have decreased 33%.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"61-71"},"PeriodicalIF":3.4,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142278707","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}