Emergency Medicine Journal最新文献

Background: In rural settings, women with ST-elevation myocardial infarction (STEMI) are less likely to receive timely reperfusion than men. We explore factors that may impact time to reperfusion by sex for patients with STEMI.

Methods: We conducted a cohort study of adults with STEMI activations from 2016 to 2020 using regional North Carolina STEMI registry data, which included eight rural emergency medical services (EMS) agencies and three percutaneous coronary intervention (PCI) centres. The primary outcome was EMS first medical contact to PCI in ≤90 min. By sex, we evaluated prehospital time intervals (dispatch, response, time-to-ECG, catheterisation laboratory activation, on-scene, transport and total EMS) and door-to-balloon time with clustered Wilcoxon rank-sum tests. We also evaluated agency and patient factors associated with timely reperfusion using generalised estimating equations.

Results: Of the 365 patients included, 30.1% (110/365) were female with a mean age of 62.5±12.7. Fewer women received PCI within 90 min compared with men (43.6% vs 67.8%, p<0.001). Women also experienced significantly longer total EMS time (42.5 vs 40.0 min, p=0.049) and door-to-balloon time (48.5 vs 40.0 min, p=0.01). Other time intervals were similar. After adjustment, women without exertional symptoms, with diabetes or with hypercholesterolaemia had lower odds of timely reperfusion. Among men, lower odds of timely reperfusion were observed among those without pain, who had catheterisation lab activation between 17:00 and 07:00, who were older or who had farther transport.

Conclusion: In rural settings, women without exertional chest pain and those with comorbid conditions were less likely to have timely reperfusion. Women experienced significantly longer total EMS time and door-to-balloon time than men.

A short systematic review assessed the diagnostic accuracy of malaria rapid diagnostic tests in febrile adults from malaria-endemic regions. A database search of MEDLINE, EMBASE, Cochrane and Google Scholar returned 138 papers. Six papers met the inclusion criteria and were included in our analysis.

Purpose: To evaluate the diagnostic accuracy of high-sensitivity point-of-care (hs-POC) cardiac troponin algorithms for rule-out and rule-in of acute myocardial infarction (AMI) in emergency departments.

Methods: This PROSPERO-registered systematic review (CRD420251170970) searched MEDLINE, CENTRAL and trial registries (2005-2025) for studies evaluating serial hs-POC troponin testing (0 hour/1 hour or 0 hour/2 hour algorithms) in adults with suspected AMI. Primary outcomes were sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.

Results: Eight studies (19 datasets; 9384 patients; 1157 AMI cases) evaluated four hs-POC platforms: Siemens Atellica VTLi, PHC Pathfast, QuidelOrtho TriageTrue and BioMérieux SPINCHIP. Rule-out algorithms achieved pooled sensitivity 98.0% (95% CI 96.0% to 99.0%) and NPV 99.9% at an assumed AMI prevalence of 10%, with no additional missed AMI events reported during follow-up among patients classified as rule-out. Rule-in algorithms achieved specificity 96.0% (94.0% to 97.0%) and PPV 68.5% assuming a disease prevalence of 10%. Complex multiparametric algorithms showed higher pooled sensitivity (99.3%, I²=0%) than simple cut-off approaches (96.9%). The 0 hour/1 hour protocol showed similar diagnostic accuracy to 0 hour/2 hour while potentially allowing clinical decisions approximately 1 hour earlier. All four evaluated platforms achieved rule-out sensitivities ≥97%. All evaluated platforms met contemporary high-sensitivity analytical criteria and reported turnaround times of 8-17 min enabling rapid clinical decision-making and high diagnostic accuracy for both rule-out and rule-in applications. Overall risk of bias was low in 75% of datasets.

Conclusions: hs-POC troponin algorithms demonstrated high diagnostic accuracy for both rule-out and rule-in of AMI. Validated serial testing pathways, including 0 hour/1 hour and 0 hour/2 hour strategies, showed favourable diagnostic performance across evaluated platforms. Further implementation studies are needed to define their impact on emergency department workflow and patient outcomes.

Prospero registration number: CRD420251170970.

Background: Communication in a family's primary language can support safe care. Vital steps within the care delivery process are contingent on successful communication, including reporting symptoms, clinical decision-making, informed consent, discharge communication and follow-up coordination. The importance of effective information exchange is particularly pronounced in paediatric emergency care, and complex interactions may arise as parents or carers advocate on behalf of children. This scoping review aimed to identify and map existing research indicating where along the care journey communication-related risks for safety lie during paediatric emergency care and what strategies exist to mitigate them.

Methods: We searched MEDLINE, Embase, CINAHL, Scopus, Web of Science and Cochrane Library for studies which examined the influence of language barriers on patient safety in paediatric emergency care as well as studies that evaluated interventions. Bibliographic database searches were executed on 18 December 2024; retrieved records were independently screened by two authors at title and abstract level followed by full text level. Data on study objectives, population characteristics, study design and their key findings were extracted.

Results: 1578 articles were identified, of which 33 were included and mapped according to (i) studies reporting safety risks linked to language barriers in paediatric emergency care (n=24) and (ii) existing interventions designed to mitigate these risks (n=9). Studies highlighted that language barriers can influence safety at multiple stages of the emergency care pathway, with discharge most frequently reported as a point of risk for paediatric patient safety. Interventions focused primarily on usage, uptake and documentation of professional interpreter services.

Conclusion: Addressing misunderstandings around follow-up and home-care advice during medical safety netting are priority areas for intervention. Future research should involve carer and clinical perspectives in exploring whether technology-enabled tools, including artificial intelligence, can safely mitigate language barriers in these situations.

A short systematic review was undertaken to assess whether the use of non-supine positioning is associated with increased first-pass success in emergency department (ED) intubation. Medline, Embase and Google Scholar databases were searched. Six prospective studies were found, including two randomised trials. A positive association was demonstrated between patient angulation and first-pass success in three studies. These results support the protocolised use of inclined positioning for ED intubation.

Background: Acute kidney injury (AKI) is a frequent condition among patients presenting to the emergency department (ED). Obstructive AKI constitutes a urological emergency requiring rapid diagnosis and intervention. The objective of this study was to derive and internally validate a predictive model of obstructive AKI in ED.

Methods: We conducted a retrospective derivation and internal validation cohort study. Adult patients presenting to the EDs of Toulouse University Hospital with AKI of any Kidney Disease: Improving Global Outcomes (KDIGO) stage between 1 July and 31 December 2019 were eligible. Included patients were randomly assigned in a 2:1 ratio to a derivation cohort (DC) and an internal validation cohort (VC). The primary outcome was obstructive AKI, defined as hydronephrosis identified on imaging and requiring either urological intervention or Foley catheter insertion. A risk stratification decision tree was developed (Kidney Injury Tree For Identification of obSTructive Origin (KIT-FISTO) model).

Results: The prevalence of obstructive AKI was 9% in the DC (64/727) and 7% in the VC (27/364). Patients presenting with lumbar, flank or hypogastric pain were classified as 'high risk' in each cohort, with a corresponding obstructive AKI risk of 55% (95% CI 45% to 64%) and 54% (95% CI 39% to 69%), respectively. Patients without pain but with a history of urinary tract surgery, abdominal cancer, a solitary functional kidney or prostatic hyperplasia were classified as 'moderate risk', with obstructive AKI risks of 4% (95% CI 1% to 10%) and 2% (95% CI 0% to 12%), respectively. All remaining patients (>70%) were classified as 'low risk', with an observed obstructive AKI risk of 0% (95% CI 0% to 1%). 'Low risk' classification had a sensitivity of 98% (95% CI 92% to 100%) and 96% (95% CI 81% to 100%), respectively.

Conclusion: The KIT-FISTO was derived and internally validated to predict obstructive AKI in ED, but requires external and prospective validation before implementation.

Background: Blood cultures are frequently performed in febrile emergency department (ED) patients despite low yield and risks of contamination. Existing prediction tools are not usable at triage. The objective was to derive and internally validate a score for predicting bloodstream infection using variables assessable immediately after ED triage.

Methods: This observational retrospective cohort study was conducted in the two EDs of a University Hospital between 1 January and 31 December 2021. Adult patients for whom a blood culture was collected during ED visit were included. The primary endpoint was bloodstream infection. A multivariate analysis using backward stepwise logistic regression was performed to identify risk factors for bloodstream infection and derive the aGe, cOmplaint, Temperature and Hemodynamic for bloodstream Infection Classification (GOTHIC) score. Diagnostic accuracy of the score was evaluated in the derivation and validation cohorts.

Main results: 6740 visits were analysed, including 4493 patients in the derivation cohort and 2247 patients in the validation cohort. The prevalence of bloodstream infection was 11% (n=512) and 10% (n=234) in each cohort, respectively. The GOTHIC score included seven factors associated with bloodstream infection: age ≥75 years (OR=2.90; +1 point), tachycardia >90 beats per minute (OR=1.51; +1 point), systolic blood pressure <100 mm Hg (OR=1.90; +1 point), diastolic blood pressure <60 mmvHg (OR=1.41; +1 point), fever >38°C (OR=2.14; +1 point), isolated fever as chief complaint at triage (OR=1.62; +1 point) and protective chief complaint (dyspnoea, COVID-19 symptoms or vaso-occlusive crisis) (OR=0.47; -1 point).

Conclusion: We propose a simple risk score for bloodstream infection that can be easily calculated using seven variables assessable at triage.