BMC Emergency Medicine最新文献

Background and objective: Patients in the emergency department (ED) are assessed and treated by the ED-Team consisting of nurses and physicians. The clinical assessment (CA) of emergency patients and the clinical reasoning (CR) of both professions play a decisive role in determining the quality of emergency care. This pilot study explores CR in daily routine practice of the ED on a cognitive-individual level, relying on the Dual-process Theory and on a social-interprofessional level, arguing interprofessional collaboration (IPC) as a part of CR. At least, organizational-structural factors influencing CR are analyzed as a third level.

Methods: This is a qualitative study of 13 semi-structured individual interviews with nurses and physicians from three EDs in Germany, analysed using content analysis and methodological fundation.

Results: In the individual-cognitive CR, both physicians and nurses groups identified similar key factors for CA and used Systems 1 and 2 of the Dual-process Theory in their CR. On the social-interprofessional level, IPC was generally described positively, naming characteristics of good IPC and communication barriers were reported as rare. As possible organizational-structural factors influencing CR working experience as a prerequisite, size and region of the ED, age structure of the team and digitization were found.

Conclusion: This pilot study provides insights into the CR of nurses and physicians in the ED and analyzes CR on an individual-cognitive, a social-interprofessional and an organizational-structural level, allowing to conclusions regarding the prerequisites for successful ED-teams.

Background: Critically ill non-trauma patients treated in the emergency department have a high risk of in-hospital mortality. While point-of-care diagnostics such as blood gas analysis are established tools for urgent management, data on their prognostic value in this specific patient cohort remain limited. This study aimed to evaluate whether initial blood gas parameters are independently associated with in-hospital mortality in critically ill non-trauma patients.

Methods: This retrospective cohort study included adult critically ill non-trauma patients treated in the emergency department of a German university hospital. Initial blood gas parameters and clinical data were analyzed using univariate and multivariable logistic regression to assess their association with in-hospital mortality.

Results: Of 879 screened patients, 542 met the inclusion criteria. In-hospital mortality was 20% (n = 110). In addition to older age and out-of-hospital cardiac arrest, anemia (hemoglobin < 12 g/dL; OR of 2.07, 95% CI 1.20-3.58; p = 0.009), acidosis (pH < 7.35; OR 2.26, 95% CI 1.09-4.95; p = 0.033) and hypobicarbonatemia (< 22 mmol/L; OR 2.79, 95% CI 1.42-5.69; p = 0.004) were independently associated with in-hospital mortality. The association for hyperlactatemia was borderline (> 2.2 mmol/L; OR 1.85, 95% CI 0.93-3.77; p = 0.08). Multivariate analysis did not reveal significant associations between other electrolyte imbalances and in-hospital mortality in this cohort.

Conclusion: In this retrospective cohort, the presence of anemia, acidosis or hypobicarbonatemia on admission to the resuscitation room were independently associated with an elevated risk of in-hospital mortality in critically ill non-trauma patients. These readily available point-of-care parameters may support early risk stratification. Prospective studies are needed to validate these findings.

Background: Mass casualty incidents (MCIs) pose substantial challenges to prehospital emergency medical systems due to limited resources and the need for rapid prioritization. Evidence regarding the impact of routine civilian MCIs on the management and outcomes of severely injured patients remains limited. This study aimed to evaluate the influence of MCIs on prehospital care, transport strategies, and clinical outcomes compared with routine individual care.

Methods: Data from the TraumaRegister DGU^® were analysed for patients treated in Germany between mid-2020 and 2023. Patients with severe trauma (Maximum Abbreviated Injury Scale; MAIS ≥ 3) were included. Mass casualty incident cases were identified based on registry documentation. A 1:4 matched cohort was performed using age group, injury pattern and traffic involvement as matching criteria. The primary endpoint was in-hospital mortality; secondary endpoints included prehospital time intervals, performed interventions, and transport strategies. An additional multivariable logistic regression was performed as a sensitivity analysis of the primary endpoint.

Results: A total of 65,152 patients were included, of whom 430 were treated during mass casualty incidents (MCIs). After matching, 423 MCI patients were compared with 1,692 controls. Patients treated during MCIs had slightly higher injury severity (Injury Severity Score (ISS) 24.8 vs. 20.3). Median total prehospital time was significantly longer in the MCI group (85 [IQR 67-100] vs. 67 [IQR 53-83] minutes; p < 0.001). Invasive interventions, including prehospital intubation (33.6% vs. 20.9%) and administration of tranexamic acid (32.1% vs. 15.0%) were more frequently performed in the MCI group. Helicopter emergency medical services (HEMS) transport was used more frequently (34.5% vs. 20.7%). In the matched cohort, in-hospital mortality did not differ significantly between groups (13.5% vs. 11.7%; p = 0.317). In an additional multivariable sensitivity analysis, MCI status was not significantly associated with in-hospital mortality (adjusted OR 1.19, 95% CI 0.77-1.85).

Conclusion: Mass casualty incidents (MCIs) were associated with prolonged prehospital care and modified transport strategies. No statistically significant difference in in-hospital mortality was observed between MCI patients and matched controls. These findings describe outcomes among severely injured patients captured by the TraumaRegister DGU^® but should be interpreted in light of residual confounding and the observational study design.

Background: Head, face, and neck injuries impose a substantial burden for emergency departments (ED); the mechanisms driving them across the life course however remain poorly understood at the population level. Large-scale, integrated analysis spanning anatomical regions, injury mechanisms, age groups, settings, and associated products or environmental surfaces offers an opportunity to identify the patterns and vulnerable populations that smaller or shorter-term studies cannot resolve.

Methods: We queried National Electronic Injury Surveillance System (NEISS) records from 2006 to 2025 for injuries to the head, face, eyes, mouth, neck, or ears. Demographics, anatomical region, injury setting, associated products or environmental surfaces, and ED disposition were extracted, and a rule-based narrative classifier assigned 1 of 17 injury mechanisms from free-text descriptions. Non-routine ED disposition was defined as admission, transfer, observation, or fatality. Analyses were descriptive and based on unweighted NEISS case records.

Results: Among 2,345,287 ED presentations, representing 31.8% of all NEISS-coded visits, the head was most often injured (51.2%), followed by the face (28.2%). Annual volume rose 35.2% (105,727 in 2006 to 142,918 in 2025), driven mainly by head injuries (+ 83.4%). Median age was 14 years and 56.4% of patients were male, but among older adults (≥ 65 years), females predominated (60.6%). Falls were the leading mechanism (53.0% across subcategories). Most patients were treated and discharged (89.4%) and admission rate rose roughly 18-fold from toddlers (1.3%) to older adults (23.3%). Non-routine ED disposition increased with age, and syncope- or medical-related falls had the highest non-routine ED disposition rate (33.9%). The home was the most common injury setting (63.1%). Injury exposures varied by age group, with beds most common in infants, tables in toddlers, sports equipment in children and adolescents, and floors in older adults.

Conclusions: Head, face, and neck injuries represent a large and growing share of NEISS-coded ED presentations, with distinct patterns by age, sex, injury mechanism, setting, and clinical outcome. These findings may assist in the planning of targeted prevention strategies and future research on risk stratification for vulnerable age groups and injury mechanisms.

Background: Mass gatherings such as the Munich Oktoberfest increase demand on Emergency Medical Services (EMS), particularly for trauma patients requiring imaging. Suspected mild traumatic brain injury (mTBI) often necessitates hospital referral and diagnostic imaging, placing strain on prehospital and hospital resources.

Methods: This retrospective observational before-after study evaluated the impact of an on-site mobile computed tomography (CT) scanner deployed during the Oktoberfest in 2022 and 2023. Patients with suspected head, facial, or cervical spine trauma requiring CT imaging were included. EMS hospital transport data during these events (with mobile CT) were compared with a historical reference period from 2015 to 2019 (without mobile CT) and with matched pre- and post-event periods. Standardized prehospital protocols guided patient assessment and imaging decisions.

Results: A total of 498 patients underwent on-site CT imaging. Of these, 429 (86%) were treated on-site and discharged after imaging and clinical evaluation, while 52 (10%) required hospital transport based on CT findings. Additional transports occurred for unrelated medical issues. On-site CT availability prevented 429 EMS transports, corresponding to an estimated 22,737 min of EMS deployment time. Trauma-related hospital admissions during Oktoberfest were lower in 2022-2023 than in 2015-2019, and the relative increase in admissions during the event was reduced.

Conclusion: This retrospective analysis of the use of a mobile CT scanner in a prehospital setting during a mass gathering found that its implementation was associated with improved patient triage, fewer hospital transports, and more efficient EMS resource utilization. While the retrospective before-after study design does not permit direct causal inference, on-site imaging may have contributed to more targeted patient management and reduced demand on hospital resources. These findings suggest that mobile CT could represent a useful model for supporting medical services at large-scale public events and warrant further prospective evaluation.

Background: Although continuous noradrenaline infusion (CNI) is standard vasopressor therapy during the initial resuscitation of patients with septic shock, hemodynamic stabilization may not be immediate. Push-dose noradrenaline (PDNA) has been proposed as a temporary measure while CNI is being established. However, its clinical use, dosing, early hemodynamic response, and short-term safety in the emergency department (ED) are not well described.

Methods: To address this gap, we conducted a single-center retrospective descriptive study at a tertiary care hospital in Japan in 2019. Adults with Sepsis-3 septic shock who received PDNA in the ED and were admitted to the intensive care unit were included. We assessed the context and dosing of PDNA administration, CNI use, mean arterial pressure (MAP) within 15 min after PDNA administration, and adverse events.

Results: Of 91 patients with septic shock, 50 (55%) received PDNA. PDNA was administered at CNI initiation in 25 patients, during CNI dose escalation in 6, and as rescue administration before CNI initiation in 19. The median (interquartile range [IQR]) initial PDNA dose was 20 (20-30) µg. During the 15-minute observation window, 32 (64%) patients received one bolus, 14 (28%) received two, 3 (6%) received three, and 1 (2%) received four. The directly observed median (IQR) MAP was 52 (44-61) mmHg at initial PDNA administration (n = 30) and 62 (50-68) mmHg 1 min later (n = 25). One of 36 patients evaluable for prespecified physiological adverse events experienced an adverse event; however, no serious adverse events were documented.

Conclusions: In this single-center retrospective descriptive study, PDNA was most commonly administered at CNI initiation, and administration was followed by an early increase in median MAP. However, the noncomparative design and concurrent resuscitative interventions preclude attribution of this change solely to PDNA administration. No serious adverse events were documented; however, safety assessment was limited owing to missing data and retrospective ascertainment. These findings do not establish the effectiveness or safety of PDNA. Prospective comparative studies with standardized monitoring are required.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) is a time-critical intervention for selected patients with refractory cardiac arrest. Survival depends on minimizing low-flow duration before ECPR initiation. Timely deployment requires organizational preparedness, trained personnel, and rapid extracorporeal membrane oxygenation (ECMO) circuit readiness. However, data on ECPR organization in centers operating without dedicated perfusionist support are limited.

Methods: A nationwide cross-sectional online survey was conducted among German ECMO centers operating without perfusionist support. The questionnaire assessed circuit readiness, responsible personnel, training frequency, and the availability of standard operating procedures (SOPs).

Results: Responses from 42 centers were evaluated, of which 64% reported performing ECPR (n = 27). Most centers (90%, n = 38) had low annual ECMO volumes (< 50 cases). ECMO use was largely limited to the Cardiohelp and iLA activve/Xenios Console systems. Setup times were significantly shorter for ECPR than for non-ECPR ECMO: median 15 min (IQR 12-18; range 5-30) versus 30 min (IQR 20-40; range 15-105) (Mann-Whitney U = 46, p < 0.0001; Cliff's delta = 0.77; 95% CI 0.54-0.94). Nurses were more frequently involved in ECMO deployment in ECPR than in non-ECPR settings (59% (16/27 centers) vs. 20% (3/15 centers)). Within ECPR programs, regular training was reported more frequently for nurses than for physicians (87.5% (14/16 centers) vs. 60% (6/10 centers)). Overall, 76% (n = 32) of centers reported regular training (at least annually) for responsible personnel, 86% (n = 36) had internal SOPs in place, and 69% (n = 29) expressed the need for a universally applicable evidence-based SOP. All centers that reported a pre-defined maximum storage duration (n = 28) adhered to the Extracorporeal Life Support Organization guidelines regarding maximum storage duration of pre-assembled ECMO systems (30 days).

Conclusions: German ECMO centers without perfusionist support reported substantial heterogeneity in ECPR readiness and operational workflows. ECPR-performing centers were associated with shorter setup times and more frequently reported interdisciplinary team structures and recurrent team training. These findings describe current organizational practices and perceived needs and support the value of interdisciplinary teamwork, structured training, and standardized protocols as organizational components that may facilitate timely, standardized ECPR deployment.

Background: The 2021 European Society of Cardiology (ESC) guidelines classify acute heart failure (AHF) into four phenotypes: acute decompensated heart failure (ADHF), acute pulmonary oedema (APO), isolated right ventricular failure (IRVF), and cardiogenic shock (CS). However, differences in clinical characteristics and long-term outcomes among these phenotypes in the emergency department (ED) remain unclear. This study aimed to evaluate their characteristics and prognostic implications in the ED setting.

Methods: In this prospective-retrospective observational real-world study, adults presenting with AHF in the ED were consecutively enrolled and categorized according to ESC-defined phenotypes. The study endpoints were 1-year all-cause and cardiovascular mortality. Associations between phenotypes and mortality were assessed using Cox regression models with progressive adjustment.

Results: A total of 2,960 patients were included. Clinical characteristics and treatment patterns differed substantially across phenotypes. The 1-year all-cause mortality rates were 10.3% in ADHF, 11.0% in APO, 24.5% in IRVF, and 58.7% in CS (P < 0.001). In multivariable Cox analyses adjusting for clinical variables and treatments, IRVF remained independently associated with increased risks of all-cause mortality (HR 1.92, 95% CI 1.02-3.63; P = 0.044) and cardiovascular mortality (HR 2.22, 95% CI 1.10-4.48; P = 0.027). CS was also independently associated with higher risks of all-cause mortality (HR 2.22, 95% CI 1.34-3.67; P = 0.002) and cardiovascular mortality (HR 2.71, 95% CI 1.57-4.66; P < 0.001).

Conclusions: In this ED-based AHF cohort, IRVF and CS were independently associated with worse 1-year outcomes, supporting phenotype-based risk stratification in the ED.