The latest medical research on Emergency Medicine

The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about emergency medicine gathered by our medical AI research bot.

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Cardiac Dysfunction in Severely Burned Patients: Current Understanding of Etiology, Pathophysiology and Treatment.

Shock

Patients that experience severe burn injuries face a massive inflammatory response resulting in hemodynamic and cardiovascular complications. Even ...

Hemophagocytic Lymphohistiocytosis in Critically Ill Patients.

Shock

The study was registered with www.ClinicalTrials.gov (NCT02854943) on August 1, 2016.

For the purpose of this retrospective observational study, we searched for suspected and diagnosed adult HLH of all patients admitted to at least one adult surgical, anesthesiological or medical ICU between January 2006 and August 2018 at the university hospital Charité - Universitätsmedizin Berlin. All cases were reviewed by two HLH experts, who confirmed or declined the diagnosis.

Of 6340 ICU patients with ferritin measurement, 40 suffered from HLH (0.63%). Of these, in-hospital mortality was 60.0% over all cases, which was highest in malignancy-associated HLH (71.4%). Infections were identified as most common triggers (42.5%). A variety of 19 different treatment strategies were applied. Non-survivors showed higher ferritin at diagnosis compared to survivors (p = 0.021), which was also seen in multivariable analyses. A minimum ferritin of 4083 μg/L after diagnosis was most predictive for 30-day mortality (AUC 0.888, 95% CI 0.771-1.000; sensitivity 93.8%, specificity 78.9%).

Mortality in adult HLH patients in the ICU is high, particularly in malignancy-associated HLH. Infections are the most frequent HLH triggers in critically ill patients. At present, there is no standardized treatment for HLH in adult patients available. Assessment of ferritin is valuable for diagnosis, prognosis, and treatment monitoring.

Neonatal Sepsis Alters the Excitability of Regular Spiking Cells in the Nucleus of the Solitary Tract in Rats.

Shock

Sepsis is a leading cause of mortality and morbidity in infants. Although the measures of autonomic dysfunction (e.g. reduced heart rate variability) predict mortality in sepsis, the mechanism of sepsis-induced autonomic dysfunction has remained elusive. The nucleus of the solitary tract hjh(NTS) is a vital structure for the integrated autonomic response to physiological challenges. In the present study we hypothesized that sepsis alters the excitability of NTS neurons in a rat model of neonatal sepsis (14-day old rats).

Sepsis was induced by intraperitoneal injection of cecal slurry (CS) in rat neonates. The presence of autonomic dysfunction was confirmed by observing a significant reduction in both short-term and long-term heart rate variably following CS injection. We investigated the effect of polymicrobial sepsis on the electrophysiological properties of the medial NTS neurons using a whole cell patch clamp recording. Our results showed that the resting membrane potential in regular spiking neurons was significantly less polarized in the septic group (-37.6 ± 1.76 mv) when compared with the control group (-54.7 ± 1.73 mv, P < 0.001). The number of spontaneous action potentials in the septic group, was also significantly higher than the control group (P < 0.05). In addition, the frequency and amplitude of the spontaneous excitatory post synaptic potentials (EPSPs) was significantly higher in neurons recorded in the septic group (P < 0.001). Interestingly, regular spiking cells in the CS group exhibited a rebound action potential following hyperpolarization. Injection of depolarizing currents was associated with lower first spike latency and changes in rise slope of action potential (P < 0.001).

We showed that polymicrobial sepsis increases the excitability of regular spiking cells in the medial NTS. These alterations can potentially affect neural coding and thus may contribute to an abnormal homeostatic or allostatic physiological response to sepsis and systemic inflammation.

Genistein Protects Against Burn-Induced Myocardial Injury via Notch1 Mediated Suppression of Oxidative/Nitrative Stress.

Shock

Genistein (Gen) exhibits strong anti-oxidative/anti-nitrative activity and cardioprotective effects in several models; however, its role in burn-in...

Overexpression of BCL-2 in the Intestinal Epithelium Prevents Sepsis-Induced Gut Barrier Function Via Altering Tight Junction Protein Expression.

Shock

Sepsis induces both intestinal hyperpermeability and epithelial apoptosis. While each has been implicated in mediating sepsis mortality, the relati...

Cardiac and Skeletal Muscle Myosin Exert Procoagulant Effects.

Shock

Trauma-induced coagulopathy (TIC) and the tissue injury-provoked procoagulant profile are prevalent in severely injured patients, but their mechanisms remain unclear. Myosin, exposed by or released from tissue injury, may play a role in promoting thrombin generation and attenuating fibrinolysis. The objective of the study is to examine the effects of cardiac and skeletal muscle myosins on coagulation in whole blood using thrombelastography (TEG).

Whole blood was collected from healthy adult volunteers (n=8) and native TEGs were performed to evaluate the global coagulation response in the presence of cardiac or skeletal muscle myosin by measuring reaction (R) time (minutes), clot angle (), and maximum amplitude (MA, mm). TEG measurements were compared using paired t tests.

Cardiac and skeletal muscle myosins decreased R, from 10.8 min to 8.0 min (P<0.0001) and 6.9 min (P =0.0007), respectively. There were no effects observed on clot propagation (angle) or clot strength (MA) with myosin addition. In the presence of tPA, both cardiac and skeletal muscle myosins shortened R from 11.1 min to 8.62 min (P=0.0245) and 7.75 min (P =0.0027), respectively), with no changes on angle or MA.

Cardiac and skeletal muscle myosins exhibit procoagulant effects in TEG assays. These whole blood TEG results support the hypothesis that cardiac and skeletal muscle myosins may be either pro-hemostatic or prothrombotic depending on context.

Sex without contraceptives in a multi-center study of adolescent emergency department patients.

Academic Emergency Medicine

In the United States (US), rates of teenage pregnancy and sexually transmitted infections (STI) remain exceptionally high and racial and ethnic disparities persist. Emergency departments (ED) care for over 19 million adolescents each year, the majority being minority and low socioeconomic status. Single-center studies demonstrate infrequent use of contraceptives among adolescent ED patients and an association between risky sex and behaviors such as alcohol and drug use; however, no multi-center ED data exist. The objective of this study was to (1) determine the prevalence of sex without contraceptives in a large multi-center adolescent ED study and (2) assess patient demographic and risky behaviors associated with sex without contraceptives.

Participants aged 14-17 (n=3247) in 16 pediatric EDs across the US completed an electronic survey. Questions focused on validated measures of risky sex, use of alcohol, tobacco, marijuana and other drugs, as well as depression and violence. In this secondary analysis, we constructed univariable and multivariable models to identify demographic and behavioral factors associated with sex without contraceptives (our primary outcome), separately for adolescent males and females.

In the prior year, 17.4% (236/1356) of males and 15.8% (299/1891) of females had sex without contraceptives. In the multivariable model, sex without contraceptives for both genders was more likely among teens who were black, with conduct problems and participated in casual sex, binge drinking, or cannabis use. Sex without contraceptives was also more likely among Hispanic and cigarette smoking males, as well as depressed females.

Adolescent ED patients across the US are participating in risky sexual behaviors that increase their likelihood of pregnancy and STI acquisition. These adolescents report a number of problem behaviors, including substance use, which are strongly correlated with unprotected sex. The ED visit may be an opportunity to identify at-risk adolescent patients, address risky behaviors, and intervene to improve adolescent health.

Patiromer for Treatment of Hyperkalemia in the Emergency Department: A Pilot Study.

Academic Emergency Medicine

Hyperkalemia is common and potentially life threatening. Patiromer is a Food and Drrug Administration (FDA) cleared oral potassium binder effective in the chronic treatment of hyperkalemia.

To investigate the potential efficacy and safety of oral patiromer in treating acute hyperkalemia in the ED.

This is a single-center, randomized, open label convenience sample pilot study in an inner-city emergency department. Adult patients with end-stage renal disease (ESRD) and a serum potassium ≥6.0 mEq/L were randomized to standard of care (SOC) or one dose of 25.2g oral patiromer plus SOC (PAT). Blood samples and electrocardiograms (ECGs) were collected at enrollment and at 1, 2, 4, and 6hrs thereafter. The primary outcome was the difference in potassium between groups at 6 hours. Secondary outcomes were the amount and number of times insulin and albuterol were given.

Thirty patients were included in the final analysis; 15 in each group. There were no differences in age, sex, or baseline serum potassium. There was no difference in mean serum potassium between SOC and PAT groups at 6hrs (6.32 CI: 6.0, 6.63 vs. 5.81 CI: 5.48, 6.14). However, 2 hours post treatment the serum potassium of the PAT group was lower than SOC group (5.90mEq/L, CI: 5.63, 6.17 vs. 6.51mE/L, CI: 6.25, 6.78) and also 0.61 mEq/L lower than basline. There were no differences in the amount or number of administrations of insulin or albuterol between groups, although the amount of albuterol used in the PAT group at 6 hours was lower but not significant (median 12.5 vs. 0 mg; p=0.097). There were no differences in adverse events between groups.

In this open label pilot study of severe hyperkalemia, a single dose of 25.2g of oral patiromer reduced serum potassium within 2 hours but did not show a difference at 6 hours. This is the first study showing patiromer may have a role in the acute management of hyperkalemia; however more rigorous studies are needed.

When a health policy cuts both ways: Impact of the National Emergency Access Target policy on staff and emergency department performance.

EMA - Emergency Medicine Australasia

To explore the impact of the Four-Hour Rule/National Emergency Access Target (4HR/NEAT) on staff and ED performance.

A mixed-methods study design was used to link performance data from 16 participating hospitals with the experiences reported by 119 ED staff during policy implementation. Quantitative and qualitative measures were triangulated to identify the staff and organisational effects on hospital performance. An overall score was developed to categorise hospitals into: high, moderate and low performers, then compared with four qualitative themes: social factors, ED management, ED outcomes and 4HR/NEAT compliance.

Key factors identified were stress and morale; intergroup dynamics; interaction with patients; resource management; education and training; financial incentives; impact on quality and safety; perceived improvements on access block and overcrowding. High performing hospitals reported increased stress and decreased morale, decreased staff-patient communication and staff shortages; significant changes in ED management and effective use of the whole-of-hospital approach. Moderate performing hospitals reported similar characteristics to a lesser degree, and the perception that 4HR/NEAT did not impact ED practice. Low performing hospitals also reported increased stress and low morale and a less effective whole-of-hospital approach. ED staff also reported a reduction in communication with patients.

There was strong evidence of an association between high stress and low morale and the implementation of the 4HR/NEAT across all levels of performance. These adverse consequences of the 4HR/NEAT implementation indicate that a more nuanced approach to efficiency improvements is required. This would balance processes measured by 4HR/NEAT against a range of other clinical and organisational performance measures.

Initiation of vasopressor infusions via peripheral versus central access in patients with early septic shock: A retrospective cohort study.

EMA - Emergency Medicine Australasia

To assess whether the initiation of vasopressor infusions via peripheral venous catheters (PVC) compared to central venous catheters (CVC) in ED patients with early septic shock was associated with differences in processes of care and outcomes.

We conducted a post-hoc analysis of the ARISE trial. We compared participants who had a vasopressor infusion first commenced via a PVC versus a CVC. The primary outcome was 90 day mortality.

We studied 937 participants. Of these, 389 (42%) had early vasopressor infusion commenced via a PVC and 548 (58%) via a CVC. Trial participants who received a vasopressor infusion via a PVC were more severely ill, with higher median (interquartile range [IQR]) Acute Physiology And Chronic Health Evaluation (APACHE II) scores (17 [13-23] versus 16 [12-21], P = 0.003), and higher median (IQR) lactate (mmol/L) (3.6 [1.9-5.8] versus 2.5 [1.5-4.5], P < 0.001). After adjusting for baseline covariates, the estimated odds ratio for mortality for PVC-treated patients was 1.26 (95% confidence interval 0.95-1.67, P = 0.11). Trial participants who had vasopressors commenced via PVC had a shorter median (IQR) time to commencement of antimicrobials (55 [32-96] versus 71.5 [39-119] min, P < 0.001) and a shorter median (IQR) time to commencement of vasopressors (2.4 [1.3-3.9] versus 4.9 [3.5-6.6] h, P < 0.001).

The practice of commencing a vasopressor infusion via a PVC was common in the ARISE trial and more frequent in trial participants with higher severity of illness. Commencement of a vasopressor infusion via a PVC was associated with some improvements in processes of care and, after adjustment, was not associated with an increased risk of death.

Limitation of treatment in prehospital care - the experiences of helicopter emergency medical service physicians in a nationwide multicentre survey.

Scandinavian Journal of

Making ethically sound treatment limitations in prehospital care is a complex topic. Helicopter Emergency Medical Service (HEMS) physicians were surveyed on their experiences with limitations of care orders in the prehospital setting, including situations where they are dispatched to healthcare facilities or nursing homes.

A nationwide multicentre study was conducted among all HEMS physicians in Finland in 2017 using a questionnaire with closed five-point Likert-scale questions and open questions. The Ethics Committee of the Tampere University Hospital approved the study protocol (R15048).

Fifty-nine (88%) physicians responded. Their median age was 43 (IQR 38-47) and median medical working experience was 15 (IQR 10-20) years. All respondents made limitation of care orders and 39% made them often. Three fourths (75%) of the physicians were often dispatched to healthcare facilities and nursing homes and the majority (93%) regularly met patients who should have already had a valid limitation of care order. Every other physician (49%) had sometimes decided not to implement a medically justifiable limitation of care order because they wanted to avoid conflicts with the patient and/or the next of kin and/or other healthcare staff. Limitation of care order practices varied between the respondents, but neither age nor working experience explained these differences in answers. Most physicians (85%) stated that limitations of care orders are part of their work and 81% did not find them especially burdensome. The most challenging patient groups for treatment limitations were the under-aged patients, the severely disabled patients and the patients in healthcare facilities or residing in nursing homes.

Making limitation of care orders is an important but often invisible part of a HEMS physician's work. HEMS physicians expressed that patients in long-term care were often without limitations of care orders in situations where an order would have been ethically in accordance with the patient's best interests.

Impact of the primary contact physiotherapy practitioner role on emergency department care for patients with musculoskeletal injuries in New South Wales.

EMA - Emergency Medicine Australasia

To determine the impact of the emergency physiotherapy service provided through different models of care on service quality indicators, patient flow, staff and patient satisfaction.

A mixed method prospective observation study was conducted between September 2014 and April 2015 in 19 EDs where a physiotherapy service is provided.

Patients seen by the primary contact physiotherapist (PCP) were associated with a significant reduction in ED length of stay by 108 min, wait time to treatment by 10 min (n = 4 EDs) and time-to-first analgesia by 18 min (n = 19 EDs) compared to those seen through usual care processes. Patients who received care by a doctor first and then physiotherapist (secondary contact model) had a prolonged length of stay compared to other care pathways. High levels of satisfaction with the PCP role were expressed by ED staff (n = 17 EDs) and patients (n = 19 EDs). More than 95% of patients who received care by PCP were satisfied with the management of their condition, understood the advice and discharge information provided and had enough time to ask questions.

ED implementation of the PCP model may improve patient flow and efficiency of clinical skill utilisation in a complex, high demand workplace.