World Journal of Emergency Medicine

Patient care during interfacility transport: a narrative review of managing diverse disease states

Quincy K. Tran, Francis O’Connell, Andrew Hakopian, Marwa SH Abrahim, Kamilla Beisenova, Ali Pourmand

2023, 14(1): 3-9. doi:10.5847/wjem.j.1920-8642.2023.009

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BACKGROUND: When critically ill patients require specialized treatment that exceeds the capability of the index hospitals, patients are frequently transferred to a tertiary or quaternary hospital for a higher level of care. Therefore, appropriate and efficient care for patients during the process of transport between two hospitals (interfacility transfer) is an essential part of patient care. While medical adverse events may occur during the interfacility transfer process, there have not been evidence-based guidelines regarding the equipment or the practice for patient care during transport.

METHODS: We conducted searches from the PubMed, Cumulative Index of Nursing and Allied Health (CINAHL), and Scopus databases up to June 2022. Two reviewers independently screened the titles and abstracts for eligibility. Studies that were not in the English language and did not involve critically ill patients were excluded.

RESULTS: The search identified 75 articles, and we included 48 studies for our narrative review. Most studies were observational studies.

CONCLUSION: The review provided the current evidence-based management of diverse disease states during the interfacility transfer process, such as proning positioning for respiratory failure, extracorporeal membrane oxygenation (ECMO), obstetric emergencies, and hypertensive emergencies (aortic dissection and spontaneous intracranial hemorrhage).

Endothelial cell metabolism in sepsis

Jue-xian Wei, Hui-lin Jiang, Xiao-hui Chen

2023, 14(1): 10-16. doi:10.5847/wjem.j.1920-8642.2023.019

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BACKGROUND: Endothelial dysfunction in sepsis is a pathophysiological feature of septic organ failure. Endothelial cells (ECs) exhibit specific metabolic traits and release metabolites to adapt to the septic state in the blood to maintain vascular homeostasis.

METHODS: Web of Science and PubMed were searched from inception to October 1, 2022. The search was limited to the English language only. Two reviewers independently identified studies related to EC metabolism in sepsis. The exclusion criteria were duplicate articles according to multiple search criteria.

RESULTS: Sixty articles were included, and most of them were cell and animal studies. These studies reported the role of glycolysis, oxidative phosphorylation, fatty acid metabolism, and amino acid metabolism in EC homeostasis. including glycolysis, oxidative phosphorylation, fatty acid metabolism and amino acid metabolism. However, dysregulation of EC metabolism can contribute to sepsis progression.

CONCLUSION: There are few clinical studies on EC metabolism in sepsis. Related research mainly focuses on basic research, but some scientific problems have also been clarified. Therefore, this review may provide an overall comprehension and novel aspects of EC metabolism in sepsis.

Nutritional status and prognostic factors for mortality in patients admitted to emergency department observation units: a national multi-center study in China

Hai-jiang Zhou, Dong-jing Zuo, Da Zhang, Xin-hua He, Shu-bin Guo

2023, 14(1): 17-24. doi:10.5847/wjem.j.1920-8642.2023.005

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BACKGROUND: Nutritional risk is common among patients admitted to the emergency department and is associated with adverse clinical outcomes. Despite its large population, few comprehensive studies have been conducted in China concerning the nutritional status of patients admitted to emergency department observation units (EDOUs).

METHODS: Patients admitted to EDOUs of 90 tertiary hospitals in China between June 2020 and December 2020 were enrolled. Demographic information, laboratory parameters, nutritional support therapies, and 28-day mortality were recorded. Risk factors for mortality were examined using multi-variate-adjusted logistic regression analysis. Receiver operating characteristic (ROC) curves for each predictor of mortality were plotted, and the area under the ROC (AUROC) curves was compared.

RESULTS: A total of 2,005 eligible patients were finally enrolled. At the 28-day follow-up, 1,911 patients survived, and 94 died. The group with a Nutritional Risk Screening 2002 (NRS 2002) score of 3-4 points was the largest (52.01%). The number of patients receiving oral nutritional supplements, enteral nutrition (EN), parenteral nutrition (PN), and the combination of EN and PN was 425, 314, 853, and 413, respectively. Among the total, 77.55% of patients had nutritional risk (NRS 2002 ≥3). The proportion of patients with high nutritional risk (NRS2002≥5) in the age group >80 years was significantly higher than that in the age group 66-80 years (29.00% vs. 23.93%, P=0.032), but not significantly higher than that in the age group 18-65 years (29.00% vs. 26.54%, P=0.449). Logistic regression analysis revealed that heart failure (odds ratio [OR] 1.856, 95% confidence interval [CI] 1.087-3.167, P=0.023), consciousness (OR 2.967, 95% CI1.894-4.648, P<0.001), Acute Physiology and Chronic Health Evaluation II (APACHE II) score (OR 1.037, 95% CI 1.017-1.058, P<0.001), NRS 2002 score (OR 1.286, 95% CI 1.115-1.483, P=0.001), and Mini Nutritional Assessment-Short Form score (OR 0.946, 95% CI 0.898-0.997, P=0.039) were all independent risk factors for 28-day mortality. APACHE II and NRS 2002 scores were superior to other predictors according to the comparison of AUROC.

CONCLUSIONS: Nutritional risk is prevalent among older patients in EDOUs in China. APACHE II and NRS 2002 scores are important risk factors for mortality in patients admitted to the EDOU. Timely and appropriate nutritional screening and support measures are critical to reduce patients’ length of hospital stay and mortality.

Prolonged dual antiplatelet therapy after drug-eluting stent implantation improves long-term prognosis for acute coronary syndrome: five-year results from a large cohort study

Jing-jing Xu, Si-da Jia, Lin Jiang, Ying Song, Pei Zhu, De-shan Yuan, Yi Yao, Xue-yan Zhao, Jian-xin Li, Yue-jin Yang, Shu-bin Qiao, Bo Xu, Run-lin Gao, Jin-qing Yuan

2023, 14(1): 25-30. doi:10.5847/wjem.j.1920-8642.2023.012

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BACKGROUND: To investigate the most appropriate dual antiplatelet therapy (DAPT) duration for patients with acute coronary syndrome (ACS) after drug-eluting stent (DES) implantation in the largest cardiovascular center of China.

METHODS: We enrolled 5,187 consecutive patients with ACS who received DES from January to December 2013. Patients were divided into four groups based on DAPT duration: standard DAPT group (11-13 months, n=1,568) and prolonged DAPT groups (13-18 months [n=308], 18-24 months [n=2,125], and >24 months [n=1,186]). Baseline characteristics and 5-year clinical outcomes were recorded.

RESULTS: Baseline characteristics were similar across the four groups. Among the four groups, those with prolonged DAPT (18-24 months) had the lowest incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) (14.1% vs. 11.7% vs. 9.6% vs. 24.2%, P<0.001), all-cause death (4.8% vs. 3.9% vs. 2.1% vs. 2.6%, P<0.001), cardiac death (3.1% vs. 2.6% vs. 1.4% vs. 1.9%, P=0.004), and myocardial infarction (MI) (3.8% vs. 4.2% vs. 2.5% vs. 5.8%, P<0.001). The incidence of bleeding was not different among the four groups (9.9% vs. 9.4% vs. 11.0% vs. 9.4%, P=0.449). Cox multivariable analysis showed that prolonged DAPT (18-24 months) was an independent protective factor for MACCEs (hazard ratio [HR] 0.802, 95% confidence interval [CI] 0.729-0.882, P<0.001), all-cause death (HR 0.660, 95% CI0.547-0.795, P<0.001), cardiac death (HR 0.663, 95% CI 0.526-0.835, P<0.001), MI (HR 0.796, 95% CI 0.662-0.957, P=0.015), and target vessel revascularization (HR 0.867, 95% CI 0.755-0.996, P=0.044). Subgroup analysis for high bleeding risk showed that prolonged DAPT remained an independent protective factor for all-cause death and MACCEs.

CONCLUSION: For patients with ACS after DES, appropriately prolonging the DAPT duration may be associated with a reduced risk of adverse ischemic events without increasing the bleeding risk.

Efficacy and safety of remimazolam-based sedation for intensive care unit patients undergoing upper gastrointestinal endoscopy: a cohort study

Yuan-rui Zhao, Ke-sheng Huang, Guo Hou, Lan Yao, Li-ping Lu, Song Xu, Ying-tao Lian, Zhun Yao, Zhui Yu

2023, 14(1): 31-36. doi:10.5847/wjem.j.1920-8642.2023.020

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BACKGROUND: Remimazolam is a novel ultra-short-acting sedative, but its safety and adverse events (AEs) in high-risk patients in the intensive care unit (ICU) setting remain unknown.

METHODS: This was a single-center, retrospective study that compared remimazolam to propofol and midazolam in patients undergoing upper gastrointestinal endoscopy. The primary outcome was the incidence of treatment-related AEs. The secondary outcomes were the time to extubation, the length of ICU stay, and the average cost of sedative per case.

RESULTS: Of the 88 patients analyzed, 47 were treated with remimazolam (mean dose, 7.90±4.84 mg), and 41 were treated with propofol (21.19±17.98 mg) or midazolam (3.08±2.17 mg). There was no statistically significant difference in the average duration of the endoscopic procedure (35.89±13.37 min vs. 44.51±21.68 min, P=0.133) or the time to extubation (15.00±9.75 h vs. 20.59±18.71 h, P=0.211) in the remimazolam group (group I) compared to the propofol or midazolam group (group II). ICU stays (5.40±2.93 d vs. 4.63±3.31 d, P=0.072) and treatment-related AEs (48.61% vs. 51.38%, P=0.056) were similar between groups. The average cost of sedative per case was significantly lower in the group I than in the group II (RMB 16.07±10.58 yuan vs. RMB 24.37±15.46 yuan, P=0.016).

CONCLUSION: Remimazolam-based sedation was noninferior to the classic sedatives and had lower average cost per case, indicating that it may be used as a promising sedative for high-risk patients during endoscopic procedures in the ICU setting.

Glutamine supplementation attenuates intestinal apoptosis by inducing heat shock protein 70 in heatstroke rats

Li-wen Du, Bao-qing Xu, Kai Xun, Fang-qi Zhang

2023, 14(1): 37-43. doi:10.5847/wjem.j.1920-8642.2023.011

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BACKGROUND: Heatstroke is the most hazardous heat-related illness and has a high fatality rate. We investigated whether glutamine supplementation could have a protective effect on heatstroke rats.

METHODS: Twenty-five 12-week-old male Wistar rats (weight 305±16 g) were randomly divided into a control group (n=5), heatstroke (HS) group (n=10), and heatstroke+glutamine (HSG) group (n=10). Seven days before heat exposure, glutamine (0.4 g/[kg·d]) was administered to the rats in the HSG group by gavage every day. Three hours after heat exposure, serum samples were collected to detect white blood cells, coagulation indicators, blood biochemical indicators, and inflammatory cytokines in the rats. The small intestine tissue was stained to analyze pathological structural changes and apoptosis. Finally, immunohistochemistry and Western blotting were used to analyze the expression levels of heat shock protein 70 (HSP70). Multiple comparisons were analyzed by using one-way analysis of variance, and the Bonferroni test was conducted for the post hoc comparisons.

RESULTS: After heat exposure, the core temperature of the HS group (40.65±0.31 °C) was higher than the criterion of heatstroke, whereas the core temperature of the HSG group (39.45±0.14 °C) was lower than the criterion. Glutamine supplementation restored the increased white blood cells, coagulation indicators, blood biochemical indicators, and inflammatory cytokines that were induced by heatstroke to normal levels. The intestinal mucosa was injured, and the structure of tight junctions was damaged in the HS group; however, the structure of intestinal mucosal epithelial cells was stable in the HSG group. Glutamine supplementation alleviated intestinal apoptosis and up-regulated HSP70 expression.

CONCLUSION: Glutamine supplementation may alleviate intestinal apoptosis by inducing the expression of HSP70 and have a protective effect on heatstroke rats.

Development and validation of a nomogram for predicting survival in patients with acute pancreatitis

Xiao-guang Zhu, Jia-mei Jiang, Yong-xia Li, Jing Gao, Wei Wu, Qi-ming Feng

2023, 14(1): 44-48. doi:10.5847/wjem.j.1920-8642.2023.022

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BACKGROUND: Acute pancreatitis (AP) is a complex and heterogeneous disease. We aimed to design and validate a prognostic nomogram for improving the prediction of short-term survival in patients with AP.

METHODS: The clinical data of 632 patients with AP were obtained from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The nomogram for the prediction of 30-day, 60-day and 90-day survival was developed by incorporating the risk factors identified by multivariate Cox analyses.

RESULTS: Multivariate Cox proportional hazard model analysis showed that age (hazard ratio [HR]=1.06, 95% confidence interval [95% CI] 1.03-1.08, P<0.001), white blood cell count (HR=1.03, 95% CI 1.00-1.06, P=0.046), systolic blood pressure (HR=0.99, 95% CI 0.97-1.00, P=0.015), serum lactate level (HR=1.10, 95% CI 1.01-1.20, P=0.023), and Simplified Acute Physiology Score II (HR=1.04, 95% CI 1.02-1.06, P<0.001) were independent predictors of 90-day mortality in patients with AP. A prognostic nomogram model for 30-day, 60-day, and 90-day survival based on these variables was built. Receiver operating characteristic (ROC) curve analysis demonstrated that the nomogram had good accuracy for predicting 30-day, 60-day, and 90-day survival (area under the ROC curve: 0.796, 0.812, and 0.854, respectively; bootstrap-corrected C-index value: 0.782, 0.799, and 0.846, respectively).

CONCLUSION: The nomogram-based prognostic model was able to accurately predict 30-day, 60-day, and 90-day survival outcomes and thus may be of value for risk stratification and clinical decision-making for critically ill patients with AP.

Development and validation of a predictive model for patients with post-extubation dysphagia

Jia-ying Tang, Xiu-qin Feng, Xiao-xia Huang, Yu-ping Zhang, Zhi-ting Guo, Lan Chen, Hao-tian Chen, Xiao-xiao Ying

2023, 14(1): 49-55. doi:10.5847/wjem.j.1920-8642.2023.021

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BACKGROUND: Swallowing disorder is a common clinical symptom that can lead to a series of complications, including aspiration, aspiration pneumonia, and malnutrition. This study aimed to investigate risk factors of post-extubation dysphagia (PED) in intensive care unit (ICU) patients with endotracheal intubation, and to develop a risk-predictive model for PED, which could serve as an assessment tool for the prevention and control of PED.

METHODS: Patients retrospectively selected from June to December 2021 in a tertiary hospital served as the derivation cohort. Patients recruited from the same hospital from March to June 2022 served as the external validation cohort for the predictive model. We used a combination of variable screening and least absolute shrinkage and selection operator (LASSO) regression to select the most useful candidate predictors and checked the multicollinearity of independent variables using the variance inflation factor method. Multivariate logistic regression analysis was performed to calculate the odds ratio (OR; 95% confidence interval [95% CI]) and P-value for each variable to predict diagnosis. The screened risk factors were introduced into R software to build a nomogram model. The performance of the model, including discrimination ability, calibration, and clinical benefit, was evaluated by plotting the receiver operating characteristic (ROC), calibration, and decision curves.

RESULTS: A total of 305 patients were included in this study. Among them, 235 patients (53 PED vs. 182 non-PED) were enrolled in the derivation cohort, while 70 patients (17 PED vs. 53 non-PED) were enrolled in the validation cohort. The independent predictors included age, pause of sedatives, level of consciousness, activities of daily living (ADL) score, nasogastric tube, sore throat, and voice disorder. These predictors were used to establish the predictive nomogram model. The model demonstrated good discriminative ability, and the area under the ROC curve (AUC) was 0.945 (95% CI 0.904-0.970). Applying the predictive model to the validation cohort demonstrated good discrimination with an AUC of 0.907 (95% CI 0.831-0.983) and good calibration. The decision-curve analysis of this nomogram showed a net benefit of the model.

CONCLUSION: A predictive model that incorporates age, pause of sedatives, level of consciousness, ADL score, nasogastric tube, sore throat, and voice disorder may have the potential to predict PED in ICU patients.

Use of anticoagulation reversal therapy in the emergency department: a single-center real-life retrospective study

Jacopo Davide Giamello, Andrea Pisano, Fabrizio Corsini, Remo Melchio, Luca Bertolaccini, Enrico Lupia, Giuseppe Lauria

2023, 14(1): 56-58. doi:10.5847/wjem.j.1920-8642.2023.004

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Symptoms and comorbidities associated with abnormal levels of serum calcium, magnesium, and phosphate in the emergency department: a prospective observational study

Korsin Laohavisudhi, Phichayut Phinyo, Borwon Wittayachamnankul, Boriboon Chenthanakij, Theerapon Tangsuwanaruk, Parinya Tianwibool, Pavita Laohakul, Wachira Wongtanasarasin

2023, 14(1): 59-61. doi:10.5847/wjem.j.1920-8642.2023.013

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Emergency department presentation changes due to the coronavirus disease pandemic in Nova Scotia, Canada

Tara Dahn, Patrick T. Fok, Hana Wiemer, Daniel J. Dutton, Valancy Cole, David Lewis, Tong Liu, Keith R. Brunt, Robert Hanlon, Jacqueline Fraser, Chris Vaillancourt, Paul Atkinson

2023, 14(1): 62-64. doi:10.5847/wjem.j.1920-8642.2023.010

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Successful treatment of acute carotid artery injuries

Yi-feng Pan, Zhen-jie Liu, Li-bin Zhang, Zhi-wei Gao, Bing Chen

2023, 14(1): 65-68. doi:10.5847/wjem.j.1920-8642.2023.024

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Unexplained hyperammonemia and encephalopathy in the emergency department: Abernethy malformation in elderly patients

Yan-ying Gao, Qing Tang, Yan-cun Liu, Xiao-he Liu, Bao-xin Qian, Yan-fen Chai, Li-jun Wang