World Journal of Emergency Medicine

Prediction of return of spontaneous circulation in out-of-hospital cardiac arrest with non-shockable initial rhythm using point-of-care testing: a retrospective observational study

Kota Shinada, Hiroyuki Koami, Ayaka Matsuoka, Yuichiro Sakamoto

2023, 14(2): 89-95. doi:10.5847/wjem.j.1920-8642.2023.031

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BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a public health concern, and many studies have been conducted on return of spontaneous circulation (ROSC) and its prognostic factors. Rotational thromboelastometry (ROTEM^®), a point-of-care testing (POCT) method, has been useful for predicting ROSC in patients with OHCA, but very few studies have focused on patients with non-shockable rhythm. We examined whether the parameters of POCT could predict ROSC in patients with OHCA and accompanying non-shockable rhythm.

METHODS: This is a single-center, retrospective observational study. Complete blood count, blood gas, and ROTEM POCT measurements were used. This study included patients with non-traumatic OHCA aged 18 years or older who were transported to the emergency department and evaluated using POCT between January 2013 and December 2021. The patients were divided into the ROSC and non-ROSC groups. Prehospital information and POCT parameters were compared using receiver operating characteristic (ROC) curve analysis, and further logistic regression analysis was performed.

RESULTS: Sixty-seven and 135 patients were in the ROSC and non-ROSC groups, respectively. The ROC curves showed a high area under the curve (AUC) for K⁺ of 0.77 (95% confidence interval [CI]: 0.71-0.83) and EXTEM amplitude 5 min after clotting time (A5) of 0.70 (95%CI: 0.62-0.77). The odds ratios for ROSC were as follows: female sex 3.67 (95%CI: 1.67-8.04); K⁺ 0.64 (95%CI: 0.48-0.84); and EXTEM A5 1.03 (95%CI: 1.01-1.06).

CONCLUSION: In OHCA patients with non-shockable rhythm, K⁺ level and the ROTEM parameter EXTEM A5 may be useful in predicting ROSC.

The impact of emergency department length of stay on the outcomes of trauma patients requiring hospitalization: a retrospective observational study

Ahmed Faidh Ramzee, Ayman El-Menyar, Mohammad Asim, Ahad Kanbar, Khalid Ahmed, Bahaa Daoud, Saji Mathradikkal, Ahmad Kloub, Hassan Al-Thani, Sandro Rizoli

2023, 14(2): 96-105. doi:10.5847/wjem.j.1920-8642.2023.016

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BACKGROUND: We aimed to explore the impact of the emergency department length of stay (EDLOS) on the outcome of trauma patients.

METHODS: A retrospective study was conducted on all trauma patients requiring hospitalization between 2015 and 2019. Patients were categorized into 4 groups based on the EDLOS (<4 h, 4-12 h,12-24 h, and >24 h). Data were analyzed using Chi-square test (categorical variables), Student’s t-test (continuous variables), correlation coefficient, analysis of variance and multivariate logistic regression analysis for identifying predictors of short EDLOS and hospital mortality.

RESULTS: The study involved 7,026 patients with a mean age of 32.1±15.6 years. One-fifth of patients had a short EDLOS (<4 h) and had higher level trauma team T1 activation (TTA-1), higher Injury Severity Score (ISS), higher shock index (SI), and more head injuries than the other groups (P=0.001). Patients with an EDLOS >24 h were older (P=0.001) and had more comorbidities (P=0.001) and fewer deaths (P=0.001). Multivariate regression analysis showed that the predictors of short EDLOS were female gender, GCS, SI, hemoglobin level, ISS, and blood transfusion. The predictors of mortality were TTA-1 (odds ratio [OR]=4.081, 95%CI: 2.364-7.045), head injury (OR=3.920, 95%CI: 2.413-6.368), blood transfusion (OR=2.773, 95%CI: 1.668-4.609), SI (OR=2.132, 95%CI: 1.364-3.332), ISS (OR=1.077, 95%CI: 1.057-1.096), and age (OR=1.040, 95%CI: 1.026-1.054).

CONCLUSIONS Patients with shorter EDLOS had different baseline characteristics and hospital outcomes compared with patients with longer EDLOS. Patients with prolonged EDLOS had better outcomes; however, the burden of prolonged boarding in the ED needs further elaboration.

Artificial intelligence promotes shared decision-making through recommending tests to febrile pediatric outpatients

Wei-hua Li, Bin Dong, Han-song Wang, Jia-jun Yuan, Han Qian, Ling-ling Zheng, Xu-lin Lin, Zhao Wang, Shi-jian Liu, Bo-tao Ning, DanTian , Lie-bin Zhao

2023, 14(2): 106-111. doi:10.5847/wjem.j.1920-8642.2023.033

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BACKGROUND: To promote the shared decision-making (SDM) between patients and doctors in pediatric outpatient departments, this study was designed to validate artificial intelligence (AI) -initiated medical tests for children with fever.

METHODS: We designed an AI model, named Xiaoyi, to suggest necessary tests for a febrile child before visiting a pediatric outpatient clinic. We calculated the sensitivity, specificity, and F1 score to evaluate the efficacy of Xiaoyi's recommendations. The patients were divided into the rejection and acceptance groups. Then we analyzed the rejected examination items in order to obtain the corresponding reasons.

RESULTS: We recruited a total of 11,867 children with fever who had used Xiaoyi in outpatient clinics. The recommended examinations given by Xiaoyi for 10,636 (89.6%) patients were qualified. The average F1 score reached 0.94. A total of 58.4% of the patients accepted Xiaoyi’s suggestions (acceptance group), and 41.6% refused (rejection group). Imaging examinations were rejected by most patients (46.7%). The tests being time-consuming were rejected by 2,133 patients (43.2%), including rejecting pathogen studies in 1,347 patients (68.5%) and image studies in 732 patients (31.8%). The difficulty of sampling was the main reason for rejecting routine tests (41.9%).

CONCLUSION: Our model has high accuracy and acceptability in recommending medical tests to febrile pediatric patients, and is worth promoting in facilitating SDM.

The influence of pressure injury risk on the association between left ventricular ejection fraction and all-cause mortality in patients with acute myocardial infarction 80 years or older

Bao-tao Huang, Yi-heng Cheng, Bo-sen Yang, Yi-ke Zhang, Fang-yang Huang, Yong Peng, Xiao-bo Pu, Mao Chen

2023, 14(2): 112-121. doi:10.5847/wjem.j.1920-8642.2023.026

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BACKGROUND: We aimed to investigate whether the pressure injury risk mediates the association of left ventricular ejection fraction (LVEF) with all-cause death in patients with acute myocardial infarction (AMI) aged 80 years or older.

METHODS: This retrospective cohort study included 677 patients with AMI aged 80 years or older from a tertiary-level hospital. Pressure injury risk was assessed using the Braden scale at admission, and three risk groups (low/minimal, intermediate, high) were defined according to the overall score of six different variables. LVEF was measured during the index hospitalization for AMI. All-cause death after hospital discharge was the primary outcome.

RESULTS: Over a median follow-up period of 1,176 d (interquartile range [IQR], 722-1,900 d), 226 (33.4%) patients died. Multivariate Cox regression analysis showed that reduced LVEF was associated with an increased risk of all-cause death only in the high-risk group of pressure injury (adjusted hazard ratios [HR]=1.81, 95% confidence interval [CI]: 1.03-3.20; P=0.040), but not in the low/minimal- (adjusted HR=1.29, 95%CI: 0.80-2.11; P=0.299) or intermediate-risk groups (adjusted HR=1.14, 95%CI: 0.65-2.02; P=0.651). Significant interactions were detected between pressure injury risk and LVEF (adjusted P=0.003). The cubic spline with hazard ratio plot revealed a distinct shaped curve relation between LVEF and all-cause death among different pressure injury risk groups.

CONCLUSIONS In older patients with AMI, the risk of pressure injury mediated the association between LVEF and all-cause death. The classification of older patients for both therapy and prognosis assessment appears to be improved by the incorporation of pressure injury risk assessment into AMI care management.

Diagnostic accuracy of the tongue blade test combined with clinical signs to detect maxillary and mandibular fractures in the emergency department

Jee Yen Kuck, Abdul Muhaimin Noor Azhar, Neena Wee, Rishya Manikam

2023, 14(2): 122-127. doi:10.5847/wjem.j.1920-8642.2023.032

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BACKGROUND: To evaluate the diagnostic accuracy of clinical signs combined with the tongue blade test (TBT) to detect maxillary and mandibular fractures.

METHODS: A cross-sectional study enrolled patients with maxillary and mandibular injuries in the emergency department. Physical examination and the TBT were performed, followed by radiological imaging (facial X-ray or computed tomography [CT]). The diagnostic accuracy was calculated for individuals and a combination of clinical findings at predicting maxillary and mandibular fractures.

RESULTS: A total of 98 patients were identified, of whom 31.6% had maxillary fractures and 9.2% had mandibular fractures. The combination of malocclusion, tenderness on palpation and swelling with positive TBT had 100% specificity to detect maxillary and mandibular fractures. In the absence of malocclusion, the combination of tenderness on palpation and swelling with positive TBT produced a specificity of 97.8% for maxillary fracture and a specificity of 96.2% for mandibular fracture. A clinical decision tool consisting of malocclusion, tenderness on palpation, swelling and TBT revealed a specificity of 100% and a positive predictive value of 100%.

CONCLUSION:The clinical decision tool is potentially useful to rule out mandibular fractures, thus preventing unnecessary radiation exposure.

Improving the approach to non-cardiac syncope in the emergency department observation unit

Filippo Numeroso, Ivo Casagranda

2023, 14(2): 128-132. doi:10.5847/wjem.j.1920-8642.2023.017

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A retrospective analysis of gender among patients admitted to a clinical decision unit at risk for acute coronary syndrome

Joby Thoppil, Lauren Kraut, Collin Montgomery, Wilfrido Castillo, Robert Silverman, Sanjey Gupta, Frederick Davis

2023, 14(2): 133-137. doi:10.5847/wjem.j.1920-8642.2023.018

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Opinions and attitudes toward targeted temperature management in the emergency department and intensive care unit in a developing country: a survey study

Abdullah Bakhsh, Hadeel Alotaibi, Sara Alothman, Abdulrahman Alothman, Rahaf Alothman, Abdulrahman Alsulami, Malak Alamoudi, Ali Alothman, Ali Al-Shareef

2023, 14(2): 138-142. doi:10.5847/wjem.j.1920-8642.2023.030

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Pneumothorax in a Thiel cadaver model of cardiopulmonary resuscitation

Daniel Auinger, Simon Orlob, Johannes Wittig, Gabriel Honnef, Stefan Heschl, Georg Feigl, Gerhard Prause

2023, 14(2): 143-147. doi:10.5847/wjem.j.1920-8642.2023.029

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Epstein-Barr virus infection mimicking acute appendicitis: a case report

Li Wang, Wei-hua Gong