World Journal of Emergency Medicine

Prevention of ventilator-associated pneumonia with inhaled antibiotics

Stephan Ehrmann, Jie Li

2024, 15(3): 165-168. doi:10.5847/wjem.j.1920-8642.2024.051

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Trends in oxycodone and oxycodone-containing analgesics administration for back pain in emergency departments in the USA (2007-2018)

Jonathan Chabon, Jemer Garrido, Deanna Schreiber-Gregory, Jefferson Drapkin, Sergey Motov

2024, 15(3): 169-174. doi:10.5847/wjem.j.1920-8642.2024.002

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BACKGROUND: To describe trends in oxycodone and oxycodone-containing analgesic prescribing for the treatment of back pain among adults in emergency departments (EDs) in the USA from 2007 to 2018.
METHODS: Data were gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007 to 2018. The study population included individuals of all ages presenting to USA EDs. The NHAMCS reasons for visit and oxycodone drug ID codes were used to isolate patients with back pain. The main outcome was the proportion of oxycodone and oxycodone-containing analgesics prescribed for back pain in the EDs over the specified time period.
RESULTS: There was a relative decrease in the overall administration of oxycodone for back pain in the EDs by 62.3% from 2007 (244,000 visits) to 2018 (92,000 visits). The proportion of ED patients prescribed with oxycodone-containing analgesics for back pain increased among patients aged 45 years and older (from 43.8% to 57.6%), female patients (from 54.5% to 62.0%), black patients (from 22.5% to 30.4%), and Hispanic/Latino patients (from 9.4% to 19.6%). Oxycodone/acetaminophen was most prescribed and accounted for 90.2% of all oxycodone-containing analgesics in 2007, with a decrease to 68.5% in 2018. Pure oxycodone was the second most prescribed medication, accounting for 6.1% in 2007 and 31.5% in 2018.
CONCLUSION: The overall number of oxycodone-containing analgesics decreased significantly from 2007 to 2018. However, that number trended upward in 45-year-old and older, female, black, or Hispanic/Latino patients from 2007 to 2018. The total amount of pure oxycodone increased significantly from 2007 to 2008.

Performance of the EDACS-ADP incorporating high-sensitivity troponin assay: Do components of major adverse cardiac events matter?

Yedalm Yoo, Shin Ahn, Bora Chae, Won Young Kim

2024, 15(3): 175-180. doi:10.5847/wjem.j.1920-8642.2024.032

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BACKGROUND: The accelerated diagnostic protocol (ADP) using the Emergency Department Assessment of Chest pain Score (EDACS-ADP), a tool to identify patients at low risk of a major adverse cardiac event (MACE) among patients presenting with chest pain to the emergency department, was developed using a contemporary troponin assay. This study was performed to validate and compare the performance of the EDACS-ADP incorporating high-sensitivity cardiac troponin I between patients who had a 30-day MACE with and without unstable angina (MACE I and II, respectively).
METHODS: A single-center prospective observational study of adult patients presenting with chest pain suggestive of acute coronary syndrome was performed. The performance of EDACS-ADP in predicting MACE was assessed by calculating the sensitivity and negative predictive value.
RESULTS: Of the 1,304 patients prospectively enrolled, 399 (30.6%; 95% confidence interval [95% CI]: 27.7%-33.8%) were considered low-risk using the EDACS-ADP. Among them, the rates of MACE I and II were 1.3% (5/399) and 1.0% (4/399), respectively. The EDACS-ADP showed sensitivities and negative predictive values of 98.8% (95% CI: 97.2%-99.6%) and 98.7% (95% CI: 97.0%-99.5%) for MACE I and 98.7% (95% CI: 96.8%-99.7%) and 99.0% (95% CI: 97.4%-99.6%) for MACE II, respectively.
CONCLUSION: EDACS-ADP could help identify patients as safe for early discharge. However, when unstable angina was added to the outcome, the 30-day MACE rate among the designated low-risk patients remained above the level acceptable for early discharge without further evaluation.

Effects of high-dose glucose-insulin-potassium on acute coronary syndrome patients receiving reperfusion therapy: a meta-analysis

Zeyu Yang, Huiruo Liu, Dazhou Lu, Shengchuan Cao, Feng Xu, Chuanbao Li

2024, 15(3): 181-189. doi:10.5847/wjem.j.1920-8642.2024.048

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BACKGROUND: This meta-analysis aimed to assess the efficacy of high-dose glucose-insulin-potassium (GIK) therapy on clinical outcomes in acute coronary syndrome (ACS) patients receiving reperfusion therapy.
METHODS: We searched the PubMed, Web of Science, MEDLINE, Embase, and Cochrane Library databases from inception to April 26, 2022, for randomized controlled trials (RCTs) that compared high-dose GIK and placebos in ACS patients receiving reperfusion therapy. The primary endpoint was major adverse cardiovascular events (MACEs).
RESULTS: Eleven RCTs with 884 patients were ultimately included. Compared with placebos, high-dose GIK markedly reduced MACEs (risk ratio [RR] 0.57, 95% confidence interval [95% CI]: 0.35 to 0.94, P=0.03) and the risk of heart failure (RR 0.48, 95% CI: 0.25 to 0.95, P=0.04) and improved the left ventricular ejection fraction (LVEF) (mean difference [MD] 2.12, 95% CI: 0.40 to 3.92, P=0.02) at 6 months. However, no difference was observed in all-cause mortality at 30 d or 1 year. Additionally, high-dose GIK was significantly associated with increased incidences of phlebitis (RR 4.78, 95% CI: 1.36 to 16.76, P=0.01), hyperglycemia (RR 9.06, 95% CI: 1.74 to 47.29, P=0.009) and hypoglycemia (RR 6.50, 95% CI: 1.28 to 33.01, P=0.02) but not reinfarction, hyperkalemia or secondary reperfusion. In terms of oxidative stress-lowering function, high-dose GIK markedly reduced superoxide dismutase (SOD) activity but not glutathione peroxidase (GSH-Px) or catalase (CAT) activity.
CONCLUSION: Patients with ACS receiving reperfusion therapy exhibited a reduction in MACEs and good oxidative stress-lowering efficacy in response to high-dose GIK. Moreover, with a higher incidence of complications such as phlebitis, hyperglycemia, and hypoglycemia. Furthermore, there were no observed survival benefits associated with high-dose GIK. More trials with long-term follow-up are still needed.

Comparison between sepsis-induced coagulopathy and sepsis-associated coagulopathy criteria in identifying sepsis-associated disseminated intravascular coagulation

Huixin Zhao, Yiming Dong, Sijia Wang, Jiayuan Shen, Zhenju Song, Mingming Xue, Mian Shao

2024, 15(3): 190-196. doi:10.5847/wjem.j.1920-8642.2024.041

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BACKGROUND: Disseminated intravascular coagulation (DIC) is associated with increased mortality in sepsis patients. In this study, we aimed to assess the clinical ability of sepsis-induced coagulopathy (SIC) and sepsis-associated coagulopathy (SAC) criteria in identifying overt-DIC and pre-DIC status in sepsis patients.
METHODS: Data from 419 sepsis patients were retrospectively collected from July 2018 to December 2022. The performances of the SIC and SAC were assessed to identify overt-DIC on days 1, 3, 7, or 14. The SIC status or SIC score on day 1, the SAC status or SAC score on day 1, and the sum of the SIC or SAC scores on days 1 and 3 were compared in terms of their ability to identify pre-DIC. The SIC or SAC status on day 1 was evaluated as a pre-DIC indicator for anticoagulant initiation.
RESULTS: On day 1, the incidences of coagulopathy according to overt-DIC, SIC and SAC criteria were 11.7%, 22.0% and 31.5%, respectively. The specificity of SIC for identifying overt-DIC was significantly higher than that of the SAC criteria from day 1 to day 14 (P<0.05). On day 1, the SIC score with a cut-off value > 3 had a significantly higher sensitivity (72.00%) and area under the curve (AUC) (0.69) in identifying pre-DIC than did the SIC or SAC status (sensitivity: SIC status 44.00%, SAC status 52.00%; AUC: SIC status 0.62, SAC status 0.61). The sum of the SIC scores on days 1 and 3 had a higher AUC value for identifying the pre-DIC state than that of SAC (0.79 vs. 0.69, P<0.001). Favorable effects of anticoagulant therapy were observed in SIC (adjusted hazard ratio [HR]=0.216, 95% confidence interval [95% CI]: 0.060-0.783, P=0.018) and SAC (adjusted HR=0.146, 95% CI: 0.041-0.513, P=0.003).
CONCLUSION: The SIC and SAC seem to be valuable for predicting overt-DIC. The sum of SIC scores on days 1 and 3 has the potential to help identify pre-DIC.

Glucose metabolic reprogramming-related parameters for the prediction of 28-day neurological prognosis and all-cause mortality in patients after cardiac arrest: a prospective single-center observational study

Subi Abudurexiti, Shihai Xu, Zhangping Sun, Yi Jiang, Ping Gong

2024, 15(3): 197-203. doi:10.5847/wjem.j.1920-8642.2024.047

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BACKGROUND: We aimed to observe the dynamic changes in glucose metabolic reprogramming-related parameters and their ability to predict neurological prognosis and all-cause mortality in cardiac arrest patients after the restoration of spontaneous circulation (ROSC).
METHODS: Adult cardiac arrest patients after ROSC who were admitted to the emergency or cardiac intensive care unit of the First Affiliated Hospital of Dalian Medical University from August 1, 2017, to May 30, 2021, were enrolled. According to 28-day survival, the patients were divided into a non-survival group (n=82) and a survival group (n=38). Healthy adult volunteers (n=40) of similar ages and sexes were selected as controls. The serum levels of glucose metabolic reprogramming-related parameters (lactate dehydrogenase [LDH], lactate and pyruvate), neuron-specific enolase (NSE) and interleukin 6 (IL-6) were measured on days 1, 3, and 7 after ROSC. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Sequential Organ Failure Assessment (SOFA) score were calculated. The Cerebral Performance Category (CPC) score was recorded on day 28 after ROSC.
RESULTS: Following ROSC, the serum LDH (607.0 U/L vs. 286.5 U/L), lactate (5.0 mmol/L vs. 2.0 mmol/L), pyruvate (178.0 μmol/L vs. 70.9 μmol/L), and lactate/pyruvate ratio (34.1 vs. 22.1) significantly increased and were higher in the non-survivors than in the survivors on admission (all P<0.05). Moreover, the serum LDH, pyruvate, IL-6, APACHE II score, and SOFA score on days 1, 3 and 7 after ROSC were significantly associated with 28-day poor neurological prognosis and 28-day all-cause mortality (all P<0.05). The serum LDH concentration on day 1 after ROSC had an area under the receiver operating characteristic curve (AUC) of 0.904 [95% confidence interval [95% CI]: 0.851-0.957]) with 96.8% specificity for predicting 28-day neurological prognosis and an AUC of 0.950 (95% CI: 0.911-0.989) with 94.7% specificity for predicting 28-day all-cause mortality, which was the highest among the glucose metabolic reprogramming-related parameters tested.
CONCLUSION: Serum parameters related to glucose metabolic reprogramming were significantly increased after ROSC. Increased serum LDH and pyruvate levels, and lactate/pyruvate ratio may be associated with 28-day poor neurological prognosis and all-cause mortality after ROSC, and the predictive efficacy of LDH during the first week was superior to others.

Xuebijing improves intestinal microcirculation dysfunction in septic rats by regulating the VEGF-A/PI3K/Akt signaling pathway

A-ling Tang, Yan Li, Li-chao Sun, Xiao-yu Liu, Nan Gao, Sheng-tao Yan, Guo-qiang Zhang

2024, 15(3): 206-213. doi:10.5847/wjem.j.1920-8642.2024.035

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BACKGROUND: This study aims to explore whether Xuebijing (XBJ) can improve intestinal microcirculation dysfunction in sepsis and its mechanism.
METHODS: A rat model of sepsis was established by cecal ligation and puncture (CLP). A total of 30 male SD rats were divided into four groups: sham group, CLP group, XBJ + axitinib group, and XBJ group. XBJ was intraperitoneally injected 2 h before CLP. Hemodynamic data (blood pressure and heart rate) were recorded. The intestinal microcirculation data of the rats were analyzed via microcirculation imaging. Enzyme-linked immunosorbent assay (ELISA) kits were used to detect the serum levels of interleukin-6 (IL-6), C-reactive protein (CRP), and tumor necrosis factor-α (TNF-α) in the rats. Histological analysis and transmission electron microscopy were used to analyze the injury of small intestinal microvascular endothelial cells and small intestinal mucosa in rats. The expression of vascular endothelial growth factor A (VEGF-A), phosphoinositide 3-kinase (PI3K), phosphorylated PI3K (p-PI3K), protein kinase B (Akt), and phosphorylated Akt (p-Akt) in the small intestine was analyzed via Western blotting.
RESULTS: XBJ improved intestinal microcirculation dysfunction in septic rats, alleviated the injury of small intestinal microvascular endothelial cells and small intestinal mucosa, and reduced the systemic inflammatory response. Moreover, XBJ upregulated the expression of VEGF-A, p-PI3K/total PI3K, and p-Akt/total Akt in the rat small intestine.
CONCLUSION: XBJ may improve intestinal microcirculation dysfunction in septic rats possibly through the VEGF-A/PI3K/Akt signaling pathway.

Chlorfenapyr poisoning: mechanisms, clinical presentations, and treatment strategies

Ji Cheng, Yulu Chen, Weidong Wang, Xueqi Zhu, Zhenluo Jiang, Peng Liu, Liwen Du

2024, 15(3): 214-219. doi:10.5847/wjem.j.1920-8642.2024.046

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BACKGROUND: Chlorfenapyr is used to kill insects that are resistant to organophosphorus insecticides. Chlorfenapyr poisoning has a high mortality rate and is difficult to treat. This article aims to review the mechanisms, clinical presentations, and treatment strategies for chlorfenapyr poisoning.
DATA RESOURCES: We conducted a review of the literature using PubMed, Web of Science, and SpringerLink from their beginnings to the end of October 2023. The inclusion criteria were systematic reviews, clinical guidelines, retrospective studies, and case reports on chlorfenapyr poisoning that focused on its mechanisms, clinical presentations, and treatment strategies. The references in the included studies were also examined to identify additional sources.
RESULTS: We included 57 studies in this review. Chlorfenapyr can be degraded into tralopyril, which is more toxic and reduces energy production by inhibiting the conversion of adenosine diphosphate to adenosine triphosphate. High fever and altered mental status are characteristic clinical presentations of chlorfenapyr poisoning. Once it occurs, respiratory failure occurs immediately, ultimately leading to cardiac arrest and death. Chlorfenapyr poisoning is difficult to treat, and there is no specific antidote.
CONCLUSION: Chlorfenapyr is a new pyrrole pesticide. Although it has been identified as a moderately toxic pesticide by the World Health Organization (WHO), the mortality rate of poisoned patients is extremely high. There is no specific antidote for chlorfenapyr poisoning. Therefore, based on the literature review, future efforts to explore rapid and effective detoxification methods, reconstitute intracellular oxidative phosphorylation couplings, identify early biomarkers of chlorfenapyr poisoning, and block the conversion of chlorfenapyr to tralopyril may be helpful for emergency physicians in the diagnosis and treatment of this disease.

Quantitative assessment of the impact of a triage physician on the Accreditation Council for Graduate Medical Education resident milestones in the emergency department

Julie Cueva, Duncan Grossman, Vishnu Muppala, Arlene Chung, Mahlaqa Butt, Jefferson Drapkin, Antonios Likourezos, Errel Khordipour

2024, 15(3): 220-222. doi:10.5847/wjem.j.1920-8642.2024.034

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The association between C-reactive protein to albumin ratio and 6-month neurological outcome in patients with in-hospital cardiac arrest

Ji Ho Lee, Dong Hun Lee, Byung Kook Lee, Seok Jin Ryu

2024, 15(3): 223-228. doi:10.5847/wjem.j.1920-8642.2024.037

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