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The American Journal of Emergency... Jun 2024The electrocardiogram (ECG) is a crucial diagnostic tool in the Emergency Department (ED) for assessing patients with Acute Coronary Syndrome (ACS). Despite its... (Review)
Review
INTRODUCTION
The electrocardiogram (ECG) is a crucial diagnostic tool in the Emergency Department (ED) for assessing patients with Acute Coronary Syndrome (ACS). Despite its widespread use, the ECG has limitations, including low sensitivity of the STEMI criteria to detect Acute Coronary Occlusion (ACO) and poor inter-rater reliability. Emerging ECG features beyond the traditional STEMI criteria show promise in improving early ACO diagnosis, but complexity hinders widespread adoption. The potential integration of Artificial Neural Networks (ANN) holds promise for enhancing diagnostic accuracy and addressing reliability issues in ECG interpretation for ACO symptoms.
METHODS
Ovid MEDLINE, CINAHL, EMBASE, Cochrane, PubMed and Scopus were searched from inception through to 8th of December 2023. A thorough search of the grey literature and reference lists of relevant articles was also performed to identify additional studies. Articles were included if they reported the use of ANN for ECG interpretation of Acute Coronary Syndrome in the Emergency Department patients.
RESULTS
The search yielded a total of 244 articles. After removing duplicates and excluding non-relevant articles, 14 remained for analysis. There was significant heterogeneity in the types of ANN models used and the outcomes assessed, making direct comparisons challenging. Nevertheless, ANN appeared to demonstrate higher accuracy than physician interpreters for the evaluated outcomes and this proved independent of both specialty and years of experience.
CONCLUSIONS
The interpretation of ECGs in patients with suspected ACS using ANN appears to be accurate and potentially superior when compared to human interpreters and computerised algorithms. This appears consistent across various ANN models and outcome variables. Future investigations should emphasise ANN interpretation of ECGs in patients with ACO, where rapid and accurate diagnosis can significantly benefit patients through timely access to reperfusion therapies.
PubMed: 38936320
DOI: 10.1016/j.ajem.2024.06.026 -
Prehospital Emergency Care Jun 2024Medical Priority Dispatch System (MPDS) is a system used to assign medical 9-1-1 calls to one of 35 chief complaints that are further categorized in order of increasing...
Medical Priority Dispatch System (MPDS) is a system used to assign medical 9-1-1 calls to one of 35 chief complaints that are further categorized in order of increasing priority, Alpha through Echo. In this descriptive study we demonstrate the methodology of matching MPDS codes to a county mortality registry. We also evaluated the ability of select MPDS codes (fall, respiratory, sick person, and abdominal pain) to predict mortality up to 30 days for all ages transported by Alameda County Emergency Medical Services (EMS). Using Alameda County EMS data, we conducted a retrospective review of all EMS encounters that occurred from November 1, 2011, to November 1, 2016. To describe mortality in this population, we identified unique patients and linked them to the Alameda County Public Health Death Registry. We identified mortality at 48 hours, 7 days, and 30 days after an EMS encounter. Approximately 99% of the EMS encounters were matched with unique patient identifiers, yielding a study sample of 202,431 (4% less than age 18, 53% between ages 18-65, and 43% over age 65). Patients with a respiratory chief complaint had the highest mortality percentage in each age group (0.23%, 2.7%, and 14.55% respectively). There was no correlation between MPDS code and mortality for patients less than age 18. An increase in Alpha through Echo designation for respiratory complaints in patients 18-65 and older than 65 years corresponded with an increase in 30-day mortality. This study demonstrates an upward trend in mortality with increasing acuity of Alpha through Echo designations for adult patients with respiratory complaints. Mortality increased with age in this cohort. Most of the deaths occurred after 7 days.
PubMed: 38935488
DOI: 10.1080/10903127.2024.2372442 -
Journal of the American Heart... Jun 2024Women are known to be disadvantaged compared with men in the early links of the Chain of Survival, receiving fewer bystander interventions. We aimed to describe...
BACKGROUND
Women are known to be disadvantaged compared with men in the early links of the Chain of Survival, receiving fewer bystander interventions. We aimed to describe sex-based disparities in emergency medical service resuscitation quality and processes of care for out-of-hospital cardiac arrest.
METHODS AND RESULTS
We conducted a retrospective analysis of patients who were nontraumatic with out-of-hospital cardiac arrest aged ≥16 years where resuscitation was attempted between March 2019 and June 2023. We investigated 18 routinely captured performance metrics and performed adjusted logistic and quantile regression analyses to assess sex-based differences in these metrics. During the study period, 10 161 patients with out-of-hospital cardiac arrest met the eligibility criteria, of whom 3216 (32%) were women. There were no clinically relevant sex-based differences observed in regard to external cardiac compressions; however, women were 34% less likely to achieve a systolic blood pressure >100 mm Hg on arrival at the hospital (adjusted odds ratio [AOR], 0.66 [95% CI, 0.47-0.92]). Furthermore, women had a longer time to 12-lead ECG acquisition after return of spontaneous circulation (median adjusted difference, 1.00 minute [95% CI, 0.38-1.62]) and 33% reduced odds of being transported to a 24-hour percutaneous coronary intervention-capable facility (AOR, 0.67 [95% CI, 0.49-0.91]). Resuscitation was also terminated sooner for women compared with men (median adjusted difference, -4.82 minutes [95% CI, -6.77 to -2.87]).
CONCLUSIONS
Although external cardiac compression quality did not vary by sex, significant sex-based disparities were seen in emergency medical services processes of care following out-of-hospital cardiac arrest. Further investigation is required to elucidate the underlying causes of these differences and examine their influence on patient outcomes.
PubMed: 38934889
DOI: 10.1161/JAHA.123.033974 -
Clinical Toxicology (Philadelphia, Pa.) Jun 2024Cannabis is the most common recreational drug worldwide and synthetic cannabinoid receptor agonists are currently the largest group of new psychoactive substances. The...
Clinical effects of cannabis compared to synthetic cannabinoid receptor agonists (SCRAs): a retrospective cohort study of presentations with acute toxicity to European hospitals between 2013 and 2020.
INTRODUCTION
Cannabis is the most common recreational drug worldwide and synthetic cannabinoid receptor agonists are currently the largest group of new psychoactive substances. The aim of this study was to compare the clinical features and outcomes of lone acute cannabis toxicity with lone acute synthetic cannabinoid receptor agonist toxicity in a large series of presentations to European emergency departments between 2013-2020.
METHODS
Self-reported drug exposure, clinical, and outcome data were extracted from the European Drug Emergencies Network Plus which is a surveillance network that records data on drug-related emergency department presentations to 36 centres in 24 European countries. Cannabis exposure was considered the control in all analyses. To compare the lone cannabis and lone synthetic cannabinoid receptor agonist groups, univariate analysis using chi squared testing was used for categorical variables and non-parametric Mann-Whitney U- testing for continuous variables. Statistical significance was defined as a value of < 0.05.
RESULTS
Between 2013-2020 there were 54,314 drug related presentations of which 2,657 were lone cannabis exposures and 503 lone synthetic cannabinoid receptor agonist exposures. Synthetic cannabinoid receptor agonist presentations had statistically significantly higher rates of drowsiness, coma, agitation, seizures and bradycardia at the time of presentation. Cannabis presentations were significantly more likely to have palpitations, chest pain, hypertension, tachycardia, anxiety, vomiting and headache.
DISCUSSION
Emergency department presentations involving lone synthetic cannabinoid receptor agonist exposures were more likely to have neuropsychiatric features and be admitted to a psychiatric ward, and lone cannabis exposures were more likely to have cardiovascular features. Previous studies have shown variability in the acute toxicity of synthetic cannabinoid receptor agonists compared with cannabis but there is little comparative data available on lone exposures. There is limited direct comparison in the current literature between lone synthetic cannabinoid receptor agonist and lone cannabis exposure, with only two previous poison centre series and two clinical series. Whilst this study is limited by self-report being used to identify the drug(s) involved in the presentations, previous studies have demonstrated that self-report is reliable in emergency department presentations with acute drug toxicity.
CONCLUSION
This study directly compares presentations with acute drug toxicity related to the lone use of cannabis or synthetic cannabinoid receptor agonists. It supports previous findings of increased neuropsychiatric toxicity from synthetic cannabinoid receptor agonists compared to cannabis and provides further data on cardiovascular toxicity in lone cannabis use.
PubMed: 38934347
DOI: 10.1080/15563650.2024.2346125 -
The Pan African Medical Journal 2024on March 21, 2020, the first case of COVID-19 was confirmed in Uganda. A total lockdown was initiated on March 30 which was gradually lifted May 5-June 30. On March 25,...
INTRODUCTION
on March 21, 2020, the first case of COVID-19 was confirmed in Uganda. A total lockdown was initiated on March 30 which was gradually lifted May 5-June 30. On March 25, a toll-free call center was organized at the Kampala Capital City Authority to respond to public concerns about COVID-19 and the lockdown. We documented the set-up and use of the call center and analyzed key concerns raised by the public.
METHODS
two hotlines were established and disseminated through media platforms in Greater Kampala. The call center was open 24 hours a day and 7 days a week. We abstracted data on incoming calls from March 25 to June 30, 2020. We summarized call data into categories and conducted descriptive analyses of public concerns raised during the lockdown.
RESULTS
among 10,167 calls, two-thirds (6,578; 64.7%) involved access to health services, 1,565 (15.4%) were about social services, and 1,375 (13.5%) involved COVID-19-related issues. Approximately one-third (2,152; 32.7%) of calls about access to health services were requests for ambulances for patients with non-COVID-19-related emergencies. About three-quarters of calls about social services were requests for food and relief items (1,184; 75.7%). Half of the calls about COVID-19 (730; 53.1%) sought disease-related information.
CONCLUSION
the toll-free call center was used by the public during the COVID-19 lockdown in Kampala. Callers were more concerned about access to essential health services, non-related to COVID-19 disease. It is important to plan for continuity of essential services before a public health emergency-related lockdown.
Topics: Humans; Uganda; COVID-19; Health Services Accessibility; Call Centers; Hotlines; Continuity of Patient Care; Communicable Disease Control
PubMed: 38933438
DOI: 10.11604/pamj.2024.47.141.36203 -
International Journal of Environmental... May 2024Switzerland, a wealthy country, has a cutting-edge healthcare system, yet per capita, it emits over one ton of CO, ranking among the world's most polluting healthcare...
Switzerland, a wealthy country, has a cutting-edge healthcare system, yet per capita, it emits over one ton of CO, ranking among the world's most polluting healthcare systems. To estimate the carbon footprint of the healthcare system of Geneva's canton, we collected raw data on the activities of its stakeholders. Our analysis shows that when excluding medicines and medical devices, hospitals are the main greenhouse gas emitter by far, accounting for 48% of the healthcare system's emission, followed by nursing homes (20%), private practice (18%), medical analysis laboratories (7%), dispensing pharmacies (4%), the homecare institution (3%), and the ambulance services (<1%). The most prominent emission items globally are medicines and medical devices by far, accounting for 59%, followed by building operation (19%), transport (11%), and catering (4%), among others. To actively reduce Geneva's healthcare carbon emissions, we propose direct and indirect measures, either with an immediate impact or implementing systemic changes concerning medicine prescription, building heating and cooling, low-carbon means of transport, less meaty diets, and health prevention. This study, the first of its kind in Switzerland, deciphers where most of the greenhouse gas emissions arise and proposes action levers to pave the way for ambitious emission reduction policies. We also invite health authorities to engage pharmaceutical and medical suppliers in addressing their own responsibilities, notably through the adaptation of procurement processes and requirements.
Topics: Carbon Footprint; Switzerland; Delivery of Health Care; Greenhouse Gases; Humans; Carbon Dioxide; Air Pollutants
PubMed: 38928936
DOI: 10.3390/ijerph21060690 -
BMJ Open Jun 2024A vital component of a prehospital emergency care system is getting an injured patient to the right hospital at the right time. Process and information flow mapping are...
OBJECTIVE
A vital component of a prehospital emergency care system is getting an injured patient to the right hospital at the right time. Process and information flow mapping are recognised methods to show where efficiencies can be made. We aimed to understand the process and information flows used by the prehospital emergency service in transporting community emergencies in Rwanda in order to identify areas for improvement.
DESIGN
Two facilitated process/information mapping workshops were conducted. Process maps were produced in real time during discussions and shared with participants for their agreement. They were further validated by field observations.
SETTING
The study took place in two prehospital care settings serving predominantly rural and predominantly urban patients.
PARTICIPANTS
24 healthcare professionals from various cadres. Field observations were done on 49 emergencies across both sites.
RESULTS
Two maps were produced, and four main process stages were described: (1) call triage by the dispatch/call centre team, (2) scene triage by the ambulance team, (3) patient monitoring by the ambulance team on the way to the health facility and (4) handover process at the health facility. The first key finding was that the rural site had multiple points of entry into the system for emergency patients, whereas the urban system had one point of entry (the national emergency number); processes were otherwise similar between sites. The second was that although large amounts of information were collected to inform decision-making about which health facility to transfer patients to, participants found it challenging to articulate the intellectual process by which they used this to make decisions; guidelines were not used for decision-making.
DISCUSSION
We have identified several areas of the prehospital care processes where there can be efficiencies. To make efficiencies in the decision-making process and produce a standard approach for all patients will require protocolising care pathways.
Topics: Humans; Rwanda; Emergency Medical Services; Triage; Ambulances; Rural Health Services; Transportation of Patients; Patient Handoff
PubMed: 38925682
DOI: 10.1136/bmjopen-2024-085064 -
Diabetes/metabolism Research and Reviews Jul 2024Fluid resuscitation during diabetic ketoacidosis (DKA) is most frequently performed with 0.9% saline despite its high chloride and sodium concentration. Balanced... (Meta-Analysis)
Meta-Analysis
Fluid resuscitation with balanced electrolyte solutions results in faster resolution of diabetic ketoacidosis than with 0.9% saline in adults - A systematic review and meta-analysis.
Fluid resuscitation during diabetic ketoacidosis (DKA) is most frequently performed with 0.9% saline despite its high chloride and sodium concentration. Balanced Electrolyte Solutions (BES) may prove a more physiological alternative, but convincing evidence is missing. We aimed to compare the efficacy of 0.9% saline to BES in DKA management. MEDLINE, Cochrane Library, and Embase databases were searched for relevant studies using predefined keywords (from inception to 27 November 2021). Relevant studies were those in which 0.9% saline (Saline-group) was compared to BES (BES-group) in adults admitted with DKA. Two reviewers independently extracted data and assessed the risk of bias. The primary outcome was time to DKA resolution (defined by each study individually), while the main secondary outcomes were changes in laboratory values, duration of insulin infusion, and mortality. We included seven randomized controlled trials and three observational studies with 1006 participants. The primary outcome was reported for 316 patients, and we found that BES resolves DKA faster than 0.9% saline with a mean difference (MD) of -5.36 [95% CI: -10.46, -0.26] hours. Post-resuscitation chloride (MD: -4.26 [-6.97, -1.54] mmoL/L) and sodium (MD: -1.38 [-2.14, -0.62] mmoL/L) levels were significantly lower. In contrast, levels of post-resuscitation bicarbonate (MD: 1.82 [0.75, 2.89] mmoL/L) were significantly elevated in the BES-group compared to the Saline-group. There was no statistically significant difference between the groups regarding the duration of parenteral insulin administration (MD: 0.16 [-3.03, 3.35] hours) or mortality (OR: -0.67 [0.12, 3.68]). Studies showed some concern or a high risk of bias, and the level of evidence for most outcomes was low. This meta-analysis indicates that the use of BES resolves DKA faster than 0.9% saline. Therefore, DKA guidelines should consider BES instead of 0.9% saline as the first choice during fluid resuscitation.
Topics: Adult; Humans; Diabetic Ketoacidosis; Electrolytes; Fluid Therapy; Prognosis; Resuscitation; Saline Solution
PubMed: 38925619
DOI: 10.1002/dmrr.3831 -
American Journal of Infection Control Jun 2024Paramedics are exposed to many infectious diseases in their daily professional activities, leading to a high risk of transmitting infectious diseases to patients in...
BACKGROUND
Paramedics are exposed to many infectious diseases in their daily professional activities, leading to a high risk of transmitting infectious diseases to patients in out-of-hospital settings, and possibly leading to healthcare associated infections in hospitals and the community. The coronavirus disease 2019 pandemic has highlighted the importance of infection prevention and control in healthcare more broadly and the role of paramedics in infection control is considered even more critical. Despite this, in many countries such as Australia, research into infection prevention and control research has mainly been focused on in-hospital health care professionals with limited out-of-hospital studies.
METHODS
This scoping review was conducted based upon Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to evaluate the literature relating to knowledge and awareness of infection prevention and control in paramedics in Australia and other countries.
RESULTS/DISCUSSION
Based upon the selection criteria applied, six papers were identified for inclusion in this review. In many studies reviewed, infection prevention and control was identified by paramedics as being important, however compliance with hand hygiene practices was low and most studies highlighting the need for more education and training on infectious disease for paramedics.
CONCLUSION
The current evidence suggests that paramedics have poor compliance with recommended IPC practices. The profession needs to improve IPC education, training, and culture.
PubMed: 38925500
DOI: 10.1016/j.ajic.2024.06.014 -
Injury Jun 2024An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of...
INTRODUCTION
An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of airway management. Two techniques exist for FONA, with literature favouring the surgical technique over the percutaneous. The reported need for a prehospital FONA is fortunately rare as the mortality has been shown to be high. Due to the low incidence, literature on FONA is limited with regards to different settings, techniques and operators. As a foundation for future research and improvement of patient care, we aim to describe the frequency, indications, technique, success, and outcomes of FONA in the Finnish helicopter emergency medical services (HEMS).
MATERIALS AND METHODS
This retrospective descriptive study reviews FONA performed at the Finnish HEMS during 1.1.2012 to 8.9.2019. The Finnish HEMS consists of six units, staffed mainly by anaesthesiologists. Clinical data was gathered from a national HEMS database and trough chart reviews. Data on mortality was obtained from a population registry. Only descriptive statistics were performed.
RESULTS
A total of 22 FONA were performed during the study period, 7 were primary and 14 performed after failure to intubate (missing data regarding indication for one attempt). This equals a 0.13 % (14/10,813) need for a rescue FONA and a rate of 0.20 % (22/10,813) FONA out of all advanced airway management. All but one FONA was performed using a surgical approach (20/21, 95 %, missing data = 1) and all were successful (22/22, 100 %). Indications were mainly cardiac arrest (10/22, 45 %) and trauma (6/22, 27 %), and the most common reason for a need for a secondary FONA was obstruction of airway by food or fluids (7/14, 50 %). On-scene mortality was 36 % (8/22) and 30-day mortality 90 % (19/21, missing data = 1).
CONCLUSION
The need for FONA is scarce in a HEMS system with experienced airway providers. Even though the procedure is successfully performed, the mortality is markedly high.
PubMed: 38924838
DOI: 10.1016/j.injury.2024.111689