Search Results (293)

Hemorrhage is the leading cause of preventable death in trauma care, requiring rapid and accurate detection to guide effective interventions. Hemorrhagic shock can be masked by underlying compensatory mechanisms, which may lead to delayed decision-making that can compromise casualty care. In this proof-of-concept study, we aimed to develop and evaluate machine learning models to predict Percent Estimated Blood Loss from a photoplethysmography waveform, offering non-invasive, field deployable solutions. Different model types were tuned and optimized using data captured during a hemorrhage and resuscitation swine study. Through this optimization process, we evaluated different time-lengths of prediction windows, machine learning model architectures, and data normalization approaches. Models were successful at predicting Percent Estimated Blood Loss in blind swine subjects with coefficient of determination values exceeding 0.8. This provides evidence that Percent Estimated Blood Loss can be accurately derived from non-invasive signals, improving its utility for trauma care and casualty triage in the pre-hospital and emergency medicine environment. Full article

Introduction: Falls are the leading cause of Emergency Department (ED) presentations among residents from residential aged care facilities (RACFs). While most current studies focus on post-fall evaluations and fall prevention, limited research has been conducted on decision-making in post-fall management. Objective: To develop and internally validate a model that can predict the likelihood of RACF residents being discharged from the ED after being presented for a fall. Methods: The study sample was obtained from a previous study conducted in Shepparton, Victoria, Australia. Consecutive samples were selected from January 2023 to November 2023. Participants aged 65 and over were included in this study. Results: A total of 261 fall presentations were initially identified. One patient with Australasian Triage Scale category 1 was excluded to avoid overfitting, leaving 260 presentations for analysis. Two logistic regression models were developed using prehospital and ED variables. The ED predictor model variables included duration of ED stay, injury severity, and the presence of an advance care directive (ACD). It demonstrated excellent discrimination (AUROC = 0.83; 95% CI: 0.79–0.89) compared to the prehospital model (AUROC = 0.77, 95% CI: 0.72–0.83). A simplified four-variable Discharge Eligibility after Fall in Elderly Residents (DEFER) score was derived from the prehospital model. The score achieved an AUROC of 0.76 (95% CI: 0.71–0.82). At a cut-off score of ≥5, the DEFER score exhibited a sensitivity of 79.7%, a specificity of 60.3%, a diagnostic odds ratio of 5.96, and a positive predictive value of 85.0%. Conclusions: The DEFER score is the first validated discharge prediction model for residents of RACFs who present to the ED after a fall. Importantly, the DEFER score advances personalised medicine in emergency care by integrating patient-specific factors, such as ACDs, to guide individualised discharge decisions for post-fall residents from RACFs. Full article

Background: Falls in residential aged care facilities (RACFs) have a significant impact, often leading to costly and unnecessary emergency department (ED) transfers. This scoping review examined the ED discharge proportions and patient characteristics of RACF residents presenting to the ED following a fall, to identify factors that could reduce unnecessary ED transfers. Methods: The databases MEDLINE, CINAHL, Scopus, and Web of Science were searched, resulting in an initial 1385 articles. Nine of these articles met the inclusion criteria and were included in this review. Results: The median age of patients reported in the nine papers ranged from 80.8 to 88 years. Discharge proportions from ED back to RACF ranged from 36% to 91%, with an average of 63%. The studies that reported on computed tomography of the brain (CTB) showed that CTB findings did not significantly influence discharge decisions. Conclusions: Many RACF residents transferred to EDs following falls are discharged without hospital admission. The heterogeneity of study methods makes it challenging to draw definitive conclusions about factors that may help identify patient groups that do not require transfer to the ED following a fall. However, this scoping review highlights potential opportunities to reduce ED transfers from RCAFs. These findings highlight a need for geriatric-specific, person-centred protocols that reduce unnecessary ED transfers while safeguarding quality of care and respecting residents’ advance care preferences. Full article

Background/Objectives: Early diagnosis of stroke is crucial for effective treatment with tissue plasminogen activator (tPA) and endovascular thrombectomy. Emergency medical services (EMSs) screening and the early activation of emergency department (ED) stroke protocols reduce treatment times and improve patient outcomes. This study aims to validate ED stroke protocol activation by EMSs in a large stroke center. Methods: This retrospective cross-sectional study was conducted at Magen David Adom and Shamir Medical Center between 1 January 2019 and 31 December 2019. Data were categorized into patients suspected by EMSs of having a stroke and those not suspected by EMSs but diagnosed as having a stroke in the ED. The primary outcome was the accuracy of EMSs in activating ED stroke protocols. Results: In this study, there were 23,061 patients, of which 11,841 (51.9%) were females. The mean age was 61.4 (SD = 22.72) years old. EMSs suspected 743 (3.22%) patients were having a stroke. In 587 (79%), EMSs activated ED stroke protocols. There were 88 cases where strokes were diagnosed in the ED when EMSs did not suspect a stroke. The overall EMSs negative predictive value (NPV) was 100% while the positive predictive value (PPV) was 20%. Conclusions: While Israeli EMSs over-activate the ED stroke protocol, stroke patients are almost never missed, achieving the goal of prehospital stroke screening. To prevent resource waste, all involved teams should be notified, and the actual activation of the stroke protocol should be carried out by an ED physician upon patient arrival. Communication between all levels regarding stroke protocol should also be increased to decrease the time to treatment. Full article

Background/Objectives: This study aimed to evaluate a regional implementation project for rural emergency care (RuralRescue) and to examine how its components and outcomes may support personalized approaches in emergency medicine. While not originally designed as a personalized medicine intervention, the project combined digital, educational, and organizational innovations that enable patient-specific adaptation of care processes. Methods: Conducted in the rural district of Vorpommern-Greifswald (Mecklenburg–Western Pomerania, Germany), the intervention included (1) standardized cardiopulmonary resuscitation (CPR) training for laypersons, (2) a geolocation-based first responder app for medically trained volunteers, and (3) integration of a tele-emergency physician (TEP) system with prehospital emergency medical services (EMSs). A multi-perspective pre–post evaluation covered medical, economic, and organizational dimensions. Primary and secondary outcomes included bystander CPR rates, responder arrival times, telemedical triage decisions, diagnostic concordance, hospital transport avoidance, economic simulations, workload, and technology acceptance. Results: Over 12,600 citizens were trained in CPR and the responder app supported early intervention in hundreds of cases. TEPs remotely assisted 3611 emergency calls, including delegated medication in 17.8% and hospital transport avoidance in 24.3% of cases. Return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA) was achieved in 35.6% of cases with early CPR. Diagnostic concordance reached 84.9%, and documentation completeness 92%. Centralized coordination of TEP units reduced implementation costs by over 90%. Psychological evaluation indicated variable digital acceptance by role and experience. Conclusions: RuralRescue demonstrates that digitally supported, context-aware, and regionally integrated emergency care models can contribute significantly to personalized emergency medicine and can be cost-effective. The project highlights how intervention intensity, responder deployment, and treatment decisions can be tailored to patient needs, professional capacity, and regional structures—even in resource-limited rural areas. Full article

Background: he surge in the use of Pre-hospital Emergency Medical Systems (EMS) and Emergency Departments (ED) has become a pressing issue worldwide after the COVID-19 pandemic. To address this challenge, we developed an experimental and innovative care pathway supported by telemedicine. The aim of this study is to describe the activity of the Integrated Medical Center (CMI): a new telemedicine-based care model for patients referring to the Emergency Medical System. Methods: A prospective observational study was conducted from January 2022 to December 2022. The CMI was established to manage patients referring to the Emergency Medical System. Results: From January to December 2022, a total of 8680 calls were managed by CMI, with an average of 24 calls per day. 6243 patients (71.9%) were managed without ED access of whom 4884 patients (78.2%) were managed through telemedicine evaluation only, and 1359 (21.8%) with telemedicine evaluation and dispatch of the Home Rapid Response Team (HRRT). The population treated by the HRRT exhibited a higher age. The mean satisfaction score was 9.1/10. Conclusions: Telemedicine evaluation allowed for remote assessments, treatment prescriptions, and teleconsultation for HRRT and was associated with high patient satisfaction. This model could be useful in future pandemics for managing patients with non-urgent illnesses at home, preventing hospital admissions for potentially infectious patients, and thereby reducing in-hospital transmission. Full article

Background/Objectives: Ultrasonography is a diagnostic modality characterized by high sensitivity in detecting hepato-biliary pathology, particularly intrahepatic biliary duct dilation. This study compares the sonographic findings obtained by a radiographer/sonographer in a Basic Emergency Service (BES) using Point-of-Care Ultrasonography (POCUS) in Portugal with the sonographic findings from the same patients acquired by radiologists at a referral hospital (RH) for suspected intrahepatic biliary dilatation. Methods: Nineteen patients presenting with right upper quadrant (RUQ) pain and suspected abdominal pathology underwent sonographic screening using POCUS in the BES. Subsequently, the same patients were referred to the RH, where a radiologist performed a comprehensive ultrasound. Both examinations were compared to determine whether the findings obtained in the BES were confirmed by radiologists in the RH. Results: Cholestasis, cholangitis, lithiasis, pancreatitis, peri-ampullary lithiasis, and neoplasms were observed in association with intrahepatic biliary dilation in this study sample. All six variables showed a strong association between the BES and RH findings (Cramer’s V > 0.6; p < 0.006). A strong kappa measure of agreement between the radiographer and radiologist findings was obtained in “cholelithiasis/sludge/gallbladder acute sonographic changes” (k = 0.802; p = 0.000). A moderate kappa value was obtained for the variable “abdominal free fluid”, (k = 0.706; p = 0.001). Conclusions: In this study, all patients referred from the BES to the RH required hospitalization for treatment and additional imaging exams. Although pre-hospital screening ultrasound is not intended for definitive diagnoses, the early detection of intrahepatic biliary tract dilatation through screening sonography played a significant role in the clinical referral of patients, with a sensitivity of 94% and specificity of 75%. Full article

Background/Objectives: Pain remains as a prevailing cause, prompting patients to seek medical attention, comprising approximately 40% of all emergency department (ED) visits annually. Timely and effective pain management is crucial for patient comfort, satisfaction, and optimal recovery. However, there is increasing evidence highlighting the concern that patients often receive inadequate pain management in both emergency departments and prehospital settings. Despite the simplicity and potential for the repetitive use of pain scales throughout a patient’s stay, it appears that a greater emphasis is often placed on monitoring hypotension or low saturation values rather than addressing pain levels above 7 on the numeric rating pain scale. Methods: This article represents an ambitious attempt to implement process improvement methodologies such as Lean Management and SixSigma, both which have been well established in service and industrial fields, within the hospital environment to improve the process of pain management in the emergency department. Results: The implementation of pain management improvement processes in the emergency department led to a statistically significant but clinically modest increase in the administration of analgesics and improved pain reporting practices. The percentage of patients receiving no analgesia decreased from 96.6% to 94.8% (p = 0.008), and the documentation of pain characteristics during triage improved. However, the escalation of pain therapy remained limited, and strong analgesics were still underutilized. Conclusions: Despite partial improvements, the lean management-based interventions did not sufficiently address the problem of oligoanalgesia in the emergency setting. Sustainable change requires enhanced clinical engagement, ongoing staff training, and the broader adoption of structured analgesia protocols across prehospital and hospital care. Full article

Background: Respiratory infections (RIs) are a common cause of care by Prehospital Emergency Medical Services (PEMS). Early Warning Scores (EWS) are tools used by PEMS to assess patients with acute pathology. However, there is little evidence of their application in RIs. The primary aim of this study was to assess the ability of five EWS to predict one-year mortality (M1Y) and two-year (M2Y) mortality in patients with suspected RI assisted by PEMS. The secondary objective was to perform a survival analysis. Methods: An observational and prospective study was conducted in adult patients with RIs transferred by EMS to their referral hospital. The variables necessary for the calculation of EWS [National Early Warning Score 2 (NEWS2), Quick Sequential Organ Failure Assessment (qSOFA) score, Quick COVID-19 Severity Index (qCSI), CURB-65 Score for Pneumonia Severity (CURB-65) and BAP-65 Score for Acute Exacerbation of COPD (BAP-65) score] were collected. The prognostic ability of the EWS was assessed by the area under the receiver operating characteristic curve (AUC). Patients were followed up and a survival study was performed. Results: A total of 819 patients met the inclusion criteria. M1Y was 55.9% and M2Y was 63.5%. BAP-65 showed the best predictive ability at both 1 and 2 years, with AUC of 0.716 and 0.711, respectively. 48.8% of deaths took place during the first month. Conclusions: BAP-65 was the score with the best ability to predict both M1Y and M2Y after the index event in patients with RIs. All other EWS analyzed showed poor performance except in patients with low comorbidity. Full article

Background: Delirium is a frequent yet pathophysiologically still poorly understood complication in the intensive care unit (ICU) and is associated with adverse outcomes for the patients. Currently, guidelines give several recommendations for treating delirium in the ICU, but to date no sufficient drug treatment exists. Dexmedetomidine, primarily used for anesthesia and sedation in ICUs has shown a preventive effect of delirium compared to other sedatives, such as propofol. We hypothesize that overnight administration of dexmedetomidine may prevent and/or shorten the duration of delirium in ICU patients. Methods: The Basel propofol dexmedetomidine (BaProDex) Study was a single-center, prospective, randomized controlled trial. We included adult ICU patients with hyperactive or mixed delirium. Patients with delirium prior to ICU admission, advanced heart block, uncontrolled hypotension, or status epilepticus were excluded. The participants were randomly assigned 1:1 to either receive dexmedetomidine (study group) or propofol (control group) as a continuous infusion overnight. The Intensive Care Delirium Screening Checklist (ICDSC) was applied at least three times per day. Delirium was defined as an ICDSC ≥ 4. The study drug was administered until the end of delirium or ICU discharge. The primary endpoint was the time to delirium episode end, which was analyzed using cumulative incidence curves and a cause specific Cox proportional hazards regression with death as a competing risk. Secondary endpoints included recurrence of delirium until 28 days after ICU discharge, death until day 28, severity of ICU delirium, number of ventilation days, ICU length of stay (LOS) in hours, hospital length of stay in days and survival after three and twelve months after ICU discharge. Due to insufficient recruitment the trial needed to be stopped prematurely. Results: In total, 38 patients were enrolled and randomized in the two groups. The median duration of delirium was shorter in the dexmedetomidine group as compared to the propofol group (ITT: 34 vs. 66 h; PP: 31 vs. 66 h), resulting in a hazard ratio of 1.92 (95% CI 0.89–4.15, p = 0.097) in the ITT and 2.95 (95% CI 1.27–6.86, p = 0.012) in the PP analysis. In the PP analysis, the 28-day mortality was lower in the dexmedetomidine group (1 vs. 5 deaths) and fewer patients needed ventilation (7 vs. 15 patients). Both ICU and hospital LOS were shorter in the dexmedetomidine group (ICU LOS: median 43 vs. 128 h; hospital LOS: median 12 vs. 22 days). Further, mortality up to three and twelve months was lower in the dexmedetomidine group compared to the propofol group (PP: 2 vs. 8 patients died within twelve months, 2 vs. 7 patients died within three months). The recurrence of delirium until 28 days after ICU discharge and severity of delirium were similar in both groups. Conclusions: Despite premature termination, BaProDex provides preliminary evidence for a reduction in the duration of delirium by nocturnal infusion of dexmedetomidine compared to propofol. Therefore, dexmedetomidine may be considered an option to treat hyperactive or mixed delirium in ICU patients. However, due to the small sample size, the study is rather of exploratory nature due to the premature termination, and we cannot rule out that the observed treatment effect is overly optimistic or by chance. Full article

Introduction: Psychomotor agitation represents a complex medical emergency, particularly challenging in prehospital settings. Since March 2020, the incidence of psychomotor agitation has significantly increased. Rationale: Emergency Medical Services (EMS) frequently serve as the first point of contact, bearing the critical responsibility of effectively managing these situations. Objective: This was to assess the feasibility and suitability of the intranasal route for administering pharmacological therapy in the prehospital management of patients experiencing psychomotor agitation. Materials and Methods: An integrative review of the literature was conducted to evaluate the use of the intranasal route for drug administration in patients with psychomotor agitation in prehospital settings. The review was carried out between September 2022 and July 2024. A total of 454 articles were identified, 15 of which met the inclusion criteria. These were supplemented by an additional 10 records, resulting in the analysis of 25 studies. Results: Seventeen studies outlined protocols for managing agitated patients, five described the correct technique for intranasal drug administration, and eleven identified drugs suitable for this route. Conclusions: The intranasal route is a safe, rapid, and accessible method for the pharmacological containment of agitated patients in prehospital settings, particularly for individuals who are uncooperative. Full article

Background/Objectives: Impaired consciousness has various causes. One such cause includes hypoglycemia, which may be symptomatic or asymptomatic and is associated with high mortality. Autonomic abnormalities are also common in hypoglycemic patients. Early detection is critical for improving prognosis. In this study, we evaluated changes in vital signs and pupillary responses before and after glucose administration in patients with hypoglycemia managed in a prehospital emergency setting. Methods: This retrospective observational study included 583 adult patients from the Tokyo Fire Department database. All patients were suspected by emergency medical technicians (EMTs) to have hypoglycemia-related impaired consciousness and showed improved consciousness after receiving intravenous glucose infusion at the scene. Vital signs, level of consciousness, and pupillary responses were assessed before and after glucose administration. Results: The mean patient age was 58.9 years, and approximately 90% had comorbid diabetes mellitus. Tachypnea was common at the scene, with 27% showing tachycardia, while blood pressure remained normal. Miosis and abnormal pupillary light reflexes were observed in 68% and 84% of cases, respectively. Anisocoria occurred in 7.6% of the patients. After glucose administration, both abnormal reflexes and anisocoria significantly decreased (both p < 0.0001). Although vital signs did not consistently reflect autonomic responses, changes in pupillary findings were prominent. Conclusions: Altered pupillary responses are common in hypoglycemic coma. Findings such as miosis and anisocoria can result from various causes, including central nervous system disorders and cholinergic toxicity; thus, careful differential diagnosis is essential. Normal blood pressure may help to distinguish hypoglycemic coma during prehospital care. Full article

Out-of-hospital cardiac arrest remains a major cause of adult mortality worldwide, with survival to hospital discharge rates around 10%. Despite advances in prehospital care, rapid recognition and high-quality chest compressions are the primary interventions, while early defibrillation is one of the few measures shown to improve survival. This literature review examines novel interventions for patients with refractory ventricular fibrillation and pulseless ventricular tachycardia, focusing on double sequential defibrillation, beta-adrenergic receptor antagonists, and extracorporeal cardiopulmonary resuscitation. Evidence suggests that double sequential defibrillation may improve survival to discharge in refractory ventricular fibrillation, but consensus and large-scale validation are lacking. Beta-blockers show promise for increasing the rates of return of spontaneous circulation and favourable neurological outcomes, yet robust evidence is still needed. Extracorporeal cardiopulmonary resuscitation, particularly when initiated rapidly in selected patients, can enhance survival and neurological outcomes, though studies show mixed results and highlight the importance of patient selection and system readiness. Overall, while these interventions offer potential, their widespread adoption requires further high-quality research to determine efficacy, optimal protocols, and resource implications in both prehospital and emergency department settings. Full article

Background: Cardiogenic shock (CS) is a life-threatening complication of ST-elevation myocardial infarction (STEMI) and remains the leading cause of in-hospital mortality, with rates ranging from 5 to 10% despite advances in reperfusion strategies. Early identification and timely intervention are critical for improving outcomes. This study investigates the utility of machine learning (ML) models for predicting the risk of CS during the early phases of care—prehospital, emergency department (ED), and cardiology-on-call—with a focus on accurate triage and prioritization for urgent angiography. Results: In the prehospital phase, the Extra Trees classifier demonstrated the highest overall performance. It achieved an accuracy (ACC) of 0.9062, precision of 0.9078, recall of 0.9062, F1-score of 0.9061, and Matthews correlation coefficient (MCC) of 0.8140, indicating both high predictive power and strong generalization. In the ED phase, the support vector machine model outperformed others with an ACC of 78.12%. During the cardiology-on-call phase, Random Forest showed the best performance with an ACC of 81.25% and consistent values across other metrics. Quadratic discriminant analysis showed consistent and generalizable performance across all early care stages. Key predictive features included the Killip class, ECG rhythm, creatinine, potassium, and markers of renal dysfunction—parameters readily available in routine emergency settings. The greatest clinical utility was observed in prehospital and ED phases, where ML models could support the early identification of critically ill patients and could prioritize coronary catheterization, especially important for centers with limited capacity for angiography. Conclusions: Machine learning-based predictive models offer a valuable tool for early risk stratification in STEMI patients at risk for cardiogenic shock. These findings support the implementation of ML-driven tools in early STEMI care pathways, potentially improving survival through faster and more accurate decision-making, especially in time-sensitive clinical environments. Full article

Background/Objectives: Acute obstructions of the upper respiratory tract are emergencies that may require a cricothyrotomy as ultima ratio. For this, precise identification of the conic ligament is essential. Point-of-care ultrasound (POCUS) offers a reliable tool for anatomical localization in challenging cases and could be used by a range of emergency medicine workers. This prospective, controlled observational study assesses the development of competencies of paramedics (PMs) in point-of-care ultrasound (POCUS) assisted identification of the conic ligament after structured training, and compares their competence level to emergency physicians (EPs). Methods: PMs and a control group of EPs received an identical structured training program as part of an ultrasound course. It included a 10-min theoretical introduction, a 10-min video, and a 45-min practical session with ultrasound devices. Questionnaires and a practical test assessed both group’s previous experiences, satisfaction with training, and the development of subjective and objective competencies before (T₁) and after (T₂) the training. Results: A total of 120 participants (N = 92 PMs and N = 28 EPs) participated. A minority had previously performed a cricothyrotomy even in training settings (PMs 17%; EPs 11%), and none had identified the conic ligament using POCUS. The study group’s subjective and objective competencies increased significantly (p < 0.001). At T2, the study group demonstrated comparable subjective (p = 0.22) and objective (p = 0.81) competencies to those of the control group. The study group needed significantly (p < 0.01) less time to perform the DOPS. While both groups were satisfied with the study material (PMs 2.2 ± 1.2 vs. Eps 1.6 ± 1.0; p = 0.02) and the training (PMs 1.8 ± 1.0 vs. EPs 1.4 ± 0.7, p = 0.03), the study group rated both significantly better. Conclusions: After structured training, paramedics successfully identified the conic ligament using POCUS comparably to emergency physicians. Integrating POCUS into paramedic training may improve prehospital airway management and enhance patient safety. Further studies should investigate long-term skill retention and real-life application. Full article