Emergency medicine for 25 Years in Iceland - history of the specialty in a nutshell

Agonal breathing upon hospital arrival as a prognostic factor in patients experiencing out-of-hospital cardiac arrest

Background

Agonal breathing is a relatively common symptom that follows cardiac arrest when the brainstem function is preserved. Agonal breathing is associated with favorable survival in patients experiencing out-of-hospital cardiac arrest (OHCA). While previous studies focused on agonal breathing observed in the pre-hospital setting for all study subjects, we focused on agonal breathing observed upon hospital arrival. In this multicenter prospective study, we aimed to assess the prognosis of patients exhibiting agonal breathing upon hospital arrival were compared. We hypothesized that agonal breathing at hospital arrival would be associated with favorable neurological outcomes among patients with OHCA.

Methods

The data on incidence of agonal breathing were prospectively collected for all evaluable participants in a multicenter, observational study in Japan (SOS-KANTO [Survey of Survivors after Out-of-Hospital Cardiac Arrest in Kanto Area] 2017 Study). Groups with and without agonal breathing were compared upon hospital arrival. Propensity-score with inverse probability of treatment weighting (IPTW) analysis was performed to adjust for confounding factors. The primary outcome was a favorable neurological outcome (Cerebral Performance Category 1-2) at 1 month.

Results

A total of 6,457 participants out of the 9,909 registered in SOS-KANTO 2017 (in which 42 facilities participated) were selected for the current study. There were 128 patients (2.0%) in the with-agonal breathing group and 6,329 (98.0%) in the withoutagonal breathing group. The primary outcome was 1.1% in the with-agonal breathing group and 0.6% in the without-agonal breathing group (risk difference, 0.55; 95% confidence interval, 0.23-0.87) after IPTW analysis.

Conclusion

In this multicenter prospective study, agonal breathing at hospital arrival was significantly associated with better neurological outcomes and increased survival at 1 month. Thus, agonal breathing at hospital arrival may be a useful prognostic predictor for patients experiencing OHCA.

The relationship between regional inequalities in the provision of emergency health services and other health services

In this research, it was aimed to examine relationship between regional inequalities in the provision of emergency health services and other health services in Turkey. The values of the number of emergency services and the population per emergency service for the years 2002-2021 were taken from the most up-to-date database published by the Ministry of Health in 2022 and were chosen as the dependent variables of the study. The "regional price level indices for consumption expenditures (PLI)" and "gross domestic product per capita, Statistical Regions Level 2 (PcGDP)" data compiled by TURKSTAT were used as independent variables. Number of emergency stations were significantly correlated with TR31 (İzmir) (r = 0.903; P < .01), TR32 (Aydin, Denizli, Muğla) (r = 0.771; P < .01), TR42 (Kocaeli, Sakarya, Düzce, Bolu, Yalova) (r = -0.798; P < .01), TR62 (Adana, Mersin) (r = 0.837; P < .01), TR63 (Hatay, K.Maraş, Osmaniye) (r = -0.749; P < .01), TR72 (Kayseri, Sivas, Yozgat) (r = -0.719; P < .01), TR83 (Samsun, Tokat, Çorum, Amasya) (r = 0.873; P < .01), TRA2 (Ağri, Kars, Iğdir, Ardahan) (r = -0.873; P < .01), TRB2 (Van, Muş, Bitlis, Hakkari) (r = -0.736; P < .01), TRC2 (Şanliurfa, Diyarbakir) (r = 0.697; P < .01), and TRC3 (Mardin, Batman, Şirnak, Siirt) (r = 0.574; P < .01). In total, 11 of 26 were significantly correlated with inequalities. Although the number of emergency services has increased since 2002 and the population density per emergency room has tended to decrease, regional inequalities also have an impact on the delivery of emergency services today.

Current postgraduate training in emergency medicine in the Nordic countries

BACKGROUND

Emergency Medicine (EM) is an independent specialty in all five Nordic countries. This study aims to evaluate the structure of post-graduate EM training in the area.

METHODS

A leading hospital or hospitals in EM training in each country were identified. An e-survey was sent to each hospital to gather data on patient volume and physician staffing, curriculum, trainee supervision, and monitoring of progression in training.

RESULTS

Data were collected from one center in Iceland and Norway, two in Finland and Sweden, and four centers in Denmark. The data from each country in Denmark, Finland, and Sweden, were pooled to represent that country. The percentage of consultants with EM specialist recognition ranged from 49-100% of all consultants working in the participating departments. The number of patients seen annually per each full time EM consultant was almost three times higher in Finland than in Sweden. In Iceland, Denmark, and Sweden a consultant was present 24/7 in the ED but not in all centers in the other countries. The level of trainee autonomy in clinical practice varied between countries. Requirements for completing standardized courses, completing final exams, scientific and quality improvement projects, and evaluation of trainee progression, varied between the countries.

CONCLUSIONS

All Nordic countries have established EM training programs. Despite cultural similarities, there are significant differences in how the EM training is structured between the countries. Writing and implementing a standardized training curriculum and assessment system for EM training in the Nordic countries should be considered.

Automatic localisation and per-region quantification of traumatic brain injury on head CT using atlas mapping

Rationale and objectives

To develop a method for automatic localisation of brain lesions on head CT, suitable for both population-level analysis and lesion management in a clinical setting.

Materials and methods

Lesions were located by mapping a bespoke CT brain atlas to the patient's head CT in which lesions had been previously segmented. The atlas mapping was achieved through robust intensity-based registration enabling the calculation of per-region lesion volumes. Quality control (QC) metrics were derived for automatic detection of failure cases. The CT brain template was built using 182 non-lesioned CT scans and an iterative template construction strategy. Individual brain regions in the CT template were defined via non-linear registration of an existing MRI-based brain atlas.Evaluation was performed on a multi-centre traumatic brain injury dataset (TBI) (n = 839 scans), including visual inspection by a trained expert. Two population-level analyses are presented as proof-of-concept: a spatial assessment of lesion prevalence, and an exploration of the distribution of lesion volume per brain region, stratified by clinical outcome.

Results

95.7% of the lesion localisation results were rated by a trained expert as suitable for approximate anatomical correspondence between lesions and brain regions, and 72.5% for more quantitatively accurate estimates of regional lesion load. The classification performance of the automatic QC showed an AUC of 0.84 when compared to binarised visual inspection scores. The localisation method has been integrated into the publicly available Brain Lesion Analysis and Segmentation Tool for CT (BLAST-CT).

Conclusion

Automatic lesion localisation with reliable QC metrics is feasible and can be used for patient-level quantitative analysis of TBI, as well as for large-scale population analysis due to its computational efficiency (<2 min/scan on GPU).

Electrodiagnostic Evaluation of Prognostic Factors Influencing the Surgical Outcomes of Upper Extremity Nerve Injuries Caused by Penetrating Trauma: A Cross-sectional Study

Background

Peripheral nerve damage is a major cause of disability, which can lead to serious limitations in daily and occupational activities. Although primary repair can restore the function of the damaged organ remarkably, factors predicting the prognosis of nerve repair are a topic of constant debate. We aimed to investigate the factors affecting the outcomes of primary nerve repair in patients afflicted by upper extremity nerve injuries following penetrating trauma.

Methods

This cross-sectional study was conducted on 51 patients referred to Shohada-ye Ashayer Hospital in Khorramabad, Iran, from 2016 to 2021. Data including the patient's age, gender, education, type, severity, and mechanism of injury, the damaged nerve, time and of method repair, the surgeon's specialty, as well as the electrodiagnostic findings, were collected and analyzed using SPSS software version 22.

Results

The mean age of the patients was 30.41 ± 12.63 years, and the majority of them (84.3%) were men. A significant relationship was found between the sensory amplitude with education (P=0.002), the type of damaged nerve (P=0.048), and the severity of injury (P=0.012). The positive sharp wave was significantly associated with the surgeon's specialty (P=0.034). Besides, the motor amplitude was considerably related to the patient's age (P=0.040) and the surgeon's specialty (P=0.035).

Conclusion

Factors determining the outcome of peripheral nerve repair following penetrating trauma to the upper extremity include age, education, the type of damaged nerve, the severity of the injury, and the surgeon's specialty.

Cost-effectiveness Analysis of Air Emergency Versus Ground Emergency Medical Services Regarding the Patient's Transportation and Treatment in Selected Hospital

Background: The prehospital emergency system is the first initiator of medical care as an alternative to hospitals and health care services that helps patients and injured people in critical situations and accidents. This study aimed to evaluate the cost-effectiveness of air ambulance versus ground ambulance regarding the patient's transportation and treatment. Methods: In this cost-effectiveness analysis study, 300 patients who were transferred to the Shohadaye HaftomTir hospital by air ambulance and 300 patients transferred by ground ambulance during the study period were selected in 2021-2022. This study examined the costs from the society's perspective. After drawing the decision tree model in TreeAge software, the incremental cost-effectiveness ratio was calculated; and to evaluate the strength of the analysis results, one-way and two-way sensitivity analyses were done on all costs and consequence parameters. Results: The effectiveness rate in the ground ambulance group and in the air ambulance group was 0.42591 and 0.5566, respectively, and the total cost of transportation and treatment by ambulance in these patients was $412.88 and for patients transported and treated by air ambulance was $11898.05. Therefore, air ambulance costs more and is more effective than ground ambulance, and the amount of incremental cost and effectiveness of air ambulance compared with ground ambulance was $11485.17 and 0.130773 units, respectively. The incremental cost-effectiveness ratio (ICER) of the 2 strategies was 87825.28, and the cost-effectiveness threshold was $7200. To determine the strength of the study results, one-way and two-way sensitivity analyses were done and the results of the cost-effectiveness analysis was not changed. Conclusion: Our study showed that ground ambulance is more cost-effective than air ambulance and the most important reason is that the total cost of air ambulance is 26 times more than ground ambulance, however, it is more effective than ground ambulance.

Predictive Factors of Outcome in Cases of Out-of-hospital Cardiac Arrest Due to Traffic Accident Injuries in Thailand; a National Database Study

INTRODUCTION

Traffic accident injury is one of the global leading causes of death and an important public health problem. This study aimed to evaluate the predictive factors of return of spontaneous circulation (ROSC) at the scene in out-of-hospital cardiac arrest (OHCA) due to traffic accidents.

METHODS

This retrospective cross-sectional study was conducted on cases of OHCA due to traffic accident, who were resuscitated at the scene by emergency medical services (EMS) in Bankok, Thiland, from January 1, 2020, to December 31, 2020 (1 year). Patients were divided into two groups of with and without ROSC and independent predictive factors of outcome were evaluated.

RESULTS

2400 OHCA cases met the inclusion criteria, among them, 1728 (72.0%) achieved ROSC at the scene. Facial injury (adjusted OR = 2.17, 95%CI: 1.37-3.44, p = 0.001); prehospital airway management using bag valve mask (adjusted OR = 1.69, 95%CI: 1.21-2.34, p = 0.002), and endotracheal tube (adjusted OR = 3.88, 95%CI: 1.84-8.18, p <0.001); and prehospital fluid therapy using normal saline (adjusted OR = 4.24, 95%CI: 3.12-5.77, p <0.001), ringer lactate (adjusted OR = 5.13, 95%CI: 3.47-7.61, p <0.001), and other solutions (adjusted OR = 5.25, 95%CI: 2.16-12.8, p <0.001) were independent predictive factors of ROSC at the scene in OHCA due to traffic accidents.

CONCLUSION

Based on the findings, the rate of ROSC at the scene for cases with OHCA due to traffic accidents, serviced by EMS was high, i.e., 72%, and three independent predictive factors of ROSC at the scene were facial injury, prehospital airway management, and prehospital fluid management.

Implementing a new emergency department: a qualitative study of health professionals' change responses and perceptions

Background

The aim of the study is two-fold. It explores how managers and key employees at the Emergency Department (ED) and specialist departments in a university hospital in the Capital Region of Denmark respond to the planned change to a new ED, and how they perceive the change involved in the implementation of the new ED. The study investigates what happens when health professionals are confronted with implementation of policy that changes their organization and everyday work lives. Few studies provide in-depth investigations of health professionals’ reactions to the implementation of new EDs, and particularly how they influence the implementation of a nationwide organizational change framed within a political strategy.

Methods

The study used semi-structured individual interviews with 51 health professionals involved in implementation activities related to an organizational change of establishing a new ED with new patient pathways for acutely ill patients. The data was deductively analyzed using Leon Coetsee’s theoretical framework of change responses, but the analysis also allowed for a more inductive reading of the material.

Results

Fourteen types of responses to establishing a new ED were identified and mapped onto six of the seven overall change responses in Coetsee’s framework. The participants perceived the change as particularly three changes. Firstly, they wished to create the best possible acute patient pathway in relation to their specialty. Whether the planned new ED would redeem this was disputed. Secondly, participants perceived the change as relocation to a new building, which both posed potentials and worries. Thirdly, both hopeful and frustrated statements were given about the newly established medical specialty of emergency medicine (EM), which was connected to the success of the new ED.

Conclusions

The study showcases how implementation processes within health care are not straightforward and that it is not only the content of the implementation that determines the success of the implementation and its outcomes but also how these are perceived by managers and employees responsible for the process and their context. In this way, managers must recognize that it cannot be pre-determined how implementation will proceed, which necessitates fluid implementation plans and demands implementation managements skills.

Handover methods between local emergency medical services and Accident and Emergency: is there a gold standard? A scoping review

BACKGROUND

Pre-hospital emergency medical systems do not appear to work totally coordinated with Accident and Emergency (A&E). Often, patient admission to A&E is marked by scarce attention to the handover between the respective healthcare professionals. This phenomenon is potentially dangerous because it exposes patients to the risk of errors in a context where the patients' critical or progressing conditions must not be worsened by avoidable errors of communication between professionals.

OBJECTIVES

to describe the evidence concerning handover between local emergency medical services and A&E.

ELIGIBILITY CRITERIA

pre-hospital emergency medical and A&E professionals, setting defined as within A&E, articles on pre-hospital to A&E handover.

SOURCES OF EVIDENCE

PubMed and CINAHL Complete databases. Grey literature.

CHARTING METHODS

the results are displayed in tables according to 'Title', 'Design', 'Country', 'Population', 'Concept', 'Context' and 'Results'.

RESULTS

10 studies were included. The following themes emerged: communication and interpersonal issues, secondary risks, need for staff training, the use of structured methods, information technology support.

CONCLUSIONS

There is a gap in the literature. Issues regarding communication, differing ideas of what should be considered as priority, interpersonal relationships and trust between staff working for different services emerge. Connected with this there are structural problems such as shortage of suitable spaces and lack of staff training. The use of structured mnemonic methods, including computerized ones, seems to improve the quality of handovers, but to date it has not been possible to establish which method would be better than another. Further studies are recommended.

Emergency medicine in Norway: The road to specialty recognition

Emergency medicine (EM) in most of Europe is a much newer specialty than in the United States. Until recently, emergency departments (EDs) in Norway were staffed with unsupervised interns, leading to a government report in 2008 that called for change. From the establishment of the Norwegian Society for Emergency Medicine in 2010 to the creation of the specialty in 2017 and the approval of the first emergency physician in Norway in 2019, our review article describes how a small group of physicians were able to work with politicians and the media to get an emergency medicine specialty approved despite resistance from a much larger group of existing specialists. Norway faced many of the same obstacles as the United States did with implementing the specialty 60 years ago. This article serves as a review of the conflict that may ensue when enacting a change in public policy and a resource to those countries that have yet to implement an emergency medicine specialty.

Vertebral Artery Injury in Cervical Spine Fractures: A Cohort Study and Review of the Literature

BACKGROUND

The risk of vertebral artery injury (VAI) secondary to cervical spine fracture is increasingly recognised in the literature. The aim of this study was to determine the incidence of VAI amongst patients presenting to the Royal Victoria Hospital (Northern Ireland's regional trauma centre with emergency surgical spinal services) with acute cervical spine fractures, and to identify fracture patterns associated with the highest risk of VAI.

METHODS

A retrospective review of 1,894 computed tomography (CT) reports of patients who underwent imaging of their cervical spine and/or vertebral arteries over a 12-month period, from June 2018 to June 2019, was conducted.

RESULTS

Sixty-eight patients (3.59%) with a confirmed cervical spine fracture were identified. These patients had an age range of 18-97 years and included 39 males (57.4%) and 29 females (42.6%). The fractures were then classified according to the AOSpine Cervical Spine Fracture Classification. Of the 68 patients with a confirmed cervical spine fracture, five (7.35%) were diagnosed with VAI, all involving fractures of their upper cervical spine. Two involved fractures extending into the transverse foramen, two involved subluxation of the vertebrae and one involved both. In all five cases, these fractures resulted from high- energy injuries. Regarding management, the patients with VAI in this study were either monitored and given no specific treatment or treated medically with antiplatelet therapy. None underwent surgical intervention.

CONCLUSIONS

Fracture patterns associated with increased risk of VAI are fractures involving the upper cervical spine, fractures with associated subluxation, and fractures of the transverse process extending into the transverse foramen - urgent CT-angiography in these cases is recommended. Further work should develop a targeted set of criteria for screening for VAI in cervical spine fractures, with consideration of high-risk fracture patterns.