Editor’s note: The Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine worldwide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals and are not peer-reviewed or edited by the Hong Kong Journal of Emergency Medicine.
African Journal of Emergency Medicine
The official journal of the African Federation for Emergency Medicine, the Emergency Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association, the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency Medicine Society, the Society of Emergency Medicine Practitioners of Nigeria, and the Rwanda Emergency Care Association.
(The print version of this article has been scheduled for November 2023.)
Factors which affect the application and implementation of a spinal motion restriction protocol by prehospital providers in a low resource setting: A scoping review
Geduld C, Muller H, Saunders CJ
Geduld et al. Afr J Emerg Med 2022; 12(4): 393–405.
doi: 10.1016/j.afjem.2022.08.005.
Introduction: The safety and effectiveness of prehospital clinical c-spine clearance or spinal motion restriction (SMR) decision support tools are unclear. The present study aimed to examine the available literature on clinical cervical spine clearance and selective SMR decision support tools to identify possible barriers to implementation, safety, and effectiveness when used by emergency medical service (EMS) practitioners.
Method: We performed a focused scoping review of published literature on the prehospital use of clinical spine clearance and SMR decision tools in adult blunt trauma patients. The Medline, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Turning Research into Practice, and EBSCOhost online databases were searched (February 2021). The type of decision support tool and facilitators and barriers to its use were extracted from each included publication in accordance with a modified descriptive-analytical framework. Extracted data were subjected to thematic analysis.
Results: Following screening, 42 articles were included in this scoping review. No studies conducted specifically in low-resource settings were found. The majority of articles (57%) evaluated the use of specific SMR decision support tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rule (CCR). Potential facilitators of safe and effective use were identified in 60%, and potential barriers to safe and effective use in 55% of included articles. Only one study evaluated the CCR when used by EMS practitioners, making it difficult to determine its appropriateness for implementation in the prehospital setting.
Conclusion: This is the first scoping review, to our knowledge, that has attempted to identify the possible barriers and facilitators to their implementation, safety, and effectiveness when used by EMS practitioners. Key issues identified included terminology, guideline compliance and implementation, and a lack of context-specific evidence. These may provide important considerations for future guideline development.
Reproduced with permission.
(The print version of this article has been scheduled for December 2023.)
Current use and perceived barriers of emergency point-of-care ultrasound by African health care practitioners
van Hoving DJ, Alenyo AN, Komagum F, Lamprecht H
van Hoving et al. Afr J Emerg Med 2022; 12(4): 333–338.
doi: 10.1016/j.afjem.2022.07.009.
Introduction: The African Federation of Emergency Medicine (AFEM) recommends the use of emergency point-of-care ultrasound (ePOCUS) as a core skill for healthcare practitioners in Africa. The study explored the use of ePOCUS by health care practitioners among AFEM members who work across Africa.
Methods: An anonymous online survey was distributed to individual members of AFEM and affiliated organizations. The questionnaire was tested by the AFEM Scientific Committee for potential content modifications prior to distribution. Summary statistics are presented.
Results: Of the 220 participants that were analyzed, 148 (67.3%) were using ePOCUS. The mean age was 36 years; 146 (66%) were male; and 198 (90%) obtained their primary medical qualification in Africa. In total, 168 (76%) were doctors, and most participants (n = 204, 93%) have worked in Africa during the last 5 years. Reasons for not using ePOCUS mainly related to lack of training and problems with ultrasound machines or consumables. Most ePOCUS users (116/148, 78%) attended courses with hands-on training, but only 65 (44%) participants were credentialed (by 18 different organizations). The median score for self-perceived level of ePOCUS skills was 75 in credentialed users versus 50 in those that were not credentialed. Ultrasound in trauma was the most frequently used module (n = 141, 99%), followed by focused cardiac assessment (n = 128, 90%) and thoracic (including lung) assessment (n = 128, 90.1%). The FASH (Focused Assessment with Sonography for HIV/TB) module was the least used (n = 69, 49%).
Conclusion: Access barriers to ePOCUS training, mentorship, equipment, and consumables are still relevant in Africa. The low credentialing rate and the potential discordance between local burden of disease and ePOCUS training require further investigation.
Reproduced with permission
Annals of Emergency Medicine
(The print version of this article has been scheduled for November 2023.)
Interpretation of cardiac standstill in children using point-of-care ultrasound
Evan Yanni, MD, James W Tsung, MD, MPH, Kevin Hu, MD, Ee Tein Tay, MD
Study objective: This study aimed to determine the level of agreement among pediatric emergency medicine (PEM) physicians on whether various point-of-care ultrasound (POCUS) video clips represent cardiac standstill in children and to highlight the factors that may be associated with the lack of agreement.
Methods: A single, online, cross-sectional, convenience sample survey was administered to PEM attendings and fellows with variable ultrasound experience. PEM attendings with an experience of 25 cardiac POCUS scans or more were the primary subgroup based on ultrasound proficiency set by the American College of Emergency Physicians. The survey contained 11 unique, 6-second video clips of cardiac POCUS performed during pulseless arrest in pediatric patients and asked the respondent if the video clip represented a cardiac standstill. The level of interobserver agreement was determined using Krippendorff’s a (Ka) coefficient across the subgroups.
Results: A total of 263 PEM attendings and fellows completed the survey (9.9% response rate). Of the 263 total responses, 110 responses were from the primary subgroup of experienced PEM attendings with at least 25 previously seen cardiac POCUS scans. Across all video clips, PEM attendings with 25 scans or more had an acceptable agreement (Ka¼ 0.740; 95% CI 0.735 to 0.745). The agreement was the highest for video clips wherein the wall motion corresponded to the valve motion. However, the agreement fell to unacceptable levels (Ka¼ 0.304; 95% CI 0.287 to 0.321) across video clips wherein the wall motion occurred without the valve motion.
Conclusion: There is an overall acceptable interobserver agreement when interpreting cardiac standstill among PEM attendings with an experience of at least 25 previously reported cardiac POCUS scans. However, factors that may influence the lack of agreement include discordances between the wall and valve motion, suboptimal views, and the lack of a formal reference standard. More specific consensus reference standards of pediatric cardiac standstill may help to improve interobserver agreement moving forward and should include more specific details regarding the wall and valve motion.
How to cite this article:
Yanni E, Tsung JW, Hu K, et al. Interpretation of cardiac standstill in children using point-of-care ultrasound. 2023. https://doi.org/10.1016/j.annemergmed.2023.04.003
(The print version of this article has been scheduled for December 2023.)
Tenecteplase versus Alteplase for acute stroke: Mortality and bleeding complications
Luke R Murphy, MD, T Preston Hill, MD, Krishna Paul, BS, Matthew Talbott, DO, Georgiy Golovko, PhD, Hashem Shaltoni, MD, Dietrich Jehle, MD
Study objective: Intravenous thrombolysis with alteplase has been the foundation of initial treatment of acute ischemic stroke for several decades. Tenecteplase is a thrombolytic agent that offers logistical advantages in cost and administration relative to alteplase. There is evidence that tenecteplase has at least similar efficacy and safety outcomes compared with alteplase for stroke. In this study, we compared tenecteplase versus alteplase for acute stroke in a large retrospective US database (TriNetX) regarding the following 3 outcomes: (1) mortality, (2) intracranial hemorrhage, and (3) the need for acute blood transfusions.
Methods: In this retrospective study using the US cohort of 54 academic medical centers/healthcare organizations in the TriNetX database, we identified 3432 patients treated with tenecteplase and 55,894 patients treated with alteplase for stroke after January 1, 2012. Propensity score matching was performed on basic demographic information and 7 previous clinical diagnostic groups, resulting in a total of 6864 patients with acute stroke evenly matched between groups. Mortality rates, the frequency of intracranial hemorrhage, and blood transfusions (as a marker of significant blood loss) were recorded for each group over the ensuing 7- and 30-day periods. Secondary subgroup analyses were conducted on a cohort treated from 2021 to 2022 in an attempt to determine whether temporal differences in acute ischemic stroke treatment would alter the results.
Results: Patients treated with tenecteplase had a significantly lower mortality rate (8.2% vs 9.8%; risk ratio (RR), 0.832) and lower risk of major bleeding as measured by the frequency of blood transfusions (0.3% vs 1.4%; RR, 0.207) than alteplase at 30 days after thrombolysis for stroke. In the larger 10-year data set of patients with stroke treated after January 1, 2012, patients receiving tenecteplase were not found to have a statistically different incidence of intracranial hemorrhage (3.5% vs 3.0%; RR, 1.185) at 30 days after the administration of the thrombolytic agents in patients. However, a subgroup analysis of 2216 evenly matched patients with stroke treated from 2021 to 2022 demonstrated notably better survival and statistically lower rates of intracranial hemorrhage than the alteplase group.
Conclusion: In our large retrospective multicenter study using real-world evidence from large health care organizations, tenecteplase for the treatment of acute stroke demonstrated a lower mortality rate, decreased intracranial hemorrhage, and less significant blood loss. The favorable mortality and safety profiles observed in this large study, taken together with previous randomized controlled trial data and operational advantages in rapid dosing and cost-effectiveness, all support the preferential use of tenecteplase in patients with ischemic stroke.
How to cite this article:
Murphy LR, Hill TP, Pual K, et al. Tenecteplase versus Alteplase for acute stroke: Mortality and bleeding complications. 2023. https://doi.org/10.1016/j.annemergmed.2023.03.022
Emergency Medicine Journal
(The print version of this article has been scheduled for November 2023)
Impact of serial cardiopulmonary point-of-care ultrasound exams in patients with acute dyspnea: a randomized, controlled trial
Arvig MD, Lassen AT, Gæde PH, Gärtner SW, Falster C, Skov IR, Petersen HØ, Posth S, Laursen CB
http://dx.doi.org/10.1136/emermed-2022-212694
Background: Serial point-of-care ultrasound (PoCUS) can potentially improve acute patient care through treatment adjusted to the dynamic ultrasound findings. The objective was to investigate if treatment guided by monitoring patients with acute dyspnea with serial cardiopulmonary PoCUS and usual care could reduce the severity of dyspnea compared with usual care alone.
Methods: This was a randomized, controlled, blinded-outcome trial conducted in three EDs in Denmark between October 9, 2019, and May 26, 2021. Patients aged ⩾ 18 years admitted with a primary complaint of dyspnea were allocated 1:1 with block randomization to usual care, which included a single cardiopulmonary PoCUS within 1 h of arrival (control group) or usual care (including a PoCUS within 1 h of arrival) plus two additional PoCUS performed at 2-h interval from the initial PoCUS (serial ultrasound group). The primary outcome was a reduction of dyspnea measured on a verbal dyspnea scale (VDS) from 0 to 10 recorded at inclusion and after 2, 4, and 5 h.
Results: There were 206 patients recruited, 102 in the serial ultrasound group and 104 in the control group, all of whom had complete follow-up. The mean difference in VDS between patients in the serial ultrasound and the control group was −1.09 (95% CI −1.51 to −0.66) and −1.66 (95% CI −2.09 to −1.23) after 4 and 5 h, respectively. The effect was more pronounced in patients with a presumptive diagnosis of acute heart failure (AHF). A larger proportion of patients received diuretics in the serial ultrasound group.
Conclusion: Therapy guided by serial cardiopulmonary PoCUS may, together with usual care, facilitate greater improvement in the severity of dyspnea, especially in patients with AHF compared with usual care with a single PoCUS in the ED. Serial PoCUS should therefore be considered for routine use to aid the physician in stabilizing the patient faster.
Trial registration number: NCT04091334.
Canadian Journal of Emergency Medicine
(The print version of this article has been scheduled for November 2023)
Patient opinion and acceptance of emergency department buprenorphine/naloxone to-go home initiation packs
Kevin Duncan, Frank Scheuermeyer, Daniel Lane, Keith Ahamad, Jessica Moe, Kathryn Dong, Seonaid Nolan, Jane Buxton, Isabelle Miles, Cheyenne Johnson, Jim Christenson, Madelyn Whyte, Raoul Daoust, Emma Garrod, Katherin Badke, Andrew Kestler
Cite this article
Duncan K, Scheuermeyer F, Lane D, et al. Patient opinion and acceptance of emergency department buprenorphine/naloxone to-go home initiation packs. Can J Emerg Med (2023). https://doi.org/10.1007/s43678-023-00568-1
Objectives: Many emergency department (ED) patients with opioid use disorder are candidates for home buprenorphine/naloxone initiation with to-go packs. We studied patient opinions and acceptance of buprenorphine/naloxone to-go packs, and factors associated with their acceptance.
Methods: We identified patients at two urban EDs in British Columbia who met opioid use disorder criteria, were not presently on opioid agonist therapy and not in active withdrawal. We offered patients buprenorphine/naloxone to-go as standard of care and then administered a survey to record buprenorphine/naloxone to-go acceptance, the primary outcome. Survey domains included current substance use, prior experience with opioid agonist therapy, and buprenorphine/naloxone-related opinions. Patient factors were examined for association with buprenorphine/naloxone to-go acceptance.
Results: Of the 89 patients enrolled, median age was 33 years, 27% were female, 67.4% had previously taken buprenorphine/naloxone, and 19.1% had never taken opioid agonist therapy. Overall, 78.7% believed that EDs should dispense buprenorphine/naloxone to-go packs. Thirty-eight (42.7%) patients accepted buprenorphine/naloxone to-go. Buprenorphine/naloxone to-go acceptance was associated with lack of prior opioid agonist therapy, less than 10 years of opioid use, and no injection drug use. Reasons to accept included initiating treatment while in withdrawal; reasons to reject included prior unsatisfactory buprenorphine/naloxone experience and interest in other treatments.
Conclusion: Although less than half of our study population accepted buprenorphine/naloxone to-go when offered, most thought this intervention was beneficial. In isolation, ED buprenorphine/naloxone to-go will not meet the needs of all patients with opioid use disorder. Clinicians and policymakers should consider buprenorphine/naloxone to-go as a low-barrier option for opioid use disorder treatment from the ED when integrated with robust addiction care services.
Keywords:
Buprenorphine/naloxone, emergency department, buprenorphine/naloxone home induction, opioid use disorder
Buprénorphine/naloxone, Service d’urgence, Buprénorphine/naloxone induction à domicile, Trouble de consommation d’opioïdes
