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Key Summary Points Aim To provide an inventory and prioritisation of research questions amongst GEM professionals throughout Europe. Findings A list of 10 research questions was identified and prioritised. Message The list of research questions may serve as guidance for scientists, policymakers and funding bodies in prioritising future research projects. Purpose Geriatric Emergency Medicine (GEM) focuses on delivering optimal care to (sub)acutely ill older people. This involves a multidisciplinary approach throughout the whole healthcare chain. However, the underpinning evidence base is weak and it is unclear which research questions have the highest priority. The aim of this study was to provide an inventory and prioritisation of research questions among GEM professionals throughout Europe. Methods A two-stage modified Delphi approach was used. In stage 1, an online survey was administered to various professionals working in GEM both in the Emergency Department (ED) and other healthcare settings throughout Europe to make an inventory of potential research questions. In the processing phase, research questions were screened, categorised, and validated by an expert panel. Subsequently, in stage 2, remaining research questions were ranked based on relevance using a second online survey administered to the same target population, to identify the top 10 prioritised research questions. Results In response to the first survey, 145 respondents submitted 233 potential research questions. A total of 61 research questions were included in the second stage, which was completed by 176 respondents. The question with the highest priority was: Is implementation of elements of CGA (comprehensive geriatric assessment), such as screening for frailty and geriatric interventions, effective in improving outcomes for older patients in the ED? Conclusion This study presents a top 10 of high-priority research questions for a European Research Agenda for Geriatric Emergency Medicine. The list of research questions may serve as guidance for researchers, policymakers and funding bodies in prioritising future research projects.

Background Acute heart failure patients are often encountered in emergency departments (ED) from 11% to 57% using emergency medical services (EMS). Our aim was to evaluate the association of EMS use with acute heart failure patients’ ED management and short-term outcomes. Methods This was a sub-analysis of a European EURODEM study. Data on patients presenting with dyspnoea were collected prospectively from European EDs. Patients with ED diagnosis of acute heart failure were categorized into two groups: those using EMS and those self-presenting (non- EMS). The independent association between EMS use and 30-day mortality was evaluated with logistic regression. Results Of the 500 acute heart failure patients, with information about the arrival mode to the ED, 309 (61.8%) arrived by EMS. These patients were older (median age 80 vs. 75 years, p  < 0.001), more often female (56.4% vs. 42.1%, p  = 0.002) and had more dementia (18.7% vs. 7.2%, p  < 0.001). On admission, EMS patients had more often confusion (14.2% vs. 2.1%, p  < 0.001) and higher respiratory rate (24/min vs. 21/min, p  = 0.014; respiratory rate > 30/min in 17.1% patients vs. 7.5%, p  = 0.005). The only difference in ED management appeared in the use of ventilatory support: 78.3% of EMS patients vs. 67.5% of non- EMS patients received supplementary oxygen ( p  = 0.007), and non-invasive ventilation was administered to 12.5% of EMS patients vs. 4.2% non- EMS patients ( p  = 0.002). EMS patients were more often hospitalized (82.4% vs. 65.9%, p  < 0.001), had higher in-hospital mortality (8.7% vs. 3.1%, p  = 0.014) and 30-day mortality (14.3% vs. 4.9%, p  < 0.001). The use of EMS was an independent predictor of 30-day mortality (OR = 2.54, 95% CI 1.11–5.81, p  = 0.027). Conclusion Most acute heart failure patients arrive at ED by EMS. These patients suffer from more severe respiratory distress and receive more often ventilatory support. EMS use is an independent predictor of 30-day mortality.

The number of critically ill patients admitted to the emergency department increases daily. To decrease mortality, interventions and treatments should be conducted in a timely manner. It has been found that the neutrophil-lymphocyte ratio (NLR) is related to mortality in some disease groups, such as acute coronary syndrome and pulmonary emboli. The effect of the NLR on mortality is unknown in critically ill patients who are admitted to the emergency department. Our aim in this study is to evaluate the effect of the NLR on mortality in critically ill patients. This study was planned as a prospective, observational cohort study. Patients who were admitted to the emergency department because they were critically ill and required the intensive care unit were included in the study. Demographic characteristics, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sepsis-related Organ Failure Assessment, Glasgow Coma Score, and NLR values were recorded upon emergency department admission. The patients were followed up for sepsis, ventilator-associated pneumonia, multiorgan failure, in-hospital mortality, and 6-month mortality. The median (interquartile range) age of the 373 patients was 74 (190) years, and 54.4% were men. Neutrophil-lymphocyte ratio values were divided into quartiles, as follows: less than 3.48, 3.48 to 6.73, 6.74-13.6, and more than 13.6. There was no difference among these 4 groups regarding demographic characteristics, APACHE II score, Sepsis-related Organ Failure Assessment score, Glasgow Coma Score, and length of hospital stay (P > .05). In the multivariable Cox regression model, in-hospital mortality and 6-month mortality NLR were hazard ratio (HR), 1.63 (1.110-2.415; P = .01) and HR, 1.58 (1.136-2.213; P = .007), respectively, and APACHE II scores were detected as independent indicators. The NLR is a simple, cheap, rapidly available, and independent indicator of short- and long-term mortalities. We suggest that the NLR can provide direction to emergency department physicians for interventions, particularly within a few hours after admission, in the critically ill patient group.

The purpose of this study is to investigate whether there are any significant changes in the diameter and the area of the internal jugular vein (IJV) during the hemorrhagic shock. Healthy volunteers donating blood were included in the study. Arterial blood pressure, pulse rate, anteroposterior (AP) and transverse diameter, and area measurements of the IJV during inspiration and expiration were performed on the volunteers before and after 450 mL of blood donation. A total of 35 volunteers were enrolled in the study. The IJV prehemorrhagic AP diameters during inspiration and expiration were 4.9 ± 2.2 and 7.9 ± 3.1 mm, and the posthemorrhagic values were 2.7 ± 1.6 and 6.6 ± 3.1 mm (respectively, P < .001 and P = .007). The jugular index–AP was 36% ± 15% before hemorrhage and 58% ± 17% after hemorrhage (P < .001). The IJV areas during inspiration and expiration were 0.40 ± 0.28 and 0.81 ± 0.51 cm2 before hemorrhage and were 0.14 ± 0.15 and 0.61 ± 0.47 cm2 after hemorrhage (for both, P < .001). The jugular index–area was found as 47% ± 18% before hemorrhage and as 73% ± 18% after hemorrhage (P < .001). We believe that measurement of the IJV and the jugular index is a reliable indicator of class 1 hemorrhagic shock. It may be used as a part of focused abdominal sonography for trauma in clinical practice.

Acute mesenteric ischemia (AMI) is an important clinical condition with a high mortality rate in abdominal emergencies due to delay in diagnosis in spite of the new strategies in the management. We have studied the role of diamine oxidase (DAO) in the early diagnosis of AMI. In the study, 21 New Zeland rabbits were used. Subjects were named as the groups of controls, sham, and ischemia. No intervention was performed in the subjects in the control group. In the subjects from sham and ischemia groups, laparotomy was performed with middle line incision. However, superior mesenteric artery was found and tied in those from ischemia group after the performance of laparotomy. From the animals in 3 groups, blood was drawn at the hours of 0, 1, 3, and 6, and DAO and amylase were studied in these samples. The increase in serum amylase levels was found to be statistically significant in the ischemia group compared with the control and the sham groups (P < .05). The decrease in serum DAO levels was found to be statistically significant in the ischemia group compared with the control and the sham groups (P < .05). Diamine oxidase levels were found to decrease, beginning from the 1 hour after ischemia had been developed, and this rise was found to continue for 6 hours (P < .05). Serum DAO levels were decreased in ischemia. Further clinical and experimental investigations would be valuable to confirm the probable role of DAO in AMI.

The 2017 International Liaison Committee on Resuscitation (ILCOR) guideline recommends that Emergency Medical Service (EMS) providers can perform cardiopulmonary resuscitation (CPR) with synchronous or asynchronous ventilation until an advanced airway has been placed. In the current literature, limited data on CPR performed with continuous compressions and asynchronous ventilation with bag-valve-mask (BVM) are available. In this study, researchers aimed to compare the effectiveness of asynchronous BVM and laryngeal mask airway (LMA) ventilation during CPR with continuous chest compressions. Emergency medicine residents and interns were included in the study. The participants were randomly assigned to resuscitation teams with two rescuers. The cross-over simulation study was conducted on two CPR scenarios: asynchronous ventilation via BVM during a continuous chest compression and asynchronous ventilation via LMA during a continuous chest compression in cardiac arrest patient with asystole. The primary endpoints were the ventilation-related measurements. A total of 92 volunteers were included in the study and 46 CPRs were performed in each group. The mean rate of ventilations of the LMA group was significantly higher than that of the BVM group (13.7 [11.7-15.7] versus 8.9 [7.5-10.3] breaths/minute; P <.001). The mean volume of ventilations of the LMA group was significantly higher than that of the BVM group (358.4 [342.3-374.4] ml versus 321.5 [303.9-339.0] ml; P = .002). The mean minute ventilation volume of the LMA group was significantly higher than that of the BVM group (4.88 [4.15-5.61] versus 2.99 [2.41-3.57] L/minute; P <.001). Ventilations exceeding the maximum volume limit occurred in two (4.3%) CPRs in the BVM group and in 11 (23.9%) CPRs in the LMA group (P = .008). The results of this study show that asynchronous BVM ventilation with continuous chest compressions is a reliable and effective strategy during CPR under simulation conditions. The clinical impact of these findings in actual cardiac arrest patients should be evaluated with further studies at real-life scenes.

Carbon monoxide (CO) poisoning frequently affects repolarization, resulting in abnormal electrocardiography findings. The goal of this study was to examine the effect of CO poisoning on the novel transmyocardial repolarization parameters T peak–T end (Tp-e), Tp-e dispersion, and Tp-e/QT and the relationship of these parameters to myocardial injury (MI). This prospective study included 94 patients with CO poisoning and 40 healthy controls. Participants received an electrocardiography and had their blood drawn at admission and 6 and 24 hours after admission. The QT, Tp-e, Tp-e dispersion, and the Tp-e/QT ratio were calculated. Myocardial injury was determined based on an elevation in troponin any time during the first 24 hours. The patients were divided into 2 subgroups: those with and without MI. T peak–T end, Tp-e dispersion, and the Tp-e/QT ratio were higher at admission than after 6 and 24 hours of hospitalization and were higher than the control group (P < .001). There was a correlation between the carboxyhemoglobin level at admission and Tp-e and Tp-e dispersion (P < .001). The MI subgroup (n = 14) had a higher Tp-e at admission than did the non-MI subgroup (n = 80) (96 [11] milliseconds vs 87 [12] milliseconds, P = .03). There were no any significant differences in the Tp-e dispersion or the Tp-e/QT ratio between the 2 MI subgroups. Receiver operating characteristic analysis showed that a Tp-e cutoff value for MI of 91.5 milliseconds had a sensitivity of 72.7% and a specificity of 67.2%. Transmyocardial repolarization parameters indicative of arrhythmia were prolonged in patients with CO poisoning. T peak–T end was associated with MI.