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ObjectivesThe major complication of rhabdomyolysis is acute kidney injury (AKI), which requires prompt treatment. Currently, few biomarkers are available for the early detection of AKI. Serum neutrophil gelatinase–associated lipocalin (NGAL) has been suggested as an early biomarker for renal ischemia. However, its capacity to predict AKI in patients presenting with rhabdomyolysis in the emergency department (ED) remains unclear. The aim of this study was to evaluate the ability of NGAL to predict 48-hour AKI.DesignProspective, multicentre study.SettingFive adult EDs in France from August 2013 to December 2015.ParticipantsNGAL levels were measured on ED admission in patients with rhabdomyolysis. A total of 197 patients were enrolled, and 189 (96%) were analysed, of whom 89 (47%) were women. Patients were included if they presented to the ED with rhabdomyolysis and a creatine phosphokinase (CPK) level above 1000 IU/L. Exclusion criteria were pregnancy, presentation with acute coronary syndrome, the need for iodinated contrast, chronic dialysis or recent use of nephrotoxic drugs (within 72 hours prior to the ED visit). Patients who withdrew consent or had AKI due to other causes were also excluded.Primary and secondary outcome measuresThe primary outcome was AKI at 48 hours, defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary outcomes included in-hospital mortality, length of hospital stay, admission to intensive care and the need for renal replacement therapy.ResultsOverall, 54 (29%) patients developed AKI by day 2. The area under the ROC curve (AUC-ROC) for NGAL in predicting AKI on day 2 was 0.60 (95% CI 0.51 to 0.70), with an optimal cut-off of 129 ng/mL. The sensitivity was 0.65, and specificity was 0.50. After adjustment for CPK levels, age, sex and oxygen saturation, the AUC-ROC for predicting AKI on day 2 increased slightly to 0.64 (95% CI 0.54 to 0.74).ConclusionNGAL has limited ability to predict day 2 AKI in patients presenting with acute rhabdomyolysis in the ED.Trail registration number NCT01544231.Comité de Protection des Personnes Sud Méditerranée III n°2011-A01059-32.

Ultrasound (US) guidance has yet to prove its applicability in radial arterial blood gas analysis (ABGA) punctures. The main objective of our study was to compare the number of first-attempt successes (NFAS) for radial arterial puncture in difficult patients with or without US guidance. The Secondary aims were to compare the number of punctures (NOP), puncture time, and patient pain. In this single-center, randomized controlled trial, patients who required a radial ABGA and in whom the arterial puncture was assessed as difficult (because of non-palpable radial arteries or two previous puncture failures by a nurse) were assigned to the US group or no-US (NUS) group (procedure performed by a trained physician). Thirty-six patients were included in the US group and 37 in the NUS groups. The NFAS was 7 (19%) in the NUS group and 19 (53%) in the US group. The relative risk of success in the US group was 2.79 (95% CI,1.34 to 5.82), p = 0.01. In the NUS and US groups, respectively, the median NOP was 3 [2; 6] vs. 1 [1; 2], estimated difference -2.0 (95%CI, -3.4 to -0.6), p < 0.01; the respective puncture time was 3.1 [1.6; 5.4] vs. 1.4 [0.6; 3.1] min, estimated difference -1.45 (95%CI, -2.57 to -0.39), p = 0.01; the respective median patient pain was 6 [4; 8] vs. 2 [1; 4], estimated difference -4.0 (95%CI, -5.8 to -2.3); p < 0.01. US guidance by a trained physician significantly improves the rate of success in difficult radial ABGA patients.

Arterial puncture for blood gas analysis is a frequent procedure and could be difficult in the emergency setting. The aim of the study was to compare ultrasonographically guided arterial radial puncture vs conventional sampling. This is a prospective, randomized study. The inclusion criteria are all patients needing arterial blood gas at admission in the emergency unit. The exclusion criteria are the following: Hallen test positive, local sepsis, local trauma, known sever local arteriopathy, refusal of consent by the patient, participation in another study, and cardiac arrest. Patients were randomized into 2 groups: radial arterial puncture obtained through an ultrasonographically guided technique (group 1) or radial arterial puncture by conventional method (group 2). The main objective is the number of attempts after enrollment. The secondary objectives are time to success, patient satisfaction and pain, and physician satisfaction. Immediate complications were collected. Groups were compared with nonparametric analysis. The data were usable for 72 of 74 patients included. Lung disease (acute exacerbation of chronic obstructive pulmonary disease and pneumonia) at 45% (n = 32) and suspicion of pulmonary embolism in 31% (n = 22) were the most common reasons. Demographics data were comparable in the 2 groups. In group 1, the number of attempts significantly increased (2.35 [1-3] vs 1.66 [1-2] [P = .017]), and the sample was 2.4 times longer (132 seconds [50-200] vs 55 [20-65] [P < .01] by standard method). There was no significant difference in terms of pain (visual analog scale [VAS], 3.6 [2-5] for both groups [P = .743]), patient satisfaction (VAS, 7.2 [5-9] vs 6.8 [5-9] [P = .494]), and physician satisfaction (VAS, 6.0 [3.5-8] vs 6.9 [5-9] [P = .233]). No immediate complications were found in the 2 groups. Ultrasonographically guided arterial puncture increases the number and duration of implementations. This technique, however, does not alter the patient's pain, the number of immediate complications, or patient and physician satisfaction.

Assessment of left ventricular ejection fraction (LVEF) is one of the primary objectives of echocardiography. The gold standard assessment technique in emergency medicine is eyeballing. A new tool is now available on pocket ultrasound devices (PUD): automatic LVEF. The primary aim of this study was to evaluate the concordance between LVEF values estimated by automatic LVEF with PUD and by cardiac magnetic resonance imaging (MRI). This was a prospective, monocentric, and observational study. All adult patients with an indication for cardiac MRI underwent a point-of-care ultrasound. Blinded to the MRI results, the emergency physician assessed LVEF using the automatic PUD tool and by visual evaluation. Sixty patients were included and analyzed. Visual estimation of LVEF was feasible for all patients and automatic evaluation for 52 (87%) patients. Lin's concordance correlation coefficient between automatic ejection fraction with PUD and by cardiac MRI was 0.23 (95% CI, 0.03-0.40). Concordance between LVEF estimated by the automatic ejection fraction with PUD and LVEF estimated by MRI was non-existent.

The diagnostic of primary or secondary headaches in emergency units is mostly based on brain imaging, which is expensive and sometimes hardly accessible. An increase in serum S100B protein has already been found in several neurological conditions inducing brain damage. The objective of this study was to assess the diagnostic performance of S100B serum assay to distinguish primary and secondary headaches among patients with non-traumatic headaches in the emergency department. This was a phase 2, prospective, monocentric diagnostic study. Eighty-one adult patients with non-traumatic headaches in the emergency department were included. In addition to the usual management, a blood assay of the S100B protein was performed in the emergency department, as well as a brain MRI between 48 and 96 h if not performed during the initial management. The primary or secondary headache diagnosis was made at one month by an expert committee, blindly of the results of the S100B assay. The primary outcome was the blood assay of the S100B protein. There was 63 patients for analysis in the primary headache group and 17 in the secondary headache group. The S100B protein assay was significantly higher in secondary headaches than primary headaches, with an AUC of the ROC curve of 0.67. The optimal threshold of 0.06 μg.L−1 allowed to obtain those diagnostic characteristics: sensitivity 75% [48; 93], specificity 62% [48; 74], PPV 35% [20; 54] and NPV 90% [76; 97]. The association between the S100B protein level and the onset of pain was significantly higher for patients with headaches <3 h. The assay of the S100B protein could be useful in the management of this pathology in emergencies. Future studies taking into account dosing time and etiologies could be conducted in order to refine its use in practice.

Background High-flow nasal cannula (HFNC) therapy is commonly used in emergency departments (EDs) to treat acute respiratory failure (ARF). However, its utilization patterns in the resuscitation room (RR) are not well documented. The aim of this study was to describe patient characteristics, management, and in-hospital trajectories according to HFNC use. Methods We conducted a prospective, monocenter, cohort study of consecutive adults admitted to the RR with ARF requiring ≥ 9 L/min of oxygen. We recorded demographic data, comorbidities, clinical and biological parameters, imaging results, treatments, and final ED diagnoses. Patients were classified according to HFNC initiation in the RR. We described clinical pathways through a structured flow diagram that included ICU admission, escalation of respiratory support and in-hospital mortality. Results Among 165 patients, 57 (35%) received HFNC and 108 (65%) did not. Patients receiving HFNC were younger (73 [59; 86] vs. 77 [70;87] years old) and had a lower Charlson index (5 [3; 7] vs. 7 [5; 9]). Median NEWS2 score at admission was 8 [6; 9] in both groups. Infectious pneumonia was the primary ED diagnosis in 84% of HFNC patients (48/57) and 53% of non-HFNC patients (57/108). Cardiogenic pulmonary oedema accounted for 5% (3/57) vs. 21% (23/108), respectively. ICU admission occurred in 39 (68%) of HFNC patients and 40 (37%) of non-HFNC patients. Intubation was performed in 3 (5.3%) vs. 10 (9.3%). In-hospital mortality was 12/57 (21%) in the HFNC group and 35/108 (33%) in the non-HFNC group. Conclusion Patients who receive HFNC therapy in the RR are younger and healthier than those who do not, regardless of the initial severity of acute respiratory failure ARF. The probability of receiving HFNC seems to be linked to the patient’s burden of comorbidities. Further study should explore its impact on patient outcomes. Clinical trial registration None.

Background Severe grade C trauma patients usually benefit from whole-body computed tomography (WBCT) to search for traumatic lesions, in the absence of clinical signs. The systematic use of WBCT in clinically stable patients with severe trauma remains controversial. Objective The aim of this study was to evaluate the diagnostic value of the blood leukocyte count in predicting the existence of traumatic lesions on WBCT in grade C severe trauma patients. Methods This was an observational, retrospective, monocentric study of severe grade C trauma patients who underwent WBCT and leukocyte blood testing in the emergency department. The diagnosis of post-traumatic injury on WBCT was based on the detection of cranial, thoracic, abdominal, large-vessel, spinal and pelvic injuries. The primary endpoint was blood leukocyte count. Results Eight hundred and six patients were included, 301 (37.3%) had severe traumatic lesions and 505 (62.7%) did not. The leukocyte count was significantly higher in patients with traumatic lesions than in those without (15.8 G/L ± 5.1 vs. 11.0 G/L ± 4.1; p  < 0.01). The AUC of the ROC curve derived from this sample was 0.79 [0.75; 0.82], corresponding to a good diagnostic value. Using the optimal threshold of 13.5 G/L, sensitivity was 66% [60%; 71%], specificity 80% [77%; 84%], PPV 67% [61%; 72%] and NPV 80% [76%; 83%]. Conclusion The leukocyte count on venous blood assay was significantly higher in severe grade C trauma patients with severe traumatic lesions on the WBCT but doesn’t seem to be a sufficient criterion to avoid WBCT. Its analysis coupled with other biological or clinical criteria could be studied. Trial registration This study was approved by the local institutional review board (no. 24.02.01).

Background Red blood cell (RBC) transfusions are essential in emergency departments (ED), but their practices lack standardization, often leading to inefficiencies and risks. Patient blood management is poorly developed in ED, particularly because of the diverse and acute nature of patients. Objectives Describe RBC transfusions in ED and develop a metric to benchmark RBC transfusion efficiency in the ED. Methods This retrospective study analyzed red blood cells transfusions at a French University Hospital (2020–2023). The yearly adjusted number of transfusions per ED-patient (YANTED) was calculated by adjusting the number of ED visits to exclude low-acuity cases. Metrics included transfusion timing, urgency level (immediate life-threatening emergency, life-threatening emergency, relative emergency and nonemergency), and the proportion of RBC transfused in the ED compared with hospital-wide transfusions. Results A total of 5,537 RBC units were transfused in the ED over four years, with a median YANTED of 16.3 (15.6-17.3) per 1,000 ED patients. Relative emergency transfusions accounted for 67% of all transfusions. Nighttime transfusions represented 45% of the total. The median time from RBC order to transfusion initiation was 182 min. The delivery and transfusion times for the immediate life-threatening emergency, life-threatening emergency patients were detailed, with 23% completed within the 30-minute threshold. ED accounted for 11% (95% CI: 10–12%) of total hospital transfusions. Conclusion Over a 4-year period, the YANTED was 16.7 (15.6–17.3) RBC units per 1,000 ED patients. Relative emergency prescriptions accounted for 67% of the transfusions and occurred mostly at night. Further studies should focus on how to decrease these indicators in the ED. Clinical trial number Not applicable.

Background Anemia affects up to 25% of emergency department (ED) patients. Restrictive red blood cell (RBC) transfusion strategies are recommended for stable patients, but ED transfusion practices often remain liberal. Benefits of ED transfusion remains unclear. Objective To evaluate the impact of ED transfusion on death-adjusted in-hospital length of stay (LOS) in stable anemic patients requiring hospitalization. Methods This single-center retrospective propensity-matched study included patients ≥ 18 years admitted to the ED of Nîmes University Hospital in 2022 with hemoglobin levels between 70 and 90 g.L − 1 . Patients with hemorrhagic shock or requiring emergent hemostatic procedures were excluded. Propensity score matching was conducted on variables including age, comorbidities, hemoglobin levels, and diastolic blood pressure. Primary outcome was adjusted in-hospital LOS. Secondary outcomes included ED LOS and RBC transfusion volumes. Results Among 564 patients, 118 (21%) were propensity-matched: 59 (50%) ED-transfused, 59 (50%) non-ED-transfused. Adjusted in-hospital LOS 13 [8–32] for ED-transfused patients and 12 [6–24] days for non-ED-transfused patients (median difference = 0; 95%CI: -10–7; p  = 0.52). Median difference in ED LOS was 7:13 (95%CI: 1:00–11:25; p  < 0.001) between ED transfused and non-ED-transfused patients. Median difference in number of RBC transfused during in hospital stay was 2 (95%CI: 1–3); p  < 0.01) between ED transfused and non-ED-transfused patients. Conclusion In stable anemic patients with 70 to 90 g.L − 1 hemoglobin level, ED transfusion did not reduce adjusted in-hospital LOS but prolonged ED LOS. Identifying patients who may safely defer transfusion could improve ED efficiency and safety.

Background Hemorrhagic shock (HS) is a critical prehospital condition. This study aimed to evaluate the predictive value of the Red Flag criteria on scene versus clinical judgment (gestalt) at initial call for massive transfusion (MT). Secondary aims included determining the proportion of prehospital interventions with packed red blood cells (pRBCs) units and to describe the characteristics of patients for whom dispatch physicians decided to send mobile prehospital team with pRBCs. Methods A retrospective study in a French tertiary care hospital (2015–2023) analyzed prehospital interventions involving RBCs. MT was defined as the transfusion of ≥ 4 pRBCs or fresh frozen plasma units within 24 h. The data included demographics, clinical parameters, and outcomes. The predictive performance of the gestalt and Red flag criteria was compared via the area under the receiver operating characteristic curve (AUROC). Results Among 38,128 interventions, 105 (0.3%) involved 2 pRBCs units transport and 11 (5%) pRBCs units were discarded. Seventy-four (72%) patients were men, median age was 50 (28–67) years old and trauma was the reason for intervention for 67 (65%) patients. A total of 69 (67%) patients received prehospital transfusion: 39 (57%) were trauma patients. The dispatch physician’s gestalt score had an AUROC of 0.81, and the Red Flags criteria had an AUCROC of 0.80 in predicting MT within 24 h for trauma patients ( p  = 0.69). Conclusion Gestalt and Red Flag criteria showed similar ability to predict massive transfusion, but gestalt requires experience and lacks reproducibility. Our results advocate for the implementation of standardized decision tools to guide prehospital transfusion practices. Clinical trial number Not applicable.