Ewoud Ter Avest’s research while affiliated with University of Groningen Medical Center and other places

Background Point-of-care ultrasound (POCUS) can potentially be used in the triage of patients with elbow injuries. However, the diagnostic accuracy of POCUS performed by non-radiologists for the exclusion of elbow fractures is yet unknown. This study aimed to investigate the diagnostic potential of POCUS of the posterior fatpad performed by non-radiologists in the workup of adult patients presenting with elbow injuries. Methods A multicentre, prospective cohort study was conducted between January 2021 and August 2022 in four EDs to determine the diagnostic accuracy of an elevated posterior fatpad on POCUS to demonstrate or exclude an elbow fracture in patients presenting with elbow injuries to the ED. The study population consisted of a convenience sample. In patients ≥16 years of age with an elbow injury for which an X-ray was ordered, POCUS was performed by emergency physicians trained in ultrasound. POCUS (index test) results were compared with X-ray outcomes (reference standard) to determine the diagnostic accuracy of POCUS. Results A total of 215 patients were included, 143 (67%) of whom had a fracture confirmed on X-ray. POCUS was positive based on a visualised elevated posterior fatpad in 127 (59%) patients. An elevated posterior fatpad on POCUS had a sensitivity of 91% (95% CIs 85% to 95%), a specificity of 93% (95% CI 85% to 98%), a negative likelihood ratio of 0.10 (95% CI 0.06 to 0.16) and a positive likelihood ratio of 13.09 (95% CI 5.61 to 30.54) for the presence of an elbow fracture. Post hoc review of the images by expert sonographers improved sensitivity to 96% (95% CI 91% to 99%). Conclusion POCUS of the posterior fatpad is a promising adjunct to physical examination to determine the need for further diagnostic studies in the triage of patients with elbow injuries. Sensitivity after a limited training is high, but not perfect, and can likely further be improved with additional training.

Background As iatrogenic hyperoxia has been related to adverse outcomes in critically ill patients, guidelines advise to titrate oxygen to physiological levels. In the prehospital setting where partial arterial oxygen (PaO 2 ) values are often not readily available, titration of oxygen is based on peripheral oxygen saturations (SpO2). In this study we aimed to investigate the efficacy of SpO 2 guided oxygen titration in the prevention of hyperoxia. Methods In a retrospective observational cohort study of patients included in the Acutelines data- and biobank of the University Medical Center Groningen between September 2020 and March 2023, we collected blood gas samples and triage data of sequentially included patients who received oxygen at the moment they were presented in the emergency department (ED). PaO 2 values were compared to (concurrently measured) SpO 2 values, and to patient- and treatment characteristics and P/F ratios were calculated in order to investigate the efficacy of SpO 2 based oxygen titration for various subgroups. Results Blood gas samples were obtained for 1042 patients, of which 178 (17.1%) had hyperoxia (PaO 2 levels > 13.5 kPa). SpO 2 readings were available for 170 of these, 68 of which (40%) had SpO 2 values above the recommended target range (94–98%; 88–92% for patients with COPD) whereas 102 patients (60%) had SpO2 values within- or even below the recommended target range. Many of these patients (44.1%) received oxygen through a low-flow device (nasal canula), and these patients almost invariably (84.4%) were not compromised in their ventilation (P/F ratio’s > 300). Conclusion When oxygen is titrated based on SpO 2 levels, this results in hyperoxemia in a significant proportion of the patients. Health care providers should especially be reluctant to administer (low flow) oxygen as a standard of care to patients who do not have clear respiratory compromise, as these patients are at a high risk of developing (occult) hyperoxia.

Background Timely and effective pre-hospital management of penetrating neck injuries (PNI) is critical to improve patient outcomes. Pre-hospital interventions in patients with PNI can be especially challenging due to the anatomical injury site coupled with a resource-limited environment. Nationally, in the United Kingdom, no consensus statement or expert agreed guidance exists on how to best manage PNI in the pre-hospital setting. Method We conducted a national modified e-Delphi study with subject matter experts (SMEs) from multiple professional specialities with experience in the management of PNI. Pre-identified SMEs were contacted and consented prior to participation allowing for a remotely conducted Delphi using REDCap and Microsoft Teams. In Round 1, statements drawn from the literature base were distributed to all SMEs. Round 2 comprised a facilitated and structured discussion of the statements and then an online survey provided final ratification in Round 3. Of the participating SMEs consensus was set a priori at 70%. Results Of the 67 pre-identified SMEs, 28 participated, resulting in a response rate of 42%. From the first two rounds, 19 statements were derived with every statement achieving consensus in Round 3. Subsequently, an algorithm for the pre-hospital management of PNI was developed and agreed with SME consensus. Conclusion Curation of national consensus statements from SMEs aims to provide principles and guidance for PNI management in a complicated patient group where pre-hospital evidence is lacking. Multi-professional national consensus on the best approach to manage these injuries alongside a novel PNI management algorithm aims to optimise time critical care and by extension improve patient outcomes.

Background and aim The passage of kidney stones through the ureter creates renal colic, a severe visceral abdominal pain. Renal colic is typically managed with non-steroidal anti-inflammatory drugs and opioids. Yet, these treatments often fail to provide adequate pain relief. The erector spinae plane block (ESPB) has emerged as a potential alternative treatment. This systematic review summarises the current body of evidence on the efficacy and safety of ESPB for renal colic in the ED. Methods A systematic review and meta-analysis of randomised controlled trials (RCTs) and case series of ESPB in ED patients were conducted. PubMed, EMBASE, Web of Science and ClinicalTrial.gov databases were electronically searched up to 10 June 2024, for studies that compared ESPB with standard care or placebo. The Cochrane risk of bias-2 tool was used to assess the risk of bias of included studies. Meta-analysis using a random effects model was performed if two or more studies reported the same outcome. The Grading of Recommendations Assessment, Development, and Evaluation tool was used to assess the certainty of the evidence. Results Four studies were included, including two RCTs and two case series. A total of 53 patients received an ESPB, compared with 40 patients who received standard care. All studies were rated as having a high overall risk of bias. Meta-analysis showed a large and significant effect of ESPB on pain reduction after 30 min (standardised mean difference (SMD) −1.41 95% CI −1.90 to −0.91) and after 60 min (SMD −1.94 95% CI −3.36 to −0.52), however the level of evidence was downgraded to very low certainty due to substantial heterogeneity (I ² =85%), serious concerns of bias and large imprecision. Heterogeneity in other outcome measurements precluded meta-analysis. Conclusions Although statistically significant, there is a low certainty regarding the positive effect of ESPB on pain reduction for renal colic in the ED. High-quality RCTs focusing on patient-reported outcomes are needed to establish the merit of ESPB for this indication. PROSPERO registration number CRD42024554077.

Trauma is a leading cause of death and disability worldwide across all age groups, with traumatic cardiac arrest (TCA) presenting a significant economic and societal burden due to the loss of productive life years. Despite TCA’s high mortality rate, recent evidence indicates that survival with good and moderate neurological recovery is possible. Successful resuscitation in TCA depends on the immediate and simultaneous treatment of reversible causes according to pre-established algorithms. The HOTT protocol, addressing hypovolaemia, oxygenation (hypoxia), tension pneumothorax, and cardiac tamponade, forms the foundation of TCA management. Advanced interventions, such as resuscitative thoracotomy and resuscitative endovascular balloon occlusion of the aorta (REBOA), further enhance treatment. Contemporary approaches also consider metabolic factors (e.g. hyperkalaemia, calcium imbalances) and hemostatic resuscitation. This narrative review explores the advanced management of TCA and peri-arrest states, discussing the epidemiology and pathophysiology of peri-arrest and TCA. It integrates classic TCA management strategies with the latest evidence and practical applications.

Please confirm that an ethics committee approval has been applied for or granted : Not relevant (see information at the bottom of this page) Background and Aims Currently three types of regional nerve blocks are in use to provide analgesia to patients with hip fractures; the Fascia-Iliaca Compartment Block (FICB), Femoral Nerve Block (FNB) and Pericapsular Nerve Group Block (PENG). It is unclear which of these provides the best analgesia and the lowest number of complications. This systematic review aims to evaluate the literature concerning the efficacy and safety of pre-operatively placed PENG block compared to FICB and FNB for hip fractures. Methods The PRISMA statement guidelines were used and a systematic search of MEDLINE (via Ovid), Embase, Web of Science and Google Scholar was performed until April 8th 2024. Results 118 studies were identified, and after review 18 studies were included. Significant heterogeneity in outcome measures was present. Patients receiving PENG block reported better pain score outcomes (12 out of 17 studies), better patient satisfaction (5 out of 7 studies), better movement or quadriceps strength (4 out of 5 studies), less additional opioid use (5 out of 10 studies) and improved EOSP (4 out of 7 studies). None of the studies found FNB or FICB be favourable on these outcomes. No significant differences were found between blocks for (serious) adverse events. Conclusions PENG block is a promising technique to provide analgesia to patients with a hip fracture. However, there is significant heterogeneity in both endpoints used and in outcomes of the various studies that compared PENG with FM or FICB blocks. Larger randomized controlled trials with patient-centred outcomes are required to definitively establish which nerve block is most effective.

Background Comparison of emergency departments (EDs) becomes more important, but differences are difficult to interpret because of the heterogeneity of the ED population regarding reason for ED presentation. The aim of this study was two-fold: First to compare patient characteristics (including diagnoses) across 7 EDs. Secondly, to compare Standardized Mortality Ratios (SMRs) across 7 EDs and in subgroups of ED patients categorized by presenting complaints (PCs). Methods Observational multicenter study including all consecutive visits of 7 EDs. Patient characteristics, including PCs as part of triage systems, and SMRs (observed divided by expected mortality) per ED and for the most common PCs (PC-SMRs) were compared across EDs and presented as funnel plots. The expected mortality was calculated with a prediction model, which was developed using multivariable logistic regression in the overall population and for PCs separately. Demographics, disease severity, diagnoses, proxies for comorbidity and complexity, and PCs (overall population only) were incorporated as covariates. Results We included 693,289 ED visits, of which 1.9% died. Patient characteristics varied markedly among EDs. Expected mortality was similar in prediction models with or without diagnoses as covariate. SMRs differed across EDs, ranging from 0.80 to 1.44. All EDs had SMRs within the 95%-Confidence Intervals of the funnel plot apart from one ED, which had an higher than expected SMR. However, PC-SMRs showed more variation and more EDs had SMRs falling outside the funnel, either higher or lower than expected. The ranking of SMRs across EDs was PC-dependent and differences across EDs are present only for specific PC-SMRs, such as in "dyspnea" and "feeling unwell”. Conclusion In summary, patient characteristics and mortality varied largely across Dutch EDs, and expected mortality across EDs is well assessed in PC subgroups without adjustment for final diagnoses. Differences in SMRs across EDs are PC-dependent. Future studies should investigate reasons of the differences in PC-SMRs across EDs and whether PC-targeted quality improvement programs can improve outcomes.