pubmed thesis topics in emergency medicine

The top 100 cited articles published in emergency medicine journals

Affiliations.

• 1 Division of Emergency Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA; Department of Emergency Medicine, Hospital General de la Plaza de Salud, Santo Domingo, Dominican Republic. Electronic address: [email protected].
• 2 Department of Clinical Epidemiology and Public Health, Universidad Autónoma de Santo Domingo, Santo Domingo, Dominican Republic.
• 3 Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan.
• 4 Department of Emergency Medicine, Hospital General de la Plaza de Salud, Santo Domingo, Dominican Republic.
• 5 Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY.
• PMID: 25979301
• DOI: 10.1016/j.ajem.2015.04.047

Introduction: Our objective was to identify trends and examine the characteristics of the top 100 cited articles in emergency medicine (EM) journals.

Methods: Scopus Library database was queried to determine the citations of the top 100 EM articles. A second database (Google Scholar) was used to gather the following information: number of authors, publication year, journal name, impact factor, country of origin, and article type (original article, review article, conference paper, or editorial). The top 100 cited articles were selected and analyzed by 2 independent investigators.

Results: We identified 100 top-cited articles published in 6 EM journals, led by Annals of Emergency Medicine (65) and American Journal of Emergency Medicine (15). All top-cited articles were published between 1980 and 2009. The common areas of study were categorized as cardiovascular medicine, emergency department administration, toxicology, pain medicine, pediatrics, traumatology, and resuscitation. A statistically significant association was found between the journal impact factor and the number of top 100 cited articles (P < .005).

Conclusion: The top-cited articles published in EM journals help us recognize the quality of the works, discoveries, and trends steering EM. Our analysis provides an insight to the prevalent areas of study being cited within our field of practice.

Copyright © 2015 Elsevier Inc. All rights reserved.

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Emergency department responses to nursing shortages

The COVID-19 pandemic exacerbated the nursing shortage, which is predicted to continue to worsen with significant numbers of nurses planning to retire within the next 5 years. There remains a lack of published...

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Bibliometric analysis of ChatGPT in medicine

The emergence of artificial intelligence (AI) chat programs has opened two distinct paths, one enhancing interaction and another potentially replacing personal understanding. Ethical and legal concerns arise d...

Clinical significance of elevated D-dimer in emergency department patients: a retrospective single-center analysis

D-dimer is a marker of coagulation and fibrinolysis widely used in clinical practice for assessing thrombotic activity. While it is commonly ordered in the Emergency Department (ED) for suspected venous thromb...

The state of emergency medicine in Greece: at critical momentum

Greece is a parliamentary republic in southeastern Europe populated by over 10 million permanent residents: 9 million reside on the mainland, with almost 4 million in the greater Athens area. The remaining 1 m...

Single intravenous dose ondansetron induces QT prolongation in adult emergency department patients: a prospective observational study

Ondansetron is one of the most commonly used drugs in the emergency department (ED) for treating nausea and vomiting, particularly in intravenous (IV) form. Nevertheless, it has been shown to prolong QT interv...

Evaluation of elevated serum apelin-13 and D-dimer concentrations in individuals diagnosed with pulmonary embolism

Given the limited specificity of D-dimer, there is a perceived need to discover a more precise marker for diagnosing individuals who are suspected of having pulmonary embolism (PE). In this study, by evaluatin...

An AI-based multiphase framework for improving the mechanical ventilation availability in emergency departments during respiratory disease seasons: a case study

Shortages of mechanical ventilation have become a constant problem in Emergency Departments (EDs), thereby affecting the timely deployment of medical interventions that counteract the severe health complicatio...

A survivor with unexplained chest scars

This case illustrates chest scars after piston-based chest compression device resuscitation and raises the awareness of the potential benefits of following up survivors of critical illness.

Natto (fermented soybeans)-induced anaphylaxis in a surfer with the possibility of sensitization to poly(γ-glutamic acid) from cutaneous exposure to jellyfish sting: a case report

We report a case of anaphylaxis induced by natto (fermented soybeans) allergy that occurred following dermal sensitization from a jellyfish sting.

Utilizing the National Early Warning Score 2 (NEWS2) to confirm the impact of emergency department management in sepsis patients: a cohort study from taiwan 1998–2020

Most sepsis patients could potentially experience advantageous outcomes from targeted medical intervention, such as fluid resuscitation, antibiotic administration, respiratory support, and nursing care, prompt...

Emergency airway management in resource limited setting

Emergency airway management in resource-limited settings presents multifaceted challenges due to shortages in essential medical resources, healthcare professionals, and infrastructure.

From compression to diagnosis: identification of superior vena cava syndrome using point-of-care ultrasound in the emergency department

Superior vena cava (SVC) syndrome is an urgent condition arising from restricted blood flow through the SVC, often linked to factors like malignancy, thrombosis, or infections. Typically, confirmation of the d...

PoCUS identification of distal biceps tendon rupture: a case report

In the Emergency Department (ED), patients may present with various injuries that damage muscles, tendons, ligaments, and bony structures. Fractures, joint dislocations, strains, and sprains are prevalent amon...

Jejunogastric intussusception associated with jejunojejunal intussusception (double telescoping) occurring 20 years after gastrojejunostomy

Jejunogastric intussusception (JGI) is a rare but potentially lethal complication following gastrectomy or gastrojejunostomy surgeries. Diagnosis of this condition can be challenging due to its rarity and non-...

Patient-controlled analgesia morphine for the management of acute pain in the emergency department: a systematic review and meta-analysis

The ideal pain control approach is typically viewed as titration of analgesia for pain reduction and periodic pain evaluation. However, this method takes time and is not always possible in the crowded Emergenc...

Use of bitemporal NACA score documentation in prehospital emergency medical services– a retrospective study

The assessment of illness severity in the prehospital setting is essential for guiding appropriate medical interventions. The National Advisory Committee for Aeronautics (NACA) score is a validated tool common...

Recurrent transitory attacks with cytotoxic edema could benefit from thrombolysis

The original article was published in International Journal of Emergency Medicine 2023 16 :62

Comparison of T-POD and SAM Pelvic Sling II and the influence of attachment level in the initial management of unstable pelvic type C injuries – a cadaveric study

Type C pelvic fractures (AO/OTA) are severe injuries that frequently lead to bleeding and hemodynamic instability. Pelvic binders play a crucial role in their initial management. Placement at the correct level...

Catheter-related gas-forming suppurative thrombophlebitis

Catheter-related suppurative thrombophlebitis (CRST) is a complication of catheter-related bloodstream infection (CRBSI). The microbiology of CRST is similar with the microbiology of CRBSI, but  Clostridium perfri...

Introduction of a formative assessment tool in a post-graduate training program in India: a mixed methods evaluation

Our institution has longstanding post-graduate education and training partnership programs in Emergency Medicine (EM) across India. A programmatic challenge has been the integration and uptake of evidence-base...

The leading role of expert safety knowledge in supporting the mission of caring for patients during man-made and natural disasters: state of emergency medicine in Ethiopia, Myanmar, and Ukraine

Preparedness to endure extreme situations such as natural disasters or military conflicts is not commonplace in healthcare training programs. Moreover, multidisciplinary teams in health services rarely (if eve...

The PIRATE mnemonic: providing a structured approach in the care for intoxicated patients at the emergency department

Expertise in toxicology is essential for acute care providers, as intoxicated patients frequently present to Emergency Departments. These patients can be challenging for care providers because they often prese...

Persistent hiccups as a rare presenting symptom of empyema: a case report

Empyema is uncommon owing to antibiotic use but still affects patient health if not treated. Hiccups as the initial symptom of empyema are rare; however, empyema should be considered if a patient has persisten...

Physicians’ challenges when working in the prehospital environment - a qualitative study using grounded theory

In the rapid development in prehospital medicine the awareness of the many challenges in prehospital care is important as it highlights which areas need improvement and where special attention during education...

A case report of an accidental iatrogenic dexmedetomidine overdose in an adult

Dexmedetomidine is a sedative drug with a wide safety margin.

Impact of teaching on use of mechanical chest compression devices: a simulation-based trial

The use of mechanical chest compression devices on patients in cardiac arrest has not shown benefits in previous trials. This is surprising, given that these devices can deliver consistently high-quality chest...

Demographics and clinical characteristics of carbon monoxide poisoning for patients attending in the emergency department at a tertiary hospital in Riyadh, Saudi Arabia

Carbon Monoxide (CO) is one of the most common environmental causes of acute intoxication globally. It can lead to the development of Delayed Neuropsychiatric Sequelae (DNS) which may develop in 2-40 days afte...

How a broken vertebra can lead to a fatal hemorrhage: a case report

Unintentional falls are common among the elderly and given the expected increase of the aging population, these falls contribute to a high number of admissions to the emergency department. Relatively low-energ...

Overview of best practices for buprenorphine initiation in the emergency department

In recent decades, opioid overdoses have increased dramatically in the United States and peer countries. Given this, emergency medicine physicians have become adept in reversing and managing complications of a...

Diagnostic challenges between takotsubo cardiomyopathy and acute myocardial infarction—where is the emergency?: a literature review

Takotsubo cardiomyopathy (TC) is an emergency cardiovascular disease, with clinical and paraclinical manifestations similar to acute myocardial infarction (AMI), but it is characterized by reversible systolic ...

Triage implementation in resource-limited emergency departments: sharing tools and experience from the Pacific region

According to the World Health Organization’s (WHO) Emergency Care Systems Framework, triage is an essential function of emergency departments (EDs). This practice innovation article describes four strategies that...

Chest tube placement in trauma patients: please use sonography

Intentional intoxication with monkshood plant leading to atrioventricular dissociation and ventricular ectopy in a 17-year-old female: a case report.

Monkshood, a toxic plant containing a potent cardio- and neurotoxin called aconitine, can lead to a range of symptoms, including nausea, vomiting, dizziness, seizures, and cardiac arrhythmias. Mortality associ...

The first reported mortality from aluminum phosphide poisoning in Lebanon: a case report

Aluminum phosphide is a commonly used pesticide, particularly in developing countries where uncontrolled insecticides and pesticides are commonly prevalent. Mortalities have been reported due to accidental and...

Using design research and human-centered design to address growing pains in a busy, urban emergency department: a faculty, clinician, and student collaboration between nursing, design, and medicine

In 2021, a large urban university-based hospital transitioned to a new two-floor emergency department. Despite the new environment, there were usability and workflow challenges with the space. The authors of t...

Strategies for improving ED-related outcomes of older adults who seek care in emergency departments: a systematic review

Despite constituting 14% of the general population, older adults make up almost a quarter of all emergency department (ED) visits. These visits often do not adequately address patient needs, with nearly 80% of...

A case report on ultrasound-guided pericardiocentesis with a right parasternal approach: a novel in-plane lateral-to-medial technique

Emergency pericardiocentesis is a life-saving procedure that is performed to aspirate fluid from the pericardial space in patients who have severe pericardial effusion that is causing hemodynamic compromise. T...

Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review

Cardiopulmonary collapse is a catastrophic event in cesarean section, which leads to adverse outcomes for both the mother and the fetus. Pulmonary embolism is one of the rare etiologies of this entity. We here...

Evaluating the effectiveness of the pre‑hospital trauma life support (PHTLS) program for the management of trauma patients in the pre-hospital emergency based on Kirkpatrick’s evaluation model

Pre-hospital trauma life support (PHTLS) training courses have been developed and widely adopted to enhance the proficiency of pre-hospital personnel in handling trauma patients. The objective of this study wa...

The diagnostic accuracy of point-of-care ultrasound parameters for airway assessment in patients undergoing intubation in emergency department—an observational study

Endotracheal intubation is an essential resuscitative procedure in the emergency setting. Airway assessment parameters such as the Mallampati classification are difficult to perform in an emergency setting. As...

Development of prehospital emergency care in Singapore

This review paper describes the development of the pre-hospital system in Singapore from the pre-war days. Every country’s prehospital community needs a deep understanding of how they developed over the years,...

History of emergency medicine in Bhutan

Emergency medicine in Bhutan has made significant progress in the past few decades and continues to evolve. In this article, we provide valuable insights into the history of emergency medicine at Jigme Dorji W...

Ruptured abdominal aortic aneurysm discovered by pocket-sized ultrasound in a low resource setting: a case report

Abdominal aortic aneurysm (AAA) is a life-threatening condition characterized by the weakening and dilation of the abdominal aorta. AAA primarily affects men, smokers, and the elderly, with rupture being a fat...

Learning Urogenital Diseases in Oddity (LUDO)—a gamification-based innovation for learning urogenital diseases in emergency medicine

Urogenital emergencies demand immediate attention within the field of emergency medicine, encompassing a range of critical conditions from ectopic pregnancies to kidney stones. Timely diagnosis and treatment a...

A review of pre-hospital extracorporeal cardiopulmonary resuscitation and its potential application in the North East of England

Patients in the UK who suffer an out-of-hospital cardiac arrest are treated with cardiopulmonary resuscitation in the pre-hospital environment. Current survival outcomes are low in out-of-hospital cardiac arre...

The utility of the abdominal series in the emergency setting: a retrospective review

The abdominal series (AXR) remains a frequently ordered test in the emergency department (ED), despite existing literature questioning its utility. The aim of this study was to characterize the use of the AXR ...

Emergency department contribution to HCV elimination in the Iberian Peninsula

Undiagnosed cases of hepatitis C virus (HCV) infection result in significant morbidity and mortality, further transmission, and increased public health costs. Testing in emergency departments (EDs) is an oppor...

Prediction of major adverse cardiac events in the emergency department using an artificial neural network with a systematic grid search

The aim of our research was to design and evaluate an Artificial Neural Network (ANN) model using a systemic grid search for the early prediction of major adverse cardiac events (MACE) among patients presentin...

Stercoral colitis in the emergency department: a review of the literature

Stercoral colitis (SC) is a rare but potentially life-threatening inflammatory colitis caused by the accumulation of impacted fecal material. Despite reported associations with bowel perforation and high morta...

Latrodectus envenomation in Ethiopia

Black widows, one of the few spiders that can sting humans with poison, are members of the spider genus Latrodectus and are well-known for the extraordinary potency of their neurotoxic venom. Latrodectism, a s...

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2022 Citation Impact 3.2 - 2-year Impact Factor 2.9 - 5-year Impact Factor 1.323 - SNIP (Source Normalized Impact per Paper) 0.773 - SJR (SCImago Journal Rank) 2023 Speed  35 days submission to first editorial decision for all manuscripts (Median) 134 days submission to accept (Median) 2023 Usage 985,950 downloads 682 Altmetric mentions 

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• ISSN: 1865-1380 (electronic)
• ISSN: 1865-1372 (print)

International Journal of Emergency Medicine

ISSN: 1865-1380

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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ADULT RESUSCITATION

Effectiveness of introducer (bougie) for tracheal intubation (January 2024)

While the tracheal tube introducer (commonly referred to as a "bougie") is widely considered an important tool for emergency intubation, high-quality evidence supporting its role has been limited. In a new systematic review and meta-analysis of 18 studies involving over 9000 adult patients, use of an introducer was associated with a higher overall rate of successful first-pass intubation compared with no introducer (in most cases an tracheal tube with a stylet) [ 1 ]. First-pass success rates were higher using an introducer regardless of the method of intubation (ie, direct versus video laryngoscopy) or where intubation was performed (eg, emergency department, intensive care unit, prehospital). The introducer was most effective in patients (n = 585 in five studies) with a Cormack-Lehane III or IV view. We consider the introducer an essential tool for difficult airway management that should be readily available in the emergency department. (See "Endotracheal tube introducers (gum elastic bougie) for emergency intubation", section on 'Evidence of effectiveness' .)

Extracorporeal cardiopulmonary resuscitation (December 2023)

Extracorporeal cardiopulmonary resuscitation (ECPR) is being increasingly used, but data are limited and the benefits are uncertain. In a recent meta-analysis of 11 studies (10,000 patients) who underwent CPR, compared with standard CPR, ECPR was associated with decreased in-hospital mortality and increased long-term favorable neurologic outcome and survival at one year [ 2 ]. The benefit of ECPR was confined to patients with in-hospital cardiac arrest. These data support the growing practice of ECPR in select patients likely to benefit. (See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Sudden cardiac arrest (extracorporeal cardiopulmonary resuscitation)' .)

Heart rate control in septic shock (December 2023)

Beta blockade has the potential to limit harm from the adrenergic overdrive that occurs in septic shock. However, data to support heart rate control in patients with septic shock are limited. In a recent, unblinded randomized trial of 126 patients with septic shock-related tachycardia (heart rate ≥95/min) who were receiving norepinephrine, the beta blocker landiolol did not reduce organ failure as measured by the sequential organ failure assessment score [ 3 ]. Furthermore, landiolol was associated with increased 28-day mortality compared with standard care (37 versus 25 percent). We continue to avoid the routine use of beta blockers in patients with septic shock. (See "Investigational and ineffective pharmacologic therapies for sepsis", section on 'Heart rate control' .)

Aerosol generation during noninvasive respiratory support modalities (October 2023)

Studies have reported conflicting data as to whether high levels of aerosols are generated when noninvasive ventilation (NIV) or high-flow nasal oxygen (HFNO) is used. In a 2023 systematic review including 12 studies in patients with respiratory infections and 15 studies in healthy volunteers, use of NIV or HFNO was not associated with increased generation of pathogen-laden aerosols compared with controls with unsupported normal or labored breathing, low-flow nasal oxygen, or oxygen or nonrebreather mask [ 4 ]. Inconsistency among studies may reflect differences in sampling and detection methodologies and operating room ventilation. Notably, the National Health Service in the United Kingdom has removed mask ventilation, intubation, and extubation from its list of aerosol-generating procedures. (See "Overview of infection control during anesthetic care", section on 'Considerations during aerosol-generating procedures' .)

GENERAL ADULT EMERGENCY MEDICINE

Unchanged emergency department discharge rates for pulmonary embolism (April 2024)

Outpatient anticoagulation to avoid hospitalization is safe for a select group of patients with acute pulmonary embolism (PE). However, a recent study of over 1.6 million emergency department (ED) visits for PE in the United States reported that ED discharge rates for PE were unchanged between 2012 and 2020 (38 versus 33 percent) [ 5 ]. Among low-risk patients, only one third were discharged from the ED. However, this study was unable to determine whether other factors may have prevented discharge such as drug accessibility, concurrent deep vein thrombosis, and right ventricular burden. Although not conclusive, this study suggests that increased physician awareness is needed to encourage safe ED discharge of low-risk patients with PE. (See "Treatment, prognosis, and follow-up of acute pulmonary embolism in adults", section on 'Outpatient anticoagulation' .)

Emergency physician-performed point-of-care ultrasound for cholecystitis (February 2024)

Emergency physician-performed point-of-care ultrasound can be helpful when evaluating an adult with right upper quadrant pain, but test characteristics vary depending on the operator and indication. A meta-analysis with over 1700 patients found that the sensitivity and specificity of point-of-care ultrasound for acute cholecystitis was 71 and 94 percent, respectively [ 6 ]. These findings suggest this rapid, bedside imaging modality can help expedite care if cholecystitis is identified but may not be sufficient to rule out the diagnosis. (See "Evaluation of the adult with nontraumatic abdominal or flank pain in the emergency department", section on 'Role of point-of-care ultrasound' .)

Guidelines on management of acute respiratory distress syndrome (February 2024)

The American Thoracic Society recently updated their guidelines on the management of patients ventilated for acute respiratory distress syndrome (ARDS) [ 7 ]. Compared with previous recommendations, emphasis was placed on the value of systemic corticosteroid administration, early use of extracorporeal membrane oxygenation, and use of neuromuscular blockade, particularly in patients with severe ARDS. Recommendations also focus on the avoidance of recruitment maneuvers, especially prolonged maneuvers. We agree with these recommendations. (See "Acute respiratory distress syndrome: Ventilator management strategies for adults", section on 'Introduction' .)

Time window to start dual antiplatelet therapy for high-risk TIA or minor ischemic stroke (January 2024)

There is evidence from several randomized trials that early initiation of short-term dual antiplatelet therapy (DAPT) for select patients with high-risk transient ischemic attack (TIA) or minor ischemic stroke reduces the risk of recurrent ischemic stroke. The evidence comes from trials that started DAPT within 12 to 24 hours of symptom onset. Results from the recent INSPIRES trial suggest that DAPT is still beneficial when started up to 72 hours after symptom onset [ 8 ]. Although the time window is extended by the results from INSPIRES, we start DAPT as soon as possible for patients with high-risk TIA or minor ischemic stroke. (See "Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack", section on 'High-risk TIA and minor ischemic stroke' .)

Guidelines for primary spontaneous pneumothorax (December 2023)

The British Thoracic Society (BTS) has recently issued new guidelines for the management of primary spontaneous pneumothorax (PSP) [ 9 ]. Major changes since 2010 include a symptom- rather than size-based approach. For patients with mild symptoms who are stable following adequate analgesia, monitored observation is preferred, while those with significant dyspnea should undergo a drainage procedure (eg, aspiration or catheter/chest tube thoracostomy). Also promoted was ambulatory management in select patients with adequate outpatient support. We agree with these recommendations. (See "Treatment of primary spontaneous pneumothorax in adults", section on 'Initial evaluation and management' .)

Timing of appendectomy for uncomplicated appendicitis (November 2023)

Appendectomy is traditionally performed urgently to reduce the risk of perforation. However, a large randomized trial showed that patients with uncomplicated appendicitis (including those with appendicolith on computed tomography) who had an in-hospital delay of up to 24 hours before surgery had no increased risk of perforation or other complications compared with those who underwent surgery within 8 hours [ 10 ]. Given these data and general acceptance of antibiotic management of these patients, we suggest performing appendectomy within 24 hours of presentation in patients with uncomplicated appendicitis who elect to undergo surgery. (See "Management of acute appendicitis in adults", section on 'Timing of appendectomy' .)

Low-dose dexamethasone for severe migraine in adults (October 2023)

Parenteral dexamethasone is used along with short-acting abortive therapies to reduce migraine recurrence for patients with severe symptoms, but optimal dosing is uncertain. Prior trials have reported benefit at doses ranging from 8 to 24 mg. In a recent trial of 209 adults with moderate to severe migraine presenting to the emergency department treated with metoclopramide and intravenous (IV) dexamethasone, rates of sustained relief at 48 hours were similar between groups randomly assigned to 4 versus 16 mg of dexamethasone [ 11 ]. Rates of immediate headache relief and medication use in the week following discharge were also similar. These results support our preference for adjunctive dexamethasone at a dose of 4 mg IV to reduce migraine recurrence. (See "Acute treatment of migraine in adults", section on 'Abortive therapy plus parenteral dexamethasone' .)

GENERAL PEDIATRIC EMERGENCY MEDICINE

Concussion and mental health disorders in children and adolescents (March 2024)

Ongoing research continues to examine the complex relationship between concussion and mental health disorders. In a recent case-control study of over 18,000 children (≤17 years old) with concussion and over 37,000 matched controls, concussion was associated with an increased risk for a new diagnosis of a behavior disorder at two and four years after injury [ 12 ]. For most diagnoses, the absolute numbers were low. Confidence in a causal relationship is limited by risk of confounding and reliance on an electronic medical record for establishing lack of baseline behavioral problems prior to injury. Whether pediatric concussion is an independent risk factor for new behavioral problems after recovery remains unclear. (See "Concussion in children and adolescents: Management", section on 'Mental health disorders' .)

Increasing exposure to illicit fentanyl in young children in the United States (March 2024)

The potent opioid fentanyl is commonly implicated in fatal adult and pediatric poisonings, but there are limited data on accidental nonfatal exposures in young children. In the United States between 2013 and 2023, calls to poison control centers for children ≤6 years of age exposed to illicit fentanyl increased from 5 to 539 annually [ 13 ]. More than 80 percent were children ≤2 years old or were exposed at home. Most patients had severe effects and half received naloxone . These data confirm the seriousness of the presence of illicit fentanyl in the households of young children and suggest it as a focus for prevention measures. (See "Opioid intoxication in children and adolescents", section on 'Epidemiology' .)

Short-course antibiotic therapy in children with febrile UTI (February 2024)

In children with urinary tract infection (UTI) without suspected kidney involvement, there is controversy about the duration of empiric antibiotic therapy. In an unblinded trial from Italy of amoxicillin-clavulanate to treat UTI, 142 children three months to five years of age were randomly assigned to a 10-day course (standard) or a 5-day course (short) of antibiotics [ 14 ]. Fewer children assigned to the short course had recurrent UTI within 30 days of antibiotic completion (2.8 versus 14.3 percent [difference -11.5 percent, 95% CI -20.5 to -2.5]). Rates of resistance to amoxicillin-clavulanate within 5 days following completion of antibiotics (1.4 versus 4.3 percent) and within 30 days (1.4 versus 0 percent) were similar. This trial lends further support for a 5-day course of antibiotics to treat UTI when kidney involvement is not suspected. (See "Urinary tract infections in infants older than one month and children less than two years: Acute management, imaging, and prognosis", section on 'Preferred empiric oral regimens' .)

PRIMARY CARE ORTHOPEDICS AND SPORTS MEDICINE

Avulsion fractures of hip and pelvis in children (October 2023)

There are few large-scale studies of pelvic avulsion fractures in children. A retrospective review of over 700 children with pelvic or hip avulsion fractures from a single tertiary care hospital reported the average patient age was just over 14 years and nearly 80 percent were sustained by males [ 15 ]. The anterior-superior and inferior iliac spines and ischial tuberosity were the most common sites, accounting for over 80 percent of fractures. Most injuries were sustained while the patient was running or kicking during sport, most often football (soccer). The incidence of avulsion fracture rose substantially during the study period, 2005 to 2020. (See "Pelvic trauma: Initial evaluation and management", section on 'Epidemiology and mechanism' .)

New guidelines for airway management in infants (January 2024)

Very young children are at higher risk of complications of airway management than children in older age groups; however, guidelines for infants have been lacking. In 2024, the European Society of Anesthesiology and Intensive Care and the British Journal of Anesthesia published joint guidelines for airway management in neonates and infants [ 16 ]. A summary of their recommendations appears in the following table ( table 1 ). (See "Airway management for pediatric anesthesia", section on 'Pediatric airway management guidelines' .)

Videolaryngoscopy for endotracheal intubation in critically ill children (January 2024)

Use of videolaryngoscopy (VL) in children provides a shared view during emergency endotracheal intubation (ETI) that permits an experienced physician observer to give assistance to the proceduralist. In a multicenter quality study of VL during ETI in pediatric intensive care units with standardized coaching by an attending, over 3500 ETIs were performed with VL, and use of VL increased from 30 percent to 89 percent of ETIs over four years [ 17 ]. Compared with direct laryngoscopy, VL was associated with lower adverse events (9 versus 15 percent). The majority of proceduralists were residents or fellows. These findings and prior studies confirm the safety of VL during emergency ETI in children and demonstrate the value of standardized coaching during the procedure for less experienced clinicians. (See "Technique of emergency endotracheal intubation in children", section on 'Video versus direct laryngoscopy' .)

Multiple-dose activated charcoal for amatoxin-containing mushroom poisoning (March 2024)

Ingesting mushrooms that contain amatoxins can cause acute liver injury, liver and multisystem organ failure, and death. Multiple-dose activated charcoal (MDAC), which increases elimination of amatoxins by blocking enterohepatic recirculation, is a frequently used therapy, typically combined with other antidotes. A systematic review that included nearly 1200 patients (665 received MDAC, 2 received single-dose activated charcoal) with amatoxin-containing mushroom poisoning found that activated charcoal administration was associated with higher transplant-free survival (83 versus 75 percent) [ 18 ]. These findings support our recommendation to administer MDAC to patients with suspected amatoxin-containing mushroom ingestion. (See "Amatoxin-containing mushroom poisoning (eg, Amanita phalloides): Clinical manifestations, diagnosis, and treatment", section on 'Elimination enhancement' .)

Delta-8 tetrahydrocannabinol use by United States adolescents (March 2024)

Delta-8 tetrahydrocannabinol (THC) is typically a minor cannabinoid found in cannabis, but can also be synthesized. It is increasingly found in United States (US) cannabis products, often marketed as low delta-9 THC. A survey of US twelfth graders in 2023 found that 11 percent reported using delta-8 THC within the past 12 months, compared with 30 percent reporting marijuana use [ 19 ]. Delta-8 THC use was lower in states with cannabis legalization (8 versus 14 percent) or delta-8 THC regulation (6 versus 14 percent). These findings suggest that delta-8 THC is a public health concern in adolescents, particularly in states that do not regulate it and have not legalized marijuana for adult use. (See "Cannabis (marijuana): Acute intoxication", section on 'Cannabis formulations' .)

Xylazine and fentanyl detection in overdose deaths (March 2024)

Xylazine (street name "Tranq") is an alpha-2 adrenergic agonist increasingly found as an adulterant in or co-administered with illicit fentanyl ; whether the combined use of xylazine with fentanyl or other opioids increases the risk of overdose death is unclear. In a retrospective study of over 3000 fentanyl-related overdose fatalities over four years, the median postmortem fentanyl concentration was higher in the 148 cases that also had xylazine detected; significantly more decedents with xylazine detected had very high fentanyl concentrations (>40 mcg/L) [ 20 ]. This finding suggests that co-administration of xylazine may permit tolerance to higher doses of fentanyl and may be associated with decreased, rather than increased, lethality. The mechanism of this effect is not clear and requires further study. (See "Clonidine, xylazine, and related imidazoline poisoning", section on 'Epidemiology' .)

Diethylene glycol poisoning outbreak in Indonesia (February 2024)

Diethylene glycol (DEG) ingestion causes gastrointestinal symptoms followed by an elevated anion gap metabolic acidosis, acute kidney injury (AKI), and delayed neurologic toxicity in survivors. Outbreaks continue to occur when DEG is substituted for the more expensive propylene glycol in liquid/syrup medications. In Indonesia in 2022, 52 previously healthy children who had taken a syrup-based antipyretic or cough medication were treated for rapidly progressing AKI [ 21 ]. DEG and/or ethylene glycol were identified in 16 out of 17 patients who had toxicology testing performed. Most children required kidney replacement therapy and 34 died. DEG and/or ethylene glycol poisoning must be on the differential diagnosis of any child with a rapidly progressing AKI. (See "Methanol and ethylene glycol poisoning: Management", section on 'Diethylene glycol' .)

Insulin-euglycemia therapy for phosphide poisoning (January 2024)

The metallic phosphide rodenticides, zinc and aluminum phosphide, cause shock, cardiac dysfunction, dysrhythmias, respiratory failure, and metabolic acidosis. In acute poisoning, mortality is very high, treatment is primarily supportive (including vasopressors, bicarbonate, and magnesium infusion), and no antidote exists. In a trial of 108 patients with aluminum phosphide poisoning and hypotension or acidosis, compared with supportive care and norepinephrine, insulin-euglycemia therapy reduced mortality (65 versus 96 percent) and tracheal intubation (61 versus 82 percent), and improved mean arterial pressure six hours after poisoning (65 versus 13 mmHg) [ 22 ]. These findings suggest that insulin-euglycemia therapy may be beneficial in critically ill patients poisoned with phosphide poisoning. (See "Overview of rodenticide poisoning", section on 'Zinc and aluminum phosphide' .)

Photobiomodulation therapy for local tissue damage from snake envenoming (January 2024)

Photobiomodulation therapy (also called low-level laser therapy [LLLT]) may decrease inflammation and enhance healing following envenoming by snake species that cause local tissue damage or myonecrosis. In a trial of 60 patients with Bothrops snakebites all of whom received antivenom, LLLT decreased pain intensity scores, extent of edema, and extremity circumference compared with no LLLT [ 23 ]. LLLT is a promising adjunct to antivenom, but more trials and access to equipment are needed before it can be recommended for routine use. (See "Snakebites worldwide: Management", section on 'Photobiomodulation' .)

National practice guidelines not associated with increased MOUD prescribing in the ED (January 2024)

In emergency department (ED) patients who survive an opioid overdose, initiation of medications for opioid use disorder (MOUD) is associated with decreased one-year mortality (approximately 5 percent without MOUD). However, prescribing rates are low and multiple barriers exist. A study of more than 20,000 ED visits for opioid toxicity in Canada found that even though MOUD prescribing increased between 2013 and 2020, it was still relatively low (<6 percent) and was not improved by the publication of Canadian clinical practice guidelines in 2018 [ 24 ]. These findings suggest that EDs and health systems need to make systematic efforts to implement and maintain MOUD-initiation programs that directly engage clinicians to overcome barriers and increase rates of prescribing. (See "Acute opioid intoxication in adults", section on 'Prevention of recurrent opioid overdose' .)

Methemoglobinemia in infants due to contaminated hospital water supply (January 2024)

Methemoglobinemia is a potentially life-threatening condition in which heme iron becomes oxidized, preventing oxygen delivery. A report from a hospital in Japan described methemoglobinemia in 10 neonates who were fed infant formula prepared with tap water from the general hospital water supply [ 25 ]. The cause was identified as high levels of nitrites, and the source was traced to contamination by an anticorrosion agent from the heating system that entered the water supply due to a malfunctioning valve. All 10 survived, although 3 required methylene blue therapy. Infants are especially susceptible to methemoglobinemia because they have lower baseline levels of the enzyme that converts heme iron back to its normal state. (See "Methemoglobinemia", section on 'Nitrates and nitrites (from foods, drugs, preservatives, and chemicals)' .)

Avoiding intubation in acutely poisoned but stable, unresponsive adults (December 2023)

In unresponsive patients with trauma or undifferentiated coma, tracheal intubation is generally recommended to protect the airway and prevent aspiration. However, the benefit of intubation is unclear in stable poisoned patients who have decreased level of consciousness but are oxygenating and ventilating adequately. In a randomized trial of 225 adults with acute poisoning and coma (GCS score ≤8), compared with airway management at the physician’s discretion, individuals not intubated unless hypoxia, seizure, vomiting, or hypotension developed had a lower likelihood of mechanical ventilation (18 versus 60 percent), intensive care unit admission (40 versus 66 percent), or adverse events from intubation (6 versus 15 percent); they also had a lower risk of pneumonia [ 26 ]. These findings support avoiding intubation solely for a GCS score ≤8 in stable, unresponsive poisoned patients who are expected not to deteriorate based upon the suspected poison (eg, ingestion of a short-acting sedative such as ethanol). (See "Initial management of the critically ill adult with an unknown overdose", section on '"A": Airway stabilization' .)

High blood lead levels in US children after eating cinnamon applesauce pouches (November 2023)

The Centers for Disease Control and Prevention have issued a health alert following reports of high blood lead levels from several states for a total of 22 children who were fed cinnamon-containing applesauce pouches that were subsequently found to contain extremely high concentrations of lead [ 27 ]. Children who have eaten a recalled product should undergo blood lead testing. Clinicians should advise parents, primary caregivers, and guardians to not buy specific cinnamon-containing apple puree or applesauce products named in the US Food and Drug Administration announcement and to discard any recalled products that they have purchased. (See "Childhood lead poisoning: Exposure and prevention", section on 'Food' and "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Laboratory evaluation' and "Childhood lead poisoning: Management" .)

Validation of an enzymatic assay for ethylene glycol poisoning in humans (November 2023)

Serum ethylene glycol (EG) concentrations are usually measured by gas chromatography, which is not widely offered by hospital clinical laboratories, leading to diagnostic uncertainty, need for empiric treatment, and delays in confirmation. Some hospitals have adopted an EG enzyme-based glycerol dehydrogenase (GDH) assay modified from a veterinary assay and run on automated chemistry analyzers. A study of 118 patient blood samples found that using a 9 mg/dL threshold (well below a toxic concentration), the GDH assay had a 100 percent positive and negative predictive value compared with gas chromatography [ 28 ]. This assay may provide a screening tool for possible EG poisoning that is associated with reduced costs and time of diagnostic uncertainty. (See "Methanol and ethylene glycol poisoning: Pharmacology, clinical manifestations, and diagnosis", section on 'Testing for methanol and ethylene glycol' .)

Skin preparation prior to fracture repair (March 2024)

The optimal preparation of contaminated or dirty wounds and whether any skin preparation can influence surgical site infection (SSI) independent of other factors (eg, prophylactic systemic antibiotics) are unknown. In a multiple-period, cluster-randomized, crossover trial comparing skin preparation with iodine povacrylex in alcohol versus chlorhexidine gluconate in alcohol in 1700 open fracture repairs, the incidence of superficial or deep SSI was similar for both approaches [ 29 ]. Based on these findings, which are consistent with those from a previous trial, either chlorhexidine- or iodine-based skin preparations can be used prior to surgery for open, traumatic lower extremity wounds. (See "Surgical management of severe lower extremity injury", section on 'Limb preparation and skin antisepsis' .

Whole blood transfusion for severe traumatic hemorrhage (January 2024)

For severe traumatic hemorrhage, whole blood transfusion is an alternative to balanced component transfusion (1:1:1 ratio of packed red blood cells/plasma/platelets). In an observational study comparing these two approaches, low titer group O whole blood transfusion was associated with lower 24-hour mortality (8 versus 19 percent) and lower volume of blood products received at 72 hours (48 versus 82 mL/kg) [ 30 ]. The survival benefit was greatest in patients with shock or coagulopathy. While this study suggests improved outcomes for whole blood transfusion, randomized trials are needed to determine which transfusion strategy might be superior and which patients would benefit the most. (See "Ongoing assessment, monitoring, and resuscitation of the severely injured patient", section on 'Whole blood transfusion' .)

Impact of pediatric trauma centers on clinical outcomes (October 2023)

Level 1 pediatric trauma centers (PTC) ( table 2 ) are the preferred sites for initial resuscitation and ongoing management of critically injured children. In a meta-analysis of 34 studies that evaluated children hospitalized for traumatic injury, treatment in a PTC was associated with lower mortality than in an adult trauma center (ATC, odds ratio 0.59) [ 31 ]. Compared with an ATC, care of children with blunt trauma in a PTC was also associated with a lower likelihood of computed tomography or operative management for blunt solid organ injury. For seriously injured infants, children, and adolescents, these findings support treatment in a PTC. When a level 1 PTC is not available, these children should receive care at a hospital that has the highest level of pediatric trauma expertise and resources. (See "Trauma management: Approach to the unstable child", section on 'Definitive care' .)

• von Hellmann R, Fuhr N, Ward A Maia I, et al. Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis. Ann Emerg Med 2024; 83:132.
• Low CJW, Ramanathan K, Ling RR, et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with cardiac arrest: a comparative meta-analysis and trial sequential analysis. Lancet Respir Med 2023; 11:883.
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• Watson NW, Carroll BJ, Krawisz A, et al. Trends in Discharge Rates for Acute Pulmonary Embolism in U.S. Emergency Departments. Ann Intern Med 2024; 177:134.
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• Qadir N, Sahetya S, Munshi L, et al. An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2024; 209:24.
• Gao Y, Chen W, Pan Y, et al. Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke. N Engl J Med 2023; 389:2413.
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• Friedman BW, Solorzano C, Kessler BD, et al. Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology 2023; 101:e1448.
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Emerging Trends and Hot Topics in Cardiopulmonary Resuscitation Research: A Bibliometric Analysis from 2010 to 2019

Cardiopulmonary resuscitation (CPR) is a topic of great scientific and clinical interest that has received much attention in the past decade. Our study aimed to predict the trends in CPR research activities and evaluate hot topics via bibliometric means, quantitatively and qualitatively.

Material/Methods

All data were collected from a search of the Web of Science Core Collection on May 12, 2020. Retrieved information was investigated with bibliometric analysis by CiteSpace and VOSviewer software and the Online Analysis Platform of Literature Metrology to analyze and predict the trends and hotspots in this field.

Our search returned a total of 9563 articles and reviews on CPR published from 2010 through 2019. The number of original research studies on CPR has been increasing annually. The journal Resuscitation published the greatest number of manuscripts involved CPR, and the leading country and institution with regard to contributions on CPR were the United States and the University of Pennsylvania. Keyword co-occurrence/co-citation-cluster analysis showed that the most popular terms associated with CPR occurred in the manner of cluster labels, such as therapeutic hypothermia and treatment recommendation, among others. In addition, palliative care, sepsis, extracorporeal membrane oxygenation, and brain injury were identified as new foci through burst detection analysis.

Conclusions

Our study showed that the scientific research focus on CPR is switching from traditional therapeutic treatments to a public health practice, with in-depth understanding and development of CPR-related techniques expanding over the past decade. These results demonstrate trends in the CPR research and detected the possible neo-foci for ensuing research.

Cardiac arrest (CA) has continuously manifested as a public health burden, with the vast majority of patients having poor outcomes, regardless of being in or out of a hospital. In the United States alone, approximately 290 000 experience in-hospital cardiac arrest (IHCA) and 350 000 people experience out-of-hospital cardiac arrest (OHCA) annually, with less than 25% and 10% surviving, respectively. Around the globe, the incidence and mortality rates of CA are increasing [ 1 – 3 ]. Modern cardiopulmonary resuscitation (CPR), which represents additional development and advances in earlier forms of CPR, encompasses rapid first-aid and life-supporting technology for sudden cardiac and respiratory arrest. It involves emergency airway management; artificial-assisted ventilation; chest compression; electric defibrillation; correction of ventricular fibrillation (VF) or pulseless ventricular tachycardia or electrical activity; and other basic or advanced cardiac life support [ 3 – 5 ]. Modern CPR is capable of saving patients by promoting the return of spontaneous circulation and decreasing CA-related mortality. Furthermore, robust CPR guidelines, especially those published by the American Heart Association (AHA) in 2015 and the latest updates on 2019, underline not only the importance of high-quality CPR, but also provide detailed information about first-aid life-chain in adult CPR, such as dispatcher-assisted CPR, cardiac arrest centers, prehospital treatment of presyncope, and so forth [ 6 , 7 ]. Nevertheless, the success rate for CPR remains low and significant controversies need to be resolved. For example, some recommendations lack persuasive evidence because large randomized controlled trials have not been conducted; further, the clinical practice of CPR varies greatly in quality and compliance with some recommended targets is poor [ 8 ]. Consequently, urgent priorities include exploring research hotspots in combination with clinical practice and continuously advancing CPR technology to improve CA/CPR-related disease prognosis.

Recently, the use of bibliometric analysis has become a popular means of identifying trends and hotspots within specific areas of research. Such analysis enables quantitative measurement of contributions of a specific field of research, including different countries/regions, institutions, journals, authors, co-cited networks, and other details that highlight research trends or hotspots in a field [ 9 ]. However, literature-metrology study on CPR is scarce, let alone any focus on analysis and prediction of research hot topics or trends [ 10 ]. In this article, we aimed to identify potential hotspots and trends in CPR research from various aspects, including technological development, pathogens, pathophysiology, complications, prognosis, and clinical guidelines. Our goal was to contribute to the improvement of CPR performance via a comprehensive analysis of information from manuscripts published worldwide from 2010 to 2019.

Material and Methods

We restricted our literature search to original articles and reviews from 2010 to 2019, using the Web of Science Core Collection (WoSCC) database, which contains the Science Citation Index-Expanded (SCIE) and the Social Science Citation Index (SSCI). The retrieval strategy was “TS=(cardiopulmonary resuscitation) AND Language=English,” with the document types refined as “article OR review.” Document retrieval and recording were entirely completed on May 12, 2020, to avoid variation in citations caused by frequent database updates. Moreover, 2 reviewers (T. Jia and C. Luo) were independently in charge of the primary search; their agreement showed a considerable accordance. They identified 9563 studies, which cited 57 688 references that were eventually obtained and bibliometrically analyzed through the Online Analysis Platform of Bibliometry ( http://bibliometric.com/ ), CiteSpace V5.6.R4, and VOSviewer 1.6.15. This analysis eventually indicated top authors, journals, institutions/countries, clustered networks of co-cited references/authors, and keywords with the strongest citation bursts.

Distribution characteristics of articles

Altogether, 9563 research publications (8492 articles and 1071 reviews) from 2010 to 2019 were filtered out by customized retrieval strategies and inclusion criteria. An increasing trend was clearly apparent for the amount of original research literature on CPR annually as a whole (from 631 in 2010 to 1192 in 2019), although there was a plateau between 2011 and 2012 and slowdown from 2016 till the end of 2019 ( Figure 1A ). Growth trends and the number of publications by separate country or region were both demonstrated by publication years (only top 10 of countries/regions are listed in Figure 1B ).

The number and linear growth trends of academic publications ( A ) and the top 10 countries/regions ( B ) for cardiopulmonary resuscitation research from 2010 to 2019.

Among all 120 countries/regions from which literature on CPR originated, the United States contributed the largest number of publications on CPR research (3653), followed by Canada (706), Japan (657), China (640), and South Korea (615). In addition, the degree of centrality index showed by CiteSpace, particularly with regard to Freeman’s betweenness centrality in social networks, was another vital indicator used to evaluate the significance of nodes in a definite network, independent of the article counts [ 11 ]. By this measure, we found that Australia (centrality=0.13), which was ranked eighth in the number of articles, had an extraordinary centrality. This finding indicated that it was the most influential, overtaking research from the United States, England (0.12), and Italy (0.10) ( Table 1 ). However, the centrality values of the top 10 institutions was below 0.15, which implies that these institutions had less influence than we expected. The top 10 research institutions included the University of Pennsylvania (606), University of Washington (509), University of Toronto (461), University of Pittsburgh (424), and University of Michigan (303) ( Table 1 ). However, the map of the CPR research network presented us with a low-density level (density=0.0267) ( Figure 2A ), which indicates that the teams devoted to CPR research are dispersed in various institutions throughout the world and deeper cooperation is needed. In addition, we used network analysis to confirm the relationship of collaboration between countries, and we found that the most frequent cooperation occurred between the United States and Canada, followed by the United States and China ( Figure 2B ).

The interagency network that engaged in cardiopulmonary resuscitation research ( A ) and the collaboration network map of countries/regions ( B ).

The top 10 countries/regions and institutions contributing to publications in cardiopulmonary resuscitation research.

Until 2019, 1150 journals have included articles on CPR research. The top 10 most active journals published 3292 articles, which accounted for 34.42% of the 9563 articles on CPR in our research. Table 2 lists the top 10 journals, sorted by article counts. Of the top 3 journals, Resuscitation alone accounted for almost 17.69% of the articles, which far exceeded the other 2 journals. However, in terms of impact factor (IF), Circulation was in first place (23.054), followed by Critical Care Medicine (6.971), Critical Care (6.959), Resuscitation (4.572), and Pediatric Critical Care Medicine (2.798). Meanwhile, the Journal Citation Reports assessment system, which is also an important evaluating tool and method for SCI journals, divided journals into 176 different subject categories and classifies them into quartiles, according to the level of a journal’s impact factor. Our study results showed that all top 10 journals were classified as either Q1 or Q2, which means that these journals likely have a strong influence on research about CPR.

The top 10 most active journals publishing articles in cardiopulmonary resuscitation research (sorted by count).

The top 10 most productive authors of all the 32 810 authors identified in the current study are shown in Table 3 ; the top 3 were Robert A. Berg, who ranked first with 160 articles; Vinay M. Nadkarni, 144 articles; and Clifton W. Callaway, 100 articles. The top 2 authors have different affiliations, but are in the same region: separately, Center for Resuscitation Science at the University of Pennsylvania and the Children’s Hospital of Philadelphia.

The top 10 most productive authors and co-cited authors contributed to publications in cardiopulmonary resuscitation research (sorted by count).

Next, the networks of citation information for authors ( Figure 3A ) and co-cited authors ( Figure 3B ) were visualized with CiteSpace software. Our research output showed that Jerry P. Nolan with 1343 co-citation counts was in first place among the top 10 co-cited authors, followed by Robert W. Neumar (1078), Gavin D. Perkins (1012), Graham Nichol (909), and Mary Ann Peberdy (985) ( Table 3 ). Of all the values of centrality among the top 10 productive authors, only 2 scholars, Jerry P. Nolan’s (0.18) and Vinay M. Nadkarni’s (0.11) were more than 0.1, which implies that both of them have made outstanding achievements in the fields of CPR research and have provided crucial foundation for follow-up scientific studies.

The network map of the most productive authors ( A ) and the most frequently cited authors ( B ) who participated in cardiopulmonary resuscitation research.

The top 10 co-cited articles with cited frequency, half-life, article, and research types are listed in Table 4 . Among these articles, most were published in Resuscitation and Circulation , which have always been the most influential and authoritative journals in the fields of critical and cardiovascular medicine. In addition, these top 10 articles are considered as clinical instruction in CPR research.

The top 10 co-cited authors and their co-cited articles (sorted by cited frequency).

The visualization of keywords co-occurrence network-based methods was applied successfully in the 9563 scholarly articles to screen out 256 keywords from a total of 17 093 samples. The selection criteria included a keyword having a minimum of 60 occurrences, and the keywords were then classified into 6 clusters via VOSviewer ( Figure 4 ).

The network map of keyword clustering showed 256 keywords from a total of 17 093 samples with a minimum of 60 occurrences and classified into 6 clusters.

Co-citation and cluster analysis of CPR research

To identify CPR-related research hotspots, we created a co-citation and clustered network from 1356 references (not excluding duplicates) cited in the 9563 learning-manuscripts and mapped via CiteSpace in a hierarchical order ( Figure 5A ). In addition, in this special network, the size of each cluster was composed of different node types representing the number and centrality of co-cited references. The representative citations displayed the major research topics and thematic concentrations of each cluster. As shown in Figure 5A , the co-cited references clustered into 9 major cluster labels, including therapeutic hypothermia, treatment recommendation, OHCA, chest compression, AHA guideline, and so forth. In addition, Figure 5B shows the clear co-citation network in a timeline view, and the top 6 have higher degrees of citation bursts. Meanwhile, it is obvious that the central points in CPR research have shifted from a concentration on brief treatment principles to pursuing technical means for life support and standardization of the CPR process.

The clustered network map of co-cited references on cardiopulmonary resuscitation research ( A ) and the timeline view of co-citation clusters with their cluster labels on the right ( B ).

A burst detection algorithm is designed to identify the emerging concepts in professional terminology. We used the keywords from the 9563 articles identified in the WoSCC database search and listed the top 25 of 98 keywords with the strongest citation bursts ( Figure 6 ). The timeline with a sky-blue background color is divided by year, and once a subject has been found to “burst,” it is marked in red on the blue timeline to signify the beginning and ending years and the duration of the burst.

Keywords with the strongest citation bursts in original articles on cardiopulmonary resuscitation research activities published from 2010 to 2019.

Although the number of keywords with the most robust citation bursts approached 100, not all of them had real significance in clinical practice. Figure 6 shows those that specifically pertain to research trends for CPR. Throughout 2010 to 2019, VF had the highest burst strength (26.6972), followed by targeted temperature management (TTM, 24.9031), cardiopulmonary resuscitation (22.4629), mild hypothermia (20.5559), and palliative care (19.379). In terms of the beginning year, of the last 8 keywords at the bottom of Figure 6 , aside from the 3 with the strongest burst strength, the rest included compression, vasopressin, Utstein style, ischemia, and automated external defibrillator were the focus of CPR research. In the ensuing years, some keywords had only a short-term burst, such as sudden death, reperfusion, neuron specific enolase, and septic shock, among others. Regardless of the beginning year of bursts, however, plenty of bursts have continued until 2019, including prognostication, TTM, and some that emerged in 2017 (i.e., sepsis, palliative care, extracorporeal membrane oxygenation [ECMO], and brain injury).

The visualization functions of CiteSpace, VOSviewer, and the Online Analysis Platform of Literature Metrology enabled conducting a bibliometric analysis of original articles involving in CPR research over the past decade. The analysis clearly showed a growing trend in the number of scientific articles published on the topic from 2010 through 2019. From this, we find that CPR has gradually become an important subject in fields of related research. Furthermore, we also find that the burst of studies during the most recent 10 years has mainly varied with the quinquennial updates of authoritative clinical guidelines, particularly those developed by the AHA-led International Liaison Committee on Resuscitation since 2000. Obviously, the development of CPR-related technology is a driving force for this research, but more importantly, thousands of scholars and researchers have gained a deeper understanding of the epidemiology, pathophysiology, treatment, and prognostication about CPR-related illnesses and complications as well as strengthened the role of evidence-based medicine.

An analogous conclusion can also be drawn from the rank of the journals with the largest number of articles published on CPR. As shown in Tables 2 and ​ and4, 4 , the journals with enormous influence in emergency/critical care and cardiovascular medicine were predictably the most prominent in our analysis: the overwhelming majority of the articles appeared in Resuscitation and Circulation , which are the publications in which significant guidelines are reported. In addition, since 1974, clinical guidelines for CPR have been constantly updated through intense discussions of new advances in the field of CPR research and problems discovered from the implementation of older guidelines. This process promotes global professional training and the popularization of CPR. Therefore, most of the top 10 co-cited articles were instructive expert consensuses on the dynamic changes of representative hot topics, such as the necessity of improving the quality of CPR during IHCA or OHCA; consensus statements on the impact of post-CA syndrome (PCAS); and discussion of the ongoing improvement in treatment strategies and technology of basic or advanced cardiac life support and their impact on CPR prognosis [ 12 – 17 ].

By combining the keyword co-occurrence and co-citation cluster analysis ( Figures 3 , 4A, 4B ), it is not difficult to find that treatment recommendation (e.g., therapeutic hypothermia, an important part of care bundle), authoritative and instructive guidelines (AHA and emergency cardiovascular care), CPR technical means (extracorporeal life support and chest compressions), and prognostication (survival and prognosis) have always been central topics of investigations on CPR. Furthermore, as previously mentioned, VF and TTM have attracted considerable research attention in the past decade, but since 2017, sepsis, palliative care, ECMO, and brain injury have become the novel foci ( Figures 5 , ​ ,6). 6 ). This shift could be explained by issues related to patient-specific pathophysiology having been solved through new techniques, so scholars have started to pay more attention to risks that threaten long-term survival of patients. Keyword bursts with the most strength and prominence can reveal recent trends and hotspots in CPR research.

VF has been considered to be a leading pathogenesis of sudden cardiac arrest, in or out of the hospital, but definitely more emergent and dangerous in OHCA [ 18 ]. Thus, a great amount of research and constantly updated guidelines during the past decade have focused on VF-related pathophysiology and explored how to correct the progress of VF and reduce the associated damage via a feasible first-aid strategy [ 4 , 7 , 19 ]. Recently, awareness and utilization of AEDs have unambiguously increased, but even so, the overall survival from CA remains low. Ample animal experiments and clinical trials support previous findings that showed improved survival to hospital discharge when CPR was provided for a prescribed time period before defibrillation rather than an immediate shock approach in patients with OHCA due to VF [ 13 , 20 , 21 ]. Moreover, as mentioned in a section of recent guidelines of the European Resuscitation Council, patients failing to receive early defibrillation can still benefit from effective chest compression provided by bystanders than those without CPR, although averaging 3% to 4% decline in survival per minute delay to defibrillation [ 16 ]. Meanwhile, assessment of the success of defibrillation is also indispensable to the process of CPR of sudden cardiac arrest resulting from VF. Most recently, a study has proposed that VF waveform measures combined with prior shock outcome may make possible prediction of defibrillation success during CPR [ 22 ].

TTM, also known as therapeutic hypothermia, was a new treatment concept first proposed by Holzer in 2010 [ 23 ]. Throughout the ensuing decade, TTM has been identified as a therapeutic intervention to limit neurologic injury after a patient’s resuscitation from CA, and it gradually became a central point of PCAS care research owing to concerns arising from equal outcomes from 2 clinical studies that used profoundly distinct target temperature levels [ 24 ]. In addition, a notable divergence has been identified via meta-analyses. Specifically, more recent meta-analyses showed that TTM may not improve mortality or neurological outcomes in postarrest survivors, while the great majority of previous studies indicated consistency with current best medical practice as recommended by international resuscitation guidelines [ 25 – 28 ]. Nevertheless, most current guidelines persist in recommending that all adult comatose survivors of OHCA with an initial shockable cardiac rhythm should receive TTM with a selected and constant temperature between 32°C and 36°C [ 3 , 29 , 30 ]. Hence, employing therapeutic hypothermia as a standard of care strategy of postarrest care in survivors may need to be reevaluated by more persuasive research evidence in the years to come.

The subtle relationship between palliative care and CPR, as an extremely controversial ethical issue, began to be explored more deeply and to provoke ongoing debate early in the 21st century. Despite palliative care and CPR appearing to be incompatible and mutually exclusive, the related national council and association of palliative medicine guidelines have stated that CPR is relevant in palliative care if the quality of a patient’s life could be promoted [ 31 ]. A review published in 2013 concluded that CPR is futile for in-hospital cancer patients with widespread incurable disease and poor performance status, and there is a trend for survival to decline with increasing extent of the cancer disease [ 32 ]. In addition, as the “do not attempt cardiopulmonary resuscitation” decisions have become embedded into clinical practice in the United Kingdom, recent studies concentrate more on the decisive role of patients’ autonomy on decision making, which is especially prominent in this policy [ 33 – 35 ]. Consequently, ongoing research is laying further stress on the feasibility of CPR in light of different populations in palliative care clinical practice.

Venoarterial ECMO, which evolved as a salvage therapeutic tool in CPR situations refractory to medical treatment including ECMO and cardiopulmonary bypass and is referred to as extracorporeal cardiac life support (ECLS) or extracorporeal cardiopulmonary resuscitation (ECPR), has been applied to striving for additional time to treat reversible underlying causes of CA over the past years, especially in patients with OHCA [ 5 , 36 – 38 ]. Moreover, Matsuoka et al. [ 39 ] recently conducted a population-based cohort study and clearly showed that hospitals’ ECPR capabilities are associated with favorable neurologic outcomes in OHCA patients who had refractory VF or pulseless ventricular tachycardia. This positive result has been demonstrated in many other meta-analyses [ 40 – 42 ] and a current case report [ 43 ]. However, in a nationally representative cross-sectional study, researchers found that patients hospitalized with CA who received ECMO had significantly higher mortality than those who did not [ 44 ]. This was no doubt different from the outcomes reported in studies on OHCA and IHCA. Thus, in the near future, conducting more high-quality evidence RCTs to identify the actual prognosis and survival of patients for whom ECMO is used, regardless of OHCA or IHCA, might be the new research focus of CPR treatments driven by emerging extracorporeal technologies.

In addition to the keywords mentioned above, sepsis/septic shock-associated CA and brain injury, which are always likely to have a worse prognosis than CA without sepsis, are also drawing increased attention. As early as 2011, sepsis was considered to be a potential prearrest predictor of mortality after IHCA in a meta-analysis, even though many broad-scale studies have not demonstrated prearrest sepsis as a predisposing factor for IHCA, and epidemiological data on sepsis-associated CA are limited [ 45 , 46 ]. Hereafter, aiming to describe the prearrest period in severe sepsis and septic shock more clearly and in greater detail, a more representative experimental swine model of human CA and CPR has been successfully made [ 47 ]. In addition, an increasing number of research studies have begun to focus on the long-term survival rate after a prearrest sepsis and multiorgan dysfunction inducing IHCA, and conclusions are in accordance with short-term outcomes [ 48 – 50 ]. Nevertheless, owing to the complexity of a combined effect generated by the pathophysiology of ongoing septic shock and PCAS and the higher rates of mortality with sepsis-associated IHCA, high-quality CPR and other traditional interventions or care are insufficient. More research should target sepsis-related pathophysiology before, during, and after CA in order to improve patient outcomes [ 46 ].

Interestingly, either severe sepsis or PCAS can lead to systemic inflammation or ischemia-reperfusion injury and finally cause some extent of brain injury, even developing into irreversible damage or brain death [ 46 , 51 ]. Meanwhile, a bibliometric analysis spanning 25 years has shown that Critical Care Medicine and Resuscitation , both universally acknowledged as international and domestic journals publishing the most articles on CPR, were also listed among the top 5 journals focusing on brain death [ 52 ]. Although there a great quantity of studies have covered a variety of potential factors that affect, assess, or predicate prognostication after CA (e.g., the length of CPR, electroencephalography, serum biomarker), the AHA writing group still determined that the overall quality of existing neurological prognostication studies and the degree of confidence in the predictors remain low [ 53 – 56 ]. Therefore, how to improve the quality of neurological prognostication in patients who survive CA has become the crux of the ensuing studies on CPR-related brain injury.

In this article, the graphs and charts formed by CiteSpace, VOSviewer, and the Online Analysis Platform of Literature Metrology showed that our understanding of CPR has markedly advanced during the past decade. Our intention was to assess past research on CPR and to predict new trends and hot topics in specific subjects and subfields. We conclude that scientific research on CPR not only focuses on therapeutic means, but is also adopting a public health practice perspective. Ultimately, the results may also foster future studies.

Strengths and limitations

Our study is the first bibliometric analysis specifically on CPR research activities. In contrast with traditional analyses, our analysis, which was based on professional bibliometric software, displays a better status of CPR research hotspots and trends, despite some limitations. First, only original articles and reviews were included. Second, some words were counted more than once because of their multiple expressions. Finally, as a result of the highly cited guidelines in the field of CPR, the accuracy of top co-cited authors and their articles was inevitably reduced.

Conflict of interests

Source of support: This study was supported by the National Natural Science Foundation of China (Grant No. 81971803 and No. 81671881)

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