Unplanned transfer to acute care during inpatient geriatric rehabilitation: incidence, risk factors, and associated short-term outcomes.

BACKGROUND: Information is scarce on unplanned transfers from geriatric rehabilitation back to acute care despite their potential impact on patients' functional recovery. This study aimed 1) to determine the incidence rate and causes of unplanned transfers; 2) to compare the characteristics and outcomes of patients with and without unplanned transfer. METHODS: Consecutive stays (n = 2375) in a tertiary geriatric rehabilitation unit were included. Unplanned transfers to acute care and their causes were analyzed from discharge summaries. Data on patients' socio-demographics, health, functional, and mental status; length of stay; discharge destination; and death, were extracted from the hospital database. Bi- and multi-variable analyses investigated the association between patients' characteristics and unplanned transfers. RESULTS: One in six (16.7%) rehabilitation stays was interrupted by a transfer, most often secondary to infections (19.3%), cardiac (16.8%), abdominal (12.7%), trauma (12.2%), and neurological problems (9.4%). Older patients (AdjORage≥85: 0.70; 95%CI: 0. 53-0.94, P = .016), and those admitted for gait disorders (AdjOR: 0.73; 95%CI: 0.53-0.99, P = .046) had lower odds of transfer to acute care. In contrast, men (AdjOR: 1.71; 95%CI: 1.29-2.26, P < .001), patients with more severe disease (AdjORCIRS: 1.05; 95%CI: 1.02-1.07, P < .001), functional impairment before (AdjOR: 1.69; 95%CI: 1.05-2.70, P = .029) and at rehabilitation admission (AdjOR: 2.07; 95%CI: 1.56- 2.76, P < .001) had higher odds of transfer. Transferred patients were significantly more likely to die than those without transfer (AdjOR 13.78; 95%CI: 6.46-29.42, P < .001) during their stay, but those surviving had similar functional performance and rate of home discharge at the end of the stay. CONCLUSION: A significant minority of patients experienced an unplanned transfer that potentially interfered with their rehabilitation and was associated with poorer outcomes. Men, patients with more severe disease and functional impairment appear at increased risk. Further studies should investigate whether interventions targeting these patients may prevent unplanned transfers and modify associated adverse outcomes.

Evaluation of the prehospital administration of tranexamic acid for injured patients: a state-wide observational study with sex and age-disaggregated analysis.

BACKGROUND: Tranexamic acid (TXA) decreases mortality in injured patients and should be administered as soon as possible. Despite international guidelines recommending TXA in the prehospital setting, its use remains low. The aim of this study was to assess the prehospital administration of TXA for injured patients in a Swiss region. METHODS: We conducted a retrospective observational study in Switzerland between 2018 and 2021. Inclusion criteria were injured patients ≥18 years for whom an ambulance or helicopter was dispatched. The exclusion criterion was minor injury defined by a National Advisory Committee for Aeronautics score <3. The primary outcome was the proportion of patients treated with TXA according to guidelines. The European guidelines were represented by the risk of death from bleeding (calculated retrospectively using the Bleeding Audit for Trauma and Triage (BATT) score). Factors impacting the likelihood of receiving TXA were assessed by multivariate analysis. RESULTS: Of 13 944 patients included in the study, 2401 (17.2%) were considered at risk of death from bleeding. Among these, 257 (11%) received prehospital TXA. This represented 38% of those meeting US guidelines. For European guidelines, the treatment rate increased with the risk of death from bleeding: 6% (95% CI 4.4% to 7.0%) for low risk (BATT score 3-4); 13% (95% CI 11.1% to 15.9%) for intermediate risk (BATT score 5-7); and 21% (95% CI 17.6% to 25.6%) for high risk (BATT score ≥8) (p<0.01). Women and the elderly were treated less often than men and younger patients, irrespective of the risk of death from bleeding and the mechanism of injury. CONCLUSION: The proportion of injured patients receiving TXA in the prehospital setting of the State of Vaud in Switzerland was low, with even lower rates for women and older patients. The reasons for this undertreatment are probably multifactorial and would require specific studies to clarify and correct them.

Older patients referred for geriatric consultation in the emergency department: characteristics and healthcare utilization.

BACKGROUND: Comprehensive geriatric assessment (CGA) is difficult to perform in the emergency department (ED) environment and performance of screening tools in identifying vulnerable older ED patients who are best candidates for a geriatric consultation remain questionable. AIM: To determine the characteristics of older patients referred for a geriatric consultation by ED staff and to investigate these patients' subsequent healthcare utilization. METHODS: Secondary analysis of data previously collected for a prospective observational study of patients aged 75 + years visiting the ED of an academic hospital in Switzerland over four months (Michalski-Monnerat et al., J Am Geriatr Soc 68(12):2914-20, 2020). Socio-demographic, health, functional (basic activities of daily living; BADL), cognitive, and affective status data were collected at admission by a research nurse using a standardized brief geriatric assessment. Information on geriatric consultations, hospitalization, discharge destination, and 30-day readmission were retrieved from hospital database. Bivariable and multivariable analyses were performed using this data set collected previously. RESULTS: Thirty-two (15.8%) of the 202 enrolled patients were referred for a geriatric consultation. Compared to the others, they were older (84.9 ± 5.4 vs 82.9 ± 5.4 years, p = .03), more impaired in BADL (4.8 ± 1.6 vs 5.5 ± 1.0, p = .01), with more comorbid conditions (5.3 ± 1.5 vs 4.5 ± 1.9, p = .03), more frequently admitted after a fall (43.7% vs 19.4%, p = .01), and hospitalized over the previous 6-month period (53.1% vs 30.6%, p = .02). Multivariable analyses that adjusted for variables significantly associated with outcomes in bivariable analysis found that being admitted after a fall (AdjOR 4.0, 95%CI 1.7-9.4, p < .01) and previously hospitalized (AdjOR 2.7, 95% CI 1.2-6.2, p = .02) remained associated with increased odds of consultation, whereas the inverse association with BADL performance remained (AdjOR 0.7, 95%CI 0.5-0.9, p = .01). Patients referred for geriatric consultation had higher odds of hospitalization (84.4% vs 49.4%; AdjOR 5.9, 95%CI 2.1-16.8, p < .01), but similar odds of home discharge when admitted, and of 30-day readmission. CONCLUSION: About one in six older ED patients were referred for a geriatric consultation who appeared to be those most vulnerable, as suggested by their increased hospitalization rate. Alternative strategies are needed to enhance access to geriatric consultation in the ED.

[Emergency management of patients with autism spectrum disorder]. / Accueil aux urgences de patients présentant un trouble du spectre de l'autisme.

People with autism spectrum disorder visit emergency departments more frequently than the rest of the population. Their ability to communicate with their environment may not only be limited but also different from the interactions of non-autistic people. In addition, the multiple sensory stimulations present in the emergency departments are likely to make interactions, and therefore the care of patients with an autism spectrum disorder more difficult. Understanding these difficulties and the special attentions to consider will allow better care for them. This article highlights the various points of attention to be had in order to offer quality welcoming and care to patients with an autism spectrum disorder.

Les personnes avec un trouble du spectre de l'autisme sont amenées à consulter les services d'urgences plus fréquemment que le reste de la population. Leur capacité à communiquer avec leur environnement peut être non seulement limitée mais aussi différente des interactions entre personnes non autistes. En outre, les multiples stimulations sensorielles inhérentes au fonctionnement des services d'urgences sont de nature à rendre difficiles les interactions et donc les soins aux patients avec un trouble du spectre de l'autisme. Comprendre ces difficultés et les attentions particulières à considérer permet de mieux les soigner. Cet article expose les divers points auxquels faire attention afin d'offrir un accueil et des soins de qualité aux patients avec un trouble du spectre de l'autisme.

Post­COVID­19 Syndrome in Outpatients: a Cohort Study.

BACKGROUND: After mild COVID-19, some outpatients experience persistent symptoms. However, data are scarce and prospective studies are urgently needed. OBJECTIVES: To characterize the post-COVID-19 syndrome after mild COVID-19 and identify predictors. PARTICIPANTS: Outpatients with symptoms suggestive of COVID-19 with (1) PCR-confirmed COVID-19 (COVID-positive) or (2) SARS-CoV-2 negative PCR (COVID-negative). DESIGN: Monocentric cohort study with prospective phone interview between more than 3 months to 10 months after initial visit to the emergency department and outpatient clinics. MAIN MEASURES: Data of the initial visits were extracted from the electronic medical file. Predefined persistent symptoms were assessed through a structured phone interview. Associations between long-term symptoms and PCR results, as well as predictors of persistent symptoms among COVID-positive, were evaluated by multivariate logistic regression adjusted for age, gender, smoking, comorbidities, and timing of the survey. KEY RESULTS: The study population consisted of 418 COVID-positive and 89 COVID-negative patients, mostly young adults (median age of 41 versus 36 years in COVID-positive and COVID-negative, respectively; p = 0.020) and healthcare workers (67% versus 82%; p = 0.006). Median time between the initial visit and the phone survey was 150 days in COVID-positive and 242 days in COVID-negative patients. Persistent symptoms were reported by 223 (53%) COVID-positive and 33 (37%) COVID-negative patients (p = 0.006) and proportions were stable among the periods of the phone interviews. Overall, 21% COVID-positive and 15% COVID-negative patients (p = 0.182) attended care for this purpose. Four surveyed symptoms were independently associated with COVID-19: fatigue (adjusted odds ratio 2.14, 95% CI 1.04-4.41), smell/taste disorder (26.5, 3.46-202), dyspnea (2.81, 1.10-7.16), and memory impairment (5.71, 1.53-21.3). Among COVID-positive, female gender (1.67, 1.09-2.56) and overweight/obesity (1.67, 1.10-2.56) were predictors of persistent symptoms. CONCLUSIONS: More than half of COVID-positive outpatients report persistent symptoms up to 10 months after a mild disease. Only 4 of 14 symptoms were associated with COVID-19 status. The symptoms and predictors of the post-COVID-19 syndrome need further characterization as this condition places a significant burden on society.

Early identification of bleeding in trauma patients: external validation of traumatic bleeding scores in the Swiss Trauma Registry.

BACKGROUND: Early identification of bleeding at the scene of an injury is important for triage and timely treatment of injured patients and transport to an appropriate facility. The aim of the study is to compare the performance of different bleeding scores. METHODS: We examined data from the Swiss Trauma Registry for the years 2015-2019. The Swiss Trauma Registry includes patients with major trauma (injury severity score (ISS) ≥ 16 and/or abbreviated injury scale (AIS) head ≥ 3) admitted to any level-one trauma centre in Switzerland. We evaluated ABC, TASH and Shock index (SI) scores, used to predict massive transfusion (MT) and the BATT score and used to predict death from bleeding. We evaluated the scores when used prehospital and in-hospital in terms of discrimination (C-Statistic) and calibration (calibration slope). The outcomes were early death within 24 h and the receipt of massive transfusion (≥ 10 Red Blood cells (RBC) units in the first 24 h or ≥ 3 RBC units in the first hour). RESULTS: We examined data from 13,222 major trauma patients. There were 1,533 (12%) deaths from any cause, 530 (4%) early deaths within 24 h, and 523 (4%) patients who received a MT (≥ 3 RBC within the first hour). In the prehospital setting, the BATT score had the highest discrimination for early death (C-statistic: 0.86, 95% CI 0.84-0.87) compared to the ABC score (0.63, 95% CI 0.60-0.65) and SI (0.53, 95% CI 0.50-0.56), P < 0.001. At hospital admission, the TASH score had the highest discrimination for MT (0.80, 95% CI 0.78-0.82). The positive likelihood ratio for early death were superior to 5 for BATT, ABC and TASH. The negative likelihood ratio for early death was below 0.1 only for the BATT score. CONCLUSIONS: The BATT score accurately estimates the risk of early death with excellent performance, low undertriage, and can be used for prehospital treatment decision-making. Scores predicting MT presented a high undertriage rate. The outcome MT seems not appropriate to stratify the risk of life-threatening bleeding. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04561050 . Registered 15 September 2020.

Establishing quality indicators for pre-hospital advanced airway management: a modified nominal group technique consensus process.

BACKGROUND: Pre-hospital advanced airway management is a complex intervention composed of numerous steps, interactions, and variables that can be delivered to a high standard in the pre-hospital setting. Standard research methods have struggled to evaluate this complex intervention because of considerable heterogeneity in patients, providers, and techniques. In this study, we aimed to develop a set of quality indicators to evaluate pre-hospital advanced airway management. METHODS: We used a modified nominal group technique consensus process comprising three email rounds and a consensus meeting among a group of 16 international experts. The final set of quality indicators was assessed for usability according to the National Quality Forum Measure Evaluation Criteria. RESULTS: Seventy-seven possible quality indicators were identified through a narrative literature review with a further 49 proposed by panel experts. A final set of 17 final quality indicators composed of three structure-, nine process-, and five outcome-related indicators, was identified through the consensus process. The quality indicators cover all steps of pre-hospital advanced airway management from preoxygenation and use of rapid sequence induction to the ventilatory state of the patient at hospital delivery, prior intubation experience of provider, success rates and complications. CONCLUSIONS: We identified a set of quality indicators for pre-hospital advanced airway management that represent a practical tool to measure, report, analyse, and monitor quality and performance of this complex intervention.

[Mass-gathering medical care: what is at stake? The example of the 2019 Fête des Vignerons]. / Dispositif sanitaire lors de grandes manifestations : quels enjeux ? - L'exemple de la Fête des Vignerons 2019.

During an event, the organizer is responsible for ensuring compliance with all standards, including in the medical and health field. It is therefore up to them to set up a display capable of handling potential patients. The planning of this display requires a preliminary risk assessment, including an estimate of the probability of occurrence and the potential severity in the event of occurrence. There are few decision-making tools available to plan such a device; the impact of major events, particularly on the surrounding care structures, or the sizing of such devices remains a poorly studied field. This article provides an update on recommendations and trends in this area, illustrated by the experience of the 2019 Fête des Vignerons.

Lors d'une manifestation, l'organisateur est responsable de s'assurer du respect de toutes les normes, y compris dans le domaine médico-sanitaire. Il lui incombe donc de mettre en place un dispositif à même de prendre en charge d'éventuels patients. La planification de ce dispositif nécessite une évaluation préalable des risques, intégrant une estimation de la probabilité d'occurrence et de la gravité potentielle en cas de survenue. Il existe peu d'outils d'aide à la décision permettant de planifier un tel dispositif ; l'impact des grands événements, en particulier sur les structures de soins environnantes, ou le dimensionnement de ces dispositifs restant un domaine peu étudié. Cet article propose une mise au point sur les recommandations et tendances dans ce domaine, en l'illustrant par l'expérience de la Fête des Vignerons 2019.

[An update on some atypical electrocardiographic forms of acute coronary syndrome The "STEMI equivalents"]. / Mise au point sur certaines formes électrocardiographiques atypiques du syndrome coronarien aigu - « Équivalents STEMI ¼.

The diagnosis of acute coronary syndrome with ST segment elevation (STEMI) is based on clinical symptoms suggestive of acute myocardial ischemia and precise ECG criteria. STEMI is due to an acute occlusion or subocclusion of a coronary artery, generating a transmural ischaemia, requiring coronary angiography with urgent coronary revascularization. However, some authors consider the current STEMI ECG criteria to be too restrictive: up to 30 % of patients who do not meet these criteria present with critical coronary artery stenosis or acute coronary occlusion. Atypical electrocardiographic patterns, known as "STEMI equivalents", can be found in some cases and justify a rapid cardiological evaluation. We present a pragmatic review of five STEMI equivalents.

Le diagnostic de syndrome coronarien aigu avec sus-décalage du segment ST (ST-Elevation Myocardial Infarction (STEMI)) est basé sur une clinique évocatrice d'une ischémie myocardique et des critères ECG précis. Le STEMI est le reflet d'une (sub)occlusion aiguë d'une artère coronaire engendrant une ischémie transmurale, nécessitant une coronarographie avec un geste de revascularisation en urgence. Certains auteurs considèrent les critères ECG actuels du STEMI comme étant trop restrictifs : jusqu'à 30 % des patients ne remplissant pas ces critères présenteraient une sténose coronarienne critique ou une occlusion coronarienne aiguë. Des aspects électrocardiographiques atypiques, dits « équivalents STEMI ¼, peuvent être mis en évidence dans certains cas et justifient une prise en charge cardiologique rapide. Nous présentons une revue pragmatique de cinq équivalents STEMI.

[Adult cardiopulmonary resuscitation : 2020 guidelines]. / Réanimation cardiopulmonaire de l'adulte : recommandations 2020.

Alerting emergency medical services, rapidly initiating chest compressions at the correct depth and frequency and delivering an electric shock as quickly as possible remain the key points of the updated guidelines for adult cardiopulmonary resuscitation (CPR). Following their five-year systematic review, both the American Heart Association (AHA) and the European Resuscitation Council (ERC) are reinforcing their messages in favour of simple and early actions, while adding nuances regarding drugs, and suggesting that the chain of survival should continue beyond the acute hospital phase. Here is an overview of the reminders and novelties of the AHA and ERC 2020 guidelines.

Alarmer les secours, débuter rapidement un massage cardiaque aux profondeur et fréquence correctes et délivrer un choc électrique aussi vite que possible restent les points clés des recommandations actualisées de la réanimation cardiopulmonaire de l'adulte. À l'issue de leur démarche de revue méthodique quinquennale, tant l'American Heart Association (AHA) que l'European Resuscitation Council (ERC) renforcent leurs messages en faveur de gestes simples et précoces, tout en apportant des nuances quant aux médicaments, et proposent de poursuivre la chaîne de survie au-delà de la phase aiguë hospitalière. Tour d'horizon des rappels et des nouveautés des recommandations de l'AHA et de l'ERC 2020.

[Emergency department : COVID-19 crisis and organizational aspects]. / Urgences hospitalières : crise COVID-19 et aspects organisationnels.

Emergency departments are on the front line in the management of COVID-19 cases, from screening to the initial management of the most severe cases. The clinical presentation of COVID-19 range from non-specific symptoms to adult acute respiratory distress syndrome (ARDS). Diagnosis is based on PCR from a nasopharyngeal swab and emergency treatment rely on oxygen therapy. Patient's orientation (home, hospitalization, admission in intensive care unit) is a central aspect of emergency management. The shift from a strategy of systematic recognition of potential cases to the one of epidemic mitigation required hospital emergency medicine services to implement crisis management measures, to guarantee admission and hospitalization capacity.

Les services d'urgences sont en première ligne dans la gestion des cas de COVID-19, qu'il s'agisse du dépistage ou de la prise en charge des cas les plus sévères. La clinique associée au COVID-19 va de symptômes non spécifiques au syndrome de détresse respiratoire aiguë de l'adulte. Le diagnostic repose sur la PCR à partir d'un frottis nasopharyngé et le traitement d'urgence sur l'oxygénothérapie. L'orientation du patient (retour à domicile, hospitalisation, indication aux soins intensifs) est un aspect central de la prise en charge aux urgences. Le passage de la stratégie de reconnaissance systématique des cas potentiels à celle de la mitigation de l'épidémie a impliqué pour les services d'urgences hospitaliers la mise en place de mesures exceptionnelles afin de garantir une capacité d'accueil et d'hospitalisation.

[Emergency Medical Services: COVID-19 crisis]. / Urgences préhospitalières†: crise COVID-19.

The COVID-19 epidemic required rapid and frequent adaptations from the prehospital emergency medical services (EMS). The exposure of EMS providers is significant, particularly during procedures at risk of aerosolization such as advanced airways management or cardiopulmonary resuscitation. EMS personal need to be equipped with appropriate personal protective equipment and trained in its use. Interhospital transfers from COVID-19 patients are complex and involve mainly intubated patients. The possible shortage of resources may motivate the implementation of dedicated pre-hospital triage and orientation recommendations, which should be consistent with the hospital processes.

L'épidémie de COVID-19 a nécessité de la part des services d'urgence préhospitaliers des adaptations rapides et fréquentes. L'exposition des intervenants au risque infectieux est significative, notamment en cas de procédures à risque d'aérosolisation (réanimation cardiopulmonaire, gestion des voies aériennes supérieures). Les moyens de protection individuelle ont dû être adaptés en conséquence et leur manipulation entraînée. Les transferts interhospitaliers médicalisés de patients COVID-19 concernent surtout des patients intubés et sont complexes. L'éventuelle pénurie des ressources motiverait la mise en application de directives préhospitalières spécifiques rédigées en cohérence avec les processus de triage hospitaliers.

[Traumatology of airborne sports in Switzerland]. / Traumatologie des sports aériens en Suisse.

Airborne sports are becoming more popular, despite an increased risk of potentially serious accidents. Most accidents are caused by pilot errors, unforeseen climatic conditions or a poor environmental assessment. Cases caused by material defects are rare. Accidents often involve damage to the spine and lower limbs, with impaired functional prognosis. Implementation of safety regulations as well as the promotion of protection material has certainly allowed some reduction in the risk of accident, the emphasis on quality training must however be continued.

Les sports aériens sont pratiqués par de plus en plus d'amateurs, malgré un risque accru d'accidents potentiellement graves. La plupart des accidents sont causés par des erreurs de pilotage, des changements météorologiques imprévus ou des mauvaises appréciations des conditions environnementales. Rares sont les cas causés par des défauts de matériel. Les accidents impliquent fréquemment des lésions de la colonne vertébrale et des membres inférieurs, avec une atteinte du pronostic fonctionnel. L'introduction d'une réglementation dans les règles de sécurité, ainsi que la promotion du port de matériel de protection ont certes permis une certaine diminution des risques d'accident, mais l'accent sur une formation de qualité doit être poursuivi.

[Emergency medicine : update 2018]. / Médecine d'urgence : update 2018.

Professionalisation of emergency medicine is currently booming. In order to offer the best care, emergency physician can refer to several new studies : 1) in a cerebral stroke, the 0° head position doesn't offer any benefit ; 2) hyperoxygenation in acute patients could raise mortality ; 3) epinephrine in prehospital cardiac arrest favors return of spontaneous circulation but worsens the neurological prognosis ; 4) systematic cross-checking reduces the risk of adverse events in the emergency department ; 5) ultrasensitive troponins better detect myocardic events, but raises the number of unusefull invasive procedures and 6) combined pre-test probability score and D-dimers potentially allows to rule out aortic dissection.

La professionnalisation de la médecine d'urgence est en plein essor. Afin d'offrir une prise en charge de qualité, les urgentistes peuvent se référer à plusieurs études récentes : 1) lors d'un AVC, la position stricte à 0° de la tête n'apporte pas de bénéfice ; 2) l'hyperoxygénation des patients aigus augmenterait la mortalité ; 3) l'adrénaline dans les ACR (arrêts cardiorespiratoires) préhospitaliers favorise le retour à une circulation spontanée, mais au prix d'un moins bon pronostic neurologique ; 4) la vérification croisée systématique entre pairs aux urgences réduit le risque d'erreurs médicales ; 5) les troponines ultrasensibles permettent une meilleure détection des événements myocardiques, mais au prix de l'augmentation de gestes invasifs inutiles et 6) un score de probabilité prétest couplé au dosage des D-dimères permettrait d'exclure la dissection aortique.

HEMS inter-facility transfer: a case-mix analysis.

BACKGROUND: Helicopter emergency medical services (HEMS) are popular rescue systems despite inconsistent evidence in the scientific literature to support their use for primary interventions, as well as for inter-facility transfer (IFT). There is little research about IFT by HEMS, hence questions remain about the appropriateness of this method of transport. The aim of this study was to describe a case-mix of operational and medical characteristics for IFT activity of a sole HEMS base, and identify indicators of over-triage. METHODS: This is a retrospective study on HEMS IFT over 36 months, from January 1st 2013 to December 31st 2015. Medical and operational data from the database of the Emergency Department of Lausanne University Hospital, which provides the emergency physicians for this helicopter base, were reviewed. It included distance and time of flight transport, type of care during flight, and estimated distance of transport if conducted by ground. RESULTS: There were 2194 HEMS missions including 979 IFT (44.6%). Most transfers involved adults (> 17 years old; 799 patients, 81.6%). Forty patients (4.1%) were classified as having benefitted from resuscitation or life-saving measures performed in flight, 615 (62.8%) from emergency treatment and 324 (33.1%) from simple clinical examination. The median distance by air between hospitals was 35.4 km. The estimated median distance by road was 47.7 km. The median duration time from origin to destination by air was 12 min. CONCLUSIONS: This case-mix of IFTs by HEMS presents a high severity. There are many signs in favour of over-triage. We propose indicators to help choosing whether HEMS is the most appropriate mean of transport to perform the transfer regarding patient condition, geography, and medical competences available aboard ground ambulances; this may reduce over-triage.

[Boerhaave syndrome: update on physiopathology, diagnosis and early management]. / Syndrome de Boerhaave : mise au point sur la physiopathologie, le diagnostic et le traitement précoce.

Boerhaave syndrome is a rare condition, usually associated with a delay in diagnosis. It is fatal in the absence of therapy. The nonspecific nature of the clinical signs contributes to the poor outcome. This syndrome should be suspected in patients with severe chest or abdominal pain, associated with a history of vomiting, clinical signs of pneumomediastinum (subcutaneous emphysema, pleural effusion) and rapid clinical deterioration. Prompt diagnosis and initial management by the primary care physician and the emergency department physician are key elements of a better outcome. This article will review the pathogenesis, clinical manifestations, diagnosis and treatment of Boerhaave syndrome in adults.

Le syndrome de Boerhaave est une entité rare, de diagnostic difficile, dont l'évolution est potentiellement fatale en l'absence d'une prise en charge rapide. Le manque de spécificité des signes cliniques participe au retard diagnostique et au mauvais pronostic. Le syndrome doit être évoqué lors d'une symptomatologie thoracique ou abdominale aiguë, avec une anamnèse de vomissements, des signes cliniques de pneumomédiastin (emphysème sous-cutané, épanchements pleuraux) et l'apparition de signes de choc. Le pronostic étant conditionné par la rapidité du diagnostic et de la prise en charge, le rôle du médecin de premier recours et de l'urgentiste est crucial. Cet article a pour but de faire le point sur la physiopathologie, les manifestations cliniques, le diagnostic et le traitement de cette pathologie chez l'adulte.

[Prehospital misconceptions]. / Idées reçues en préhospitalier.

We confronted some of the most prevalent prehospital misconceptions with the available literature. We found that: the diminution of a retrosternal pain following nitrate administration is not predictive of a cardiac origin of the pain ; survival of traumatic cardiac arrest may not be as bad as usually believed ; peripheral venous administration of vasopressors through proximal catheters during short times may be considered as a safe temporary alternative to central venous access ; using the pulse palpation usually lead to an under-estimation of the systolic blood pressure ; applying a pelvic belt at the level of the iliac crests doesn't aggravate an open-book fracture; there is no 90 mmHg threshold values below which mortality increases in traumatic brain injuries.

Nous nous sommes intéressés à certaines idées reçues en médecine d'urgence préhospitalière, en les confrontant avec les évidences de la littérature. Certaines de ces notions sont ainsi remises en question : les douleurs rétrosternales d'origine non cardiaque s'améliorent tout autant suite à l'administration de nitrés que celles d'origine cardiaque ; les arrêts cardiaques traumatiques ne sont pas toujours irréversibles ; les vasopresseurs peuvent être donnés transitoirement de manière sécuritaire sur une voie veineuse périphérique ; l'estimation de la tension artérielle à l'aide du pouls n'est pas fiable ; une ceinture pelvienne sur les crêtes iliaques n'aggrave pas une fracture « open-book ¼ ; il n'y a pas de « valeur seuil ¼ de tension artérielle systolique à 90 mmHg au-dessous de laquelle la mortalité augmenterait lors de traumatisme crânien.