[Ketamine for medically-delegated analgesia in the Emergency Department]. / Kétamine pour l'antalgie médico-déléguée aux urgences.

Ketamine has the optimal characteristics for use in an Emergency Department. Added in 2020 to the Emergency Department's medically delegated analgesia protocol of the Cantonal Hospital of Neuchâtel (RHNe), it has become a valuable ally for the management of acute pain. The purpose of this article is to present the advantages of its use in an Emergency Department by means of a review of evidence and experience.

La kétamine, employée comme analgésique, possède les caractéristiques optimales pour une utilisation au sein d'un service d'urgences. Ajoutée en 2020 au protocole d'antalgie médico-déléguée des Urgences du Réseau hospitalier neuchâtelois (RHNe), son adoption par l'équipe en fait désormais un précieux allié pour la prise en charge de la douleur aiguë. Cet article a pour but de présenter les avantages liés à son utilisation au sein d'un département d'urgences par un retour d'expérience et une revue de la littérature d'évidence et d'expérience.

[Vulnerability of patients with intellectual disabilities in emergency]. / Vulnérabilité aux urgences des patients vivant avec un handicap mental.

People with intellectual disabilities should receive the same healthcare as those offered to the general population. However, they have weakened defense capabilities compared to the rest of the population and are therefore more vulnerable, with somatic, psychological, and psychosocial crises being more frequent and becoming complicated to manage. Usually, a primary assessment can reduce the need for transfer to emergency departments, but some situations may become complex and require hospital-based care. In this article, we will examine the issues related to the vulnerability of patients with intellectual disabilities in emergent or urgent situations, addressing the challenges they face and the measure that can be taken to ensure care that is tailored to their needs.

Les personnes en situation de déficience intellectuelle (DI) doivent bénéficier des mêmes soins que ceux proposés à la population générale. Cependant, elles possèdent des capacités de défense amoindries par rapport au reste de la population et sont donc plus vulnérables. Ainsi, les crises somatiques, psychologiques ou psychosociales sont plus fréquentes et peuvent s'avérer compliquées à gérer. Habituellement, une évaluation primaire permet de diminuer un transfert aux urgences. Certaines situations sont néanmoins susceptibles de devenir complexes et de nécessiter une prise en charge en milieu hospitalier. Dans cet article, nous examinons les problèmes liés à la vulnérabilité des patients présentant une DI aux urgences, en abordant les défis qu'ils rencontrent et les mesures possibles afin de garantir des soins adaptés à leurs besoins.

["White code protocol": model of interprofessional collaboration in the emergency room]. / « Code blanc ¼ : modèle de collaboration interprofessionnelle aux urgences.

Acute agitation is a frequent cause of emergency department's consultation. Managing an agitated patient is complex due to many factors and require from healthcare teams a close interdisciplinary collaboration. Scope of this article is to describe the management of agitated patients in an emergency department and to present an interprofessional medical care protocol (white code protocol), giving also the opinion of principal actors of this healthcare interdisciplinary model.

L'agitation psychomotrice aiguë est fréquente dans les services d'urgences. La prise en charge d'un patient agité s'avère complexe en raison de multiples facteurs et nécessite de la part des intervenants une collaboration interdisciplinaire étroite. Cet article a pour but de synthétiser les principes de prise en charge d'une agitation aiguë dans un service d'urgences et de détailler un protocole interprofessionnel de prise en charge (code blanc), en présentant l'opinion des principaux intervenants de ce modèle interprofessionnel de soins.

[Cervical spine trauma in the era of choosing wisely: less immobilization and no cervical collars]. / Traumatisme du rachis cervical à l'ère du choosing wisely : moins d'immobilisation complète du rachis et pas de minerve.

In the 1950s and 60s, the imprudent handling of trauma patients with suspected cervical spine injury resulted in a number of reported cases of neurological deterioration during management. This led to promote the systematic immobilization of patients using rigid devices such as rigid cervical collars and spineboards. Today, this practice is being challenged and those tools are reevaluated, and some situations simply abandoned. Beginning of the 21st century, new scores allowed, initially in the emergency department, and then in recent years in prehospital setting, to select which trauma patients deserved to be X-rayed and by extension immobilized.

Les manipulations peu précautionneuses de patients traumatisés du rachis cervical dans les années 50 et 60 ont entraîné des cas décrits d'aggravation neurologique lors des prises en charge. Cela a promu l'immobilisation systématique des patients à l'aide d'outils tels que la minerve rigide ou la « planche trauma ¼ (spineboard). Aujourd'hui, on observe une remise en question de ces pratiques et la réévaluation, voire l'abandon en préhospitalier, dans certaines situations de ces techniques d'immobilisation. Au début du 21e siècle, de nouveaux outils cliniques ont permis de sélectionner, en intrahospitalier, et depuis quelques années en préhospitalier, les patients nécessitant une imagerie cervicale et par extension une immobilisation.

[Management of related contact sport mTBI]. / Prise en charge des traumatismes craniocérébraux simples dans les sports de contact.

Sports and hobbies are important cause of accident and the incidence of reported traumatic brain injury is about 10 000 case/years in Switzerland. Hockey and handball are very high-risk contact sports. The term «â€…mild traumatic brain injury ¼ (mTBI) involves a patient with an initial Glasgow coma scale between 13 and 15. Signs and symptoms are variable and non-specific. They extend to loss of consciousness to neurocognitive disorders. TBI are potentially life threatening. Therefore, their management must be fast and effective in the emergency department. Long-term complications are also frequent and caregivers have to identify and support the patients who are at risk to develop post-concussion syndrome. Multidisciplinary supportive care and decision-making related to return to sport are necessary.

Les loisirs constituent un risque accidentel, notamment de traumatisme craniocérébral (TCC). L'incidence de cas signalés avoisine les 10 000 cas/année en Suisse. Parmi les sports de contact, le hockey et le handball sont associés au plus haut risque. Le terme TCC simple regroupe les patients présentant un score de Glasgow initial de 13 à 15. Les signes et symptômes sont variables et non spécifiques, allant de la perte de connaissance à des déficits cognitifs. Les TCC sont potentiellement graves et parfois mortels, raison pour laquelle la prise en charge doit être rapide et efficace pour détecter les lésions graves. Les TCC simples peuvent également se compliquer à moyen terme d'un syndrome post-commotionnel. Les populations à risque doivent être détectées et suivies dans leur reprise du sport selon les recommandations spécifiques.

[Proctological emergencies in pregnant women]. / Les urgences proctologiques chez la femme enceinte.

Hemorrhoids affect up to 85 % of pregnant women during the last two trimesters. The maximum incidence for anal fissure is 20 %. One of the common risk factors is constipation promoted during pregnancy. The history of anal pathology, the length of delivery and the baby's birth weight also promote these two entities. The treatment includes above all hygiene and dietary measures to prevent constipation and conservative measures (local anesthetics, sitz baths). Surgical procedures should be avoided and indicated only in case of failure of conservative treatment. Rectal prolapse is more rare and must be reduced manually before surgery. Measures to prevent constipation also apply.

Les hémorroïdes concernent jusqu'à 85 % des femmes enceintes durant les deux derniers trimestres. L'incidence maximale pour la fissure anale atteint 20 %. Un des facteurs de risque communs est la constipation favorisée durant la grossesse. Les antécédents de pathologies anales, la durée de l'accouchement et le poids de naissance du bébé favorisent aussi ces deux entités. Le traitement comprend avant tout des mesures hygiéno-diététiques pour prévenir la constipation et des mesures conservatives (anesthésiants locaux, bains de siège). Les interventions chirurgicales sont à éviter et indiquées uniquement en cas d'échec du traitement conservateur. Le prolapsus rectal est plus rare et doit être réduit manuellement avant une intervention chirurgicale à réaliser en postpartum. Les mesures de prévention de la constipation s'appliquent également.

[Cutaneous surgery myths and traditions in the Emergency Department]. / Mythes et traditions des urgences chirurgicales cutanées.

Traditions and myths die hard in many fields of medicine but especially in the field of cutaneous surgical emergencies. In a few selected paragraphs, we set out to undo some of these myths with the aim of a less ritualized approach to daily gestures.

Les traditions, agrémentées de mythes, ont la vie dure dans de nombreux domaines de la médecine, mais en particulier dans le domaine des urgences chirurgicales cutanées. Par quelques chapitres choisis, nous nous attelons à briser quelques mythes dans le sens d'une approche moins ritualisée de gestes quotidiens dans nos services d'urgences et dans les cabinets médicaux et policliniques.

[Cutaneous infections in the emergency department : the devil in the detail]. / Infections cutanées aux urgences :le diable se cache dans les détails.

Skin and soft tissue infections, which are a common cause of admission, are characterized by a clinical polymorphism leading to diagnostic errors. To a certain point, confusion exists between used terms and indicated treatment, especially since the emergence of methicillin-resistant Staphylococcus aureus (MRSA) infections.The paucity of cutaneous findings early in the course of deep soft tissue infections makes diagnosis challenging for physicians in charge. Some of these infections are warranted to achieve a lower mortality and morbidity by the administration of effective surgical treatment.

Les infections cutanées sont un motif de consultation fréquent et se caractérisent par un polymorphisme clinique qui peut conduire à des erreurs diagnostiques. Une certaine confusion peut exister quant aux termes utilisés pour décrire certaines lésions et quant au traitement, surtout depuis l'émergence des infections par le staphylocoque doré résistant à la méticilline (SARM).Au stade initial, le diagnostic différentiel d'une infection profonde est difficile en raison de lésions cutanées peu spécifiques. Pour certaines de ces infections, seule une prise en charge chirurgicale rapide permet la diminution de la mortalité et de la morbidité.

[Non invasive ventilation in the emergency setting]. / Ventilation non invasive en urgence.

Before the development of non invasive ventilation (NIV), endotracheal intubation was the only ventilatory therapy available in case of severe respiratory distress and acute respiratory failure. NIV used to be employed in intensive care settings only. Nowadays, the use of NIV has been democratized to include the emergency room, and the pre-hospital care setting for treatment of acute respiratory failure. Cardiogenic pulmonary edema and acute exacerbation of COPD are indications of choice, since NIV improves mortality. The efficiency of the therapy depends on early treatment; however, endotracheal intubation should not be delayed when it becomes necessary.

Gender-based differential management of acute low back pain in the emergency department: A survey based on a clinical vignette.

BACKGROUND: Women may receive suboptimal pain management compared with men, and this disparity might be related to gender stereotypes. OBJECTIVES: To assess the influence of patient gender on the management of acute low back pain. DESIGN: We assessed pain management by 231 physicians using an online clinical vignette describing a consultation for acute low back pain in a female or male patient. The vignette was followed by a questionnaire that assessed physicians' management decisions and their gender stereotypes. METHODS: We created an online clinical vignette presenting a patient with acute low back pain and assessed the influence of a patient's gender on pain management. We investigated gender-related stereotyping regarding pain care by emergency physicians using the Gender Role Expectation of Pain questionnaire. RESULTS: Both male and female physicians tended to consider that a typical man was more sensitive to pain, had less pain endurance, and was more willing to report pain than a typical woman. These stereotypes did not translate into significant differences in pain management between men and women. However, women tended to be referred less often for imaging examinations than men and were also prescribed lower doses of ibuprofen and opioids. The physician's gender had a modest influence on management decisions, female physicians being more likely to prescribe ancillary examinations. CONCLUSION: We observed gender stereotypes among physicians. Our findings support the hypothesis that social characteristics attributed to men and women influence pain management. Prospective clinical studies are needed to provide a deeper understanding of gender stereotypes and their impact on clinical management.

PLUS-IS-LESS project: Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments: study protocol for a pragmatic stepped-wedge cluster-randomized trial.

BACKGROUND: Lower respiratory tract infections (LRTIs) are among the most frequent infections and a significant contributor to inappropriate antibiotic prescription. Currently, no single diagnostic tool can reliably identify bacterial pneumonia. We thus evaluate a multimodal approach based on a clinical score, lung ultrasound (LUS), and the inflammatory biomarker, procalcitonin (PCT) to guide prescription of antibiotics. LUS outperforms chest X-ray in the identification of pneumonia, while PCT is known to be elevated in bacterial and/or severe infections. We propose a trial to test their synergistic potential in reducing antibiotic prescription while preserving patient safety in emergency departments (ED). METHODS: The PLUS-IS-LESS study is a pragmatic, stepped-wedge cluster-randomized, clinical trial conducted in 10 Swiss EDs. It assesses the PLUS algorithm, which combines a clinical prediction score, LUS, PCT, and a clinical severity score to guide antibiotics among adults with LRTIs, compared with usual care. The co-primary endpoints are the proportion of patients prescribed antibiotics and the proportion of patients with clinical failure by day 28. Secondary endpoints include measurement of change in quality of life, length of hospital stay, antibiotic-related side effects, barriers and facilitators to the implementation of the algorithm, cost-effectiveness of the intervention, and identification of patterns of pneumonia in LUS using machine learning. DISCUSSION: The PLUS algorithm aims to optimize prescription of antibiotics through improved diagnostic performance and maximization of physician adherence, while ensuring safety. It is based on previously validated tests and does therefore not expose participants to unforeseeable risks. Cluster randomization prevents cross-contamination between study groups, as physicians are not exposed to the intervention during or before the control period. The stepped-wedge implementation of the intervention allows effect calculation from both between- and within-cluster comparisons, which enhances statistical power and allows smaller sample size than a parallel cluster design. Moreover, it enables the training of all centers for the intervention, simplifying implementation if the results prove successful. The PLUS algorithm has the potential to improve the identification of LRTIs that would benefit from antibiotics. When scaled, the expected reduction in the proportion of antibiotics prescribed has the potential to not only decrease side effects and costs but also mitigate antibiotic resistance. TRIAL REGISTRATION: This study was registered on July 19, 2022, on the ClinicalTrials.gov registry using reference number: NCT05463406. TRIAL STATUS: Recruitment started on December 5, 2022, and will be completed on November 3, 2024. Current protocol version is version 3.0, dated April 3, 2023.

Opiophobia in Emergency Department Healthcare Providers: A Survey in Western Switzerland.

Opiophobia contributes to oligoanalgesia in the emergency department (ED), but its definition varies, and its association to healthcare providers' personality traits has been scantly explored. Our purpose was to study the different definitions of opiophobia and their association with two personality traits of doctors and nurses working in EDs, namely the stress from uncertainty and risk-taking. We used three online questionnaires: the 'Attitude Towards Morphine Use' Score (ATMS), the Stress From Uncertainty Scale (SUS) and the Risk-Taking Scale (RTS). Doctors and nurses from nine hospital EDs in francophone Switzerland were invited to participate. The ATMS score was analyzed according to demographic characteristics, SUS, and RTS. The response rate was 56%, with 57% of respondents being nurses and 63% women. Doctors, less experienced and non-indigenous participants had a significantly higher ATMS (all p ≤ 0.01). The main contributors of the ATMS were the fear of side effects and of addiction. In multivariate analysis, being a doctor, less experience and non-indigenous status were predictive of the ATMS; each point of the SUS increased the ATMS by 0.24 point. The fear of side effects and of addiction were the major contributors of opiophobia among ED healthcare providers; opiophobia was also associated with their personality traits.

Merger of two dispatch centres: does it improve quality and patient safety?

BACKGROUND: Dispatch centres (DCs) are considered an essential but expensive component of many highly developed healthcare systems. The number of DCs in a country, region, or state is usually based on local history and often related to highly decentralised healthcare systems. Today, current technology (Global Positioning System or Internet access) abolishes the need for closeness between DCs and the population. Switzerland went from 22 DCs in 2006 to 17 today. This study describes from a quality and patient safety point of view the merger of two DCs. METHODS: The study analysed the performance (over and under-triage) of two medical DCs for 12 months prior to merging and for 12 months again after the merger in 2015. Performance was measured comparing the priority level chosen by dispatcher and the severity of cases assessed by paramedics on site using the National Advisory Committee for Aeronautics (NACA) score. We ruled that NACA score > 3 (injuries/diseases which can possibly lead to deterioration of vital signs) to 7 (lethal injuries/diseases) should require a priority dispatch with lights and siren (L&S). While NACA score < 4 should require a priority dispatch without L&S. Over-triage was defined as the proportion of L&S dispatches with a NACA score < 4, and under-triage as the proportion of dispatches without L&S with a NACA > 3. RESULTS: Prior to merging, Dispatch A had a sensitivity/specificity regarding the use of lights and sirens and severity of cases of 86%/48% with over- and under-triage rates of 78% and 5%, respectively. Dispatch B had sensitivity and specificity of 92%/20% and over- and under-triage rates of 84% and 7%, respectively. After they merged, global sensitivity/specificity reached 87%/67%, and over- and under-triage rates were 71% and 3%, respectively CONCLUSIONS: A part the potential cost advantage achieved by the merger of two DCs, it can improve the quality of services to the population, reducing over- and under-triage and the use of lights and sirens and therefore, the risk of accidents. This is especially the case when a DC with poor triage performance merges with a high-performing DC.