[Abuse: emergency department management]. / La maltraitance : conduite à tenir aux urgences.

Abuse has many forms. Its societal impact is substantial. Abused patients are insufficiently identified as such. Mistreatment represents a real challenge for our societies and for the medical profession in particular. The emergency physician is on the front line to identify, assess and refer the abused patients. Knowledge of the typology of abuse, the legal framework and the local resources at his disposal allows him to treat and guide safely the victim.

La maltraitance est une violence aux multiples formes avec un impact sociétal considérable. Souvent taboue, elle est insuffisamment identifiée. Elle représente un véritable défi pour nos sociétés et pour le corps médical en particulier. L'urgentiste est en première ligne pour identifier, évaluer et orienter les patients victimes de maltraitance. Une connaissance du mode de présentation, du cadre juridique et des ressources locales à disposition permettent d'orienter la victime en toute sécurité.

Opioid-related adverse drug reactions in patients visiting the emergency division of a tertiary hospital.

Opioid use and associated morbidity and mortality have increased in several countries during the past 20 years. We performed a study whose objective was to assess the frequency and causes of opioid-related emergency division (ED) visits in an adult tertiary Swiss University Hospital over 9 weeks in 2018. We primarily assessed opioid-related adverse drug reactions (ADR), secondary overdose, misuse, abuse, and insufficient pain relief. Current opioid use was identified in 1037 (8.3%) of the 12 470 included ED visits. In 64 opioid users, an ADR was identified as a contributing cause of the ED visit, representing 6.2% of opioid users, and 0.5% of the total ED visits. Moreover, we identified an overdose in 16 opioid users, misuse or abuse in 19 opioid users, and compatible withdrawal symptoms in 7 opioid users. After pooling all these events, we conclude that the ED visits could be related to opioid use in 10.2% of opioid users. Finally, in 201 opioid users, insufficient pain relief (pain not responding to the current pharmacological treatment) was identified as a contributing cause of ED visits. In these cases, other factors than simply pharmacological nonresponse may have been involved. In the context of an ever-increasing opioid use to better control chronic pain situations, these results should reinforce emergency network epidemiological surveillance studies at a national level.

[Interdisciplinarity and critical care in emergency medicine]. / Interdisciplinarité et urgences vitales en médecine d'urgence.

Cardiorespiratory arrest, stroke and severe trauma have serious consequences if untreated with strict procedures in a timely manner. This temporal imperative implies the implementation of a succession of actions coordinated by healthcare providers with diverse expertise, and operating according to known, mastered and trained standards of care. Simple and clear communication principles ensure the consistency and fluidity of these actions. Competent and inclusive leadership promotes the achievement of set objectives and allows the team to adapt to demanding or unforeseen situations. Interdisciplinarity as it is practiced in the emergency setting for critical pathways such as those mentioned, then takes on its full meaning.

L'arrêt cardiorespiratoire, l'accident vasculaire cérébral et le traumatisé grave sont grevés de lourdes conséquences s'ils ne sont pas traités avec des procédures strictes dans des délais adéquats. Cet impératif temporel implique la mise en œuvre d'une succession d'actions coordonnées par des intervenants à l'expertise diverse et opérant selon des standards de soins connus, maîtrisés et entraînés. Des principes de communication simples et clairs assurent la cohérence et la fluidité de ces actions. Un leadership, compétent et inclusif, favorise l'atteinte des objectifs fixés et permet l'adaptation de l'équipe aux situations exigeantes ou imprévues. L'interdisciplinarité telle qu'elle est pratiquée pour ces filières de soins critiques prend alors tout son sens.

A new screening tool for SARS-CoV-2 infection based on self-reported patient clinical characteristics: the COV19-ID score.

BACKGROUND: While several studies aimed to identify risk factors for severe COVID-19 cases to better anticipate intensive care unit admissions, very few have been conducted on self-reported patient symptoms and characteristics, predictive of RT-PCR test positivity. We therefore aimed to identify those predictive factors and construct a predictive score for the screening of patients at admission. METHODS: This was a monocentric retrospective analysis of clinical data from 9081 patients tested for SARS-CoV-2 infection from August 1 to November 30 2020. A multivariable logistic regression using least absolute shrinkage and selection operator (LASSO) was performed on a training dataset (60% of the data) to determine associations between self-reported patient characteristics and COVID-19 diagnosis. Regression coefficients were used to construct the Coronavirus 2019 Identification score (COV19-ID) and the optimal threshold calculated on the validation dataset (20%). Its predictive performance was finally evaluated on a test dataset (20%). RESULTS: A total of 2084 (22.9%) patients were tested positive to SARS-CoV-2 infection. Using the LASSO model, COVID-19 was independently associated with loss of smell (Odds Ratio, 6.4), fever (OR, 2.7), history of contact with an infected person (OR, 1.7), loss of taste (OR, 1.5), muscle stiffness (OR, 1.5), cough (OR, 1.5), back pain (OR, 1.4), loss of appetite (OR, 1.3), as well as male sex (OR, 1.05). Conversely, COVID-19 was less likely associated with smoking (OR, 0.5), sore throat (OR, 0.9) and ear pain (OR, 0.9). All aforementioned variables were included in the COV19-ID score, which demonstrated on the test dataset an area under the receiver-operating characteristic curve of 82.9% (95% CI 80.6%-84.9%), and an accuracy of 74.2% (95% CI 74.1%-74.3%) with a high sensitivity (80.4%, 95% CI [80.3%-80.6%]) and specificity (72.2%, 95% CI [72.2%-72.4%]). CONCLUSIONS: The COV19-ID score could be useful in early triage of patients needing RT-PCR testing thus alleviating the burden on laboratories, emergency rooms, and wards.

[The toxicological testing in the emergency room in the era of choosing wisely]. / Examens toxicologiques aux urgences à l'ère du choosing wisely.

The emergency physician is frequently called upon to take care of intoxicated patients. The identification of the culprit is a diagnostic challenge when the clinical picture is discordant, or the poisoning uncertain. Toxicological screening is of limited usefulness to the ED physician. Results from indiscriminate use can be misleading. The « all-out ¼ search for toxins is expensive and rarely influences the treatment strategy. In the era of the « choosing wisely ¼ campaign, a pragmatic and thoughtful use of toxicological testing is justified.

L'urgentiste est fréquemment amené à prendre en charge des patients intoxiqués. L'identification du toxique représente un défi diagnostique lorsque la clinique est discordante ou l'intoxication incertaine. Aux urgences, les examens toxicologiques ont une utilité limitée. Les résultats issus d'une utilisation sans discernement peuvent être trompeurs. La recherche « tous azimuts ¼ du toxique est coûteuse et n'influence que rarement la stratégie thérapeutique. À l'ère du mouvement choosing wisely, un usage pragmatique et réfléchi des examens toxicologiques est justifié.

[The diagnostic approach of stable coronary heart disease†: What risk can you trust†?] / La démarche diagnostique de la maladie coronarienne stable : à quel risque se fier ?

We present the case of a 72-year-old patient, with multiple cardiovascular risk factors, investigated for exertional dyspnea. The diagnostic workup led to a percutaneous coronary intervention. During the procedure, catheter-induced iatrogenic coronary artery dissection (CICAD) resulted in cardiorespiratory arrest. This article reviews the key elements and the risk assessment at each step of the diagnostic strategy of stable coronary syndromes in accordance to the latest 2019 European Society of Cardiology guidelines.

Nous présentons le cas d'une patiente de 72 ans, aux multiples facteurs de risque cardiovasculaire, avec une dyspnée d'effort. Les investigations aboutissent à un cathétérisme coronarien percutané. L'intervention se complique d'une dissection coronarienne iatrogène suivie d'un arrêt cardiorespiratoire. Cet article revient sur les éléments clés de la stratégie diagnostique de la maladie coronarienne stable, conformément aux dernières recommandations européennes de 2019, et sur l'évaluation des risques à chacune des étapes.

Impact of a patient-flow physician coordinator on waiting times and length of stay in an emergency department: A before-after cohort study.

OBJECTIVE: Overcrowding is common in most emergency departments (ED). Despite the use of validated triage systems, some patients are at risk of delayed medical evaluation. The objective of this study was to assess the impact of a patient-flow physician coordinator (PFPC) on the proportion of patients offered medical evaluation within time limits imposed by the Swiss Emergency Triage Scale (SETS) and on patient flow within the emergency department of a teaching urban hospital. METHODS: In this before-after retrospective cohort study, we compared the proportions of patients who received their first medical contact within SETS-imposed time limits, mean waiting times before first medical consultation, mean length of stay, and number of patients who left without being seen by a physician, between two periods before and after introducing a PFPC. The PFPC was a senior physician charged with quickly assessing in the waiting area patients who could not immediately be seen and managing patient flow within the department. RESULTS: Before introducing the PFPC position, 33,605 patients were admitted, versus 36,288 after. Introducing a PFPC enabled the department to increase the proportion of patients seen within the SETS-imposed time limits from 60.1% to 69.0% (p <0.0001). Waiting times until first medical consultation were reduced on average by 27.7 minutes (95% confidence interval [95% CI]: 25.9-29.5, p < .0001). No significant differences were observed as to length of stay or number of patients who left without being seen between the two study periods. CONCLUSIONS: Introducing a physician dedicated to managing patient flow enabled waiting times until first medical consultation to be reduced, yet had no significant benefit for patient flow within the ED, nor did it reduce the number of patients who left without being seen.

[Analgesia and sedation in the pregnant patient]. / Analgo-sédation de la femme enceinte.

Nonobstetric emergencies are frequent during pregnancy. The emergency physician must be knowledgeable regarding the physiological changes related to pregnancy, and must evaluate the benefit/risk ratio of any medication given to the mother. Though maternal side-effects are easy to predict, the fetal risk remains difficult to evaluate as medications are numerous and clinical evidence scarce. For analgesia as for sedation, the choice will depend on both the clinical context of the patient, the desired objective, and the assumed fetal risk.

Les urgences non obstétricales de la femme enceinte sont fréquentes. La prise en charge de ces patientes implique de la part de l'urgentiste une connaissance des modifications physio-lo-giques liées à la grossesse et du rapport risques/bénéfices de toute médication administrée à la mère. Alors que les risques maternels peuvent être anticipés, le risque fœtal reste difficile à cerner tant les molécules sont nombreuses et les données cliniques rares. Pour l'analgo-sédation, le choix des molécules dépend à la fois du contexte clinique de la patiente, de l'objectif souhaité, et du risque fœtal présumé.

[Emergency medicine : update 2017]. / Médecine d'urgence.

Emergency medicine is part of the current stream of efficient and qualitative medicine : 1) the modified Valsava maneuver results in the resolution of almost 50% of supra-ventricular tachycardia without any drug; 2) lung echography performed by emergency physicians is a very sensitive and specific diagnostic tool for most thoracic emergencies; 3) cardiopulmonary resuscitation initiated by lay-rescuers improves short and long-term outcome; 4) no anticoagulant treatment is warranted in distal deep vein thrombosis and 5) systematic unenhanced abdominal CT might improve evaluation of elderly patients with acute abdominal pain.

Dans le courant actuel d'une médecine de qualité visant l'efficience, la médecine d'urgence n'est pas en reste : 1) la manœuvre de Valsalva modifiée permet une cardioversion dans près de 50 % des tachycardies supraventriculaires paroxystiques sans aucun autre traitement ; 2) l'échographie pulmonaire pratiquée par l'urgentiste est rapide avec de très bonnes sensibilité et spécificité dans plusieurs pathologies thoraciques ; 3) une réanimation initiée par des témoins permet une meilleure survie et améliore le pronostic à long terme ; 4) un traitement anticoagulant n'est pas nécessaire lors de thrombose veineuse profonde sous-poplitée et 5) un scanner abdominal non injecté systématique pourrait améliorer la prise en charge de patients âgés souffrant de douleurs abdominales aiguës.

Brugada Pattern Caused by a Flecainide Overdose.

BACKGROUND: Brugada pattern can be found on the electrocardiogram (ECG) of patients with altered mental status, usually with fever or drug intoxication. Diagnosis remains challenging, because the ECG changes are dynamic and variable. In addition, triggers are not always clearly identified. In patients with atrial fibrillation (AF), the use of class IC antidysrhythmic drugs can unmask a Brugada pattern on the ECG, especially if combined with other medications acting on sodium channels. CASE REPORT: A 62-year-old man with a medical history of AF was admitted to our emergency department for altered mental status. The ECG at the time of admission showed a Brugada pattern, triggered by a flecainide overdose (about 1 g), in association with an unknown dose of lamotrigine and quetiapine. After discontinuation of all medications, the Brugada pattern disappeared and his ECG showed no abnormalities. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In patients with AF, the use of class IC antidysrhythmic drugs, if overdosed, can trigger a Brugada ECG pattern, and therefore it can increase the risk for malignant dysrhythmias. It is important to provide, to all patients with a Brugada ECG pattern, a list of drugs to avoid, and to underline the synergistic interplay between drugs, taking into consideration all patients' comorbidities.

[Acute dyspnea in the emergency room: from pathophysiology to ultrasonography]. / Dyspnée aiguë aux urgences: de la physiopathologie à l'échographie.

Acute dyspnea is one of the leading clinical symptoms encountered in the emergency room. Its differential diagnosis is wide, ranging from noisy panic attacks to threatening acute heart failure. History taking and physical examination, even when exhaustive are of limited diagnostic value. Patient reported descriptions are fairly correlated to pathophysiology. Vital signs such as the respiratory rate and pulse oximetry carry prognostic significance. Ancillary tests like the chest x-ray lack sensitivity and specificity. The most astonishing adjunct to testing is the chest ultrasound. Its integration into the emergency physician's armamentarium considerably changed clinical management. Fast and accurate, ultrasonography has become the modern era stethoscope. This review discusses acute dyspnea through the main elements useful to diagnosis.

[Acute analgesia: implementation of a dedicated protocol in an emergency department]. / AntaIgie aiguë: mise en oeuvre d'un protocole dans un service d'urgences.

Acute pain relief is an ongoing challenge for both nurses and emergency physicians. Its management remains suboptimal or delayed, despite the existence of valid recommendations. The complexity of the emergency department and the diversity of encountered situations justify a tailored approach, taking into account the patient's clinical characteristics and needs. Such an approach must, under safety conditions assign sufficient autonomy to care providers in order to achieve pain relief. The benefits of an optimal analgesia are numerous. They include a greater patient satisfaction, a reduced length of stay, and a rapid return to mobility. This article highlights the key elements of acute pain management in the emergency department of the Geneva University Hospitals.

[Shock: diagnostic evaluation in the emergency department]. / Etat de choc: approche diagnostique aux urgences.

The identification of shock may be sometimes easy or on the other hand difficult due to the lack of accuracy of ancillary tests. The use of ultrasound has modified the initial emergency assessment of patients presenting with shock, in that it can now be used to differentiate between different types of shock (cardiogenic versus hypovolemic). The use, performance, and clinical benefits of ultrasound protocols applied by emergency physicians, still remain to be validated before to be implemented.