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BACKGROUND AND IMPORTANCE: The Swiss Emergency Triage Scale (SETS) is an adult triage tool used in several emergency departments. It has been recently adapted to the pediatric population but, before advocating for its use, performance assessment of this tool is needed. OBJECTIVES: The purpose of this study was to assess the reliability and the accuracy of the pediatric version of the SETS for the triage of pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: This study was a cross-sectional study among a sample of emergency triage nurses (ETNs) exposed to 17 clinical scenarios using a computerized simulator. OUTCOME MEASURES AND ANALYSIS: The primary outcome was the reliability of the triage level performed by the ETNs. It was assessed using an intraclass correlation coefficient.Secondary outcomes included accuracy of triage compared with expert-based triage levels and factors associated with accurate triage. MAIN RESULTS: Eighteen ETNs participated in the study and completed the evaluation of all scenarios, for a total of 306 triage decisions. The intraclass correlation coefficient was 0.80 (95% confidence interval, 0.69-0.91), with an agreement by scenario ranging from 61.1% to 100%. The overall accuracy was 85.8%, and nurses were more likely to undertriage (16.0%) than to overtriage (4.3%). No factor for accurate triage was identified. CONCLUSIONS: This simulator-based study showed that the SETS is reliable and accurate among a pediatric population. Future research is needed to confirm these results, compare this triage scale head-to-head with other recognized international tools, and study the SETSped in real-life setting.
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Serviço Hospitalar de Emergência , Triagem , Humanos , Triagem/métodos , Estudos Transversais , Suíça , Reprodutibilidade dos Testes , Feminino , Masculino , Criança , Enfermagem em Emergência , Adulto , Simulação por ComputadorRESUMO
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.
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BACKGROUND: Ultrasound-guided fascia iliaca compartment block (US-FICB) is not part of the learning curriculum of the emergency physicians (EP) and is usually performed by anesthesiologists. However, several studies promote EP to use this procedure. The goal of this study was to assess the feasibility of a training concept for non-anesthesiologists for the US-FICB on a simulator based on a validating learning path. METHOD: This was a feasibility study. Emergency physicians and medical students received a 1-day training with a learning phase (theoretical and practical skills), followed by an assessment phase. The primary outcome at the assessment phase was the number of attempts before successfully completing the procedure. The secondary outcomes were the success rate at first attempt, the length of procedure (LOP), and the stability of the probe, corresponding to the visualization of the needle tip (and its tracking) throughout the procedure, evaluated on a Likert scale. RESULTS: A total of 25 participants were included. The median number of attempts was 2.0 for emergency physicians and 2.5 for medical students, and this difference was not significant (p = 0.140). Seven participants (28%) succeeded at the first attempt of the procedure; the difference between emergency physicians and medical students was not significant (37% versus 21%; p = 0.409). The average LOP was 19.7 min with a significant difference between emergency physicians and medical students (p = 0.001). There was no significant difference regarding the stability of the probe between the two groups. CONCLUSION: Our 1-day training for non-anesthesiologists with or without previous skills in ultrasound seems to be feasible for learning the US-FICB procedure on a simulator.
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OBJECTIVE: The aim of this study was to assess the effect of prehospital noninvasive ventilation for acute cardiogenic pulmonary edema on endotracheal intubation rate and on ICU admission rate. METHODS: We carried out a retrospective study on patients' prehospital files between 2007 and 2010 (control period), and between 2013 and 2016 (intervention period). Adult patients were included if a diagnosis of acute cardiogenic pulmonary edema was made by the prehospital physician. Exclusion criteria were a Glasgow coma scale score less than 9 or any other respiratory diagnosis. We analyzed the association between noninvasive ventilation implementation and endotracheal intubation or ICU admission with univariable and multivariable regression models. The primary outcome was prehospital endotracheal intubation rate. Secondary outcomes were admission to an ICU, prehospital intervention length, and 30-day mortality. RESULTS: A total of 1491 patients were included. Noninvasive ventilation availability was associated with a significant decrease in endotracheal intubation rate (2.6% in the control versus 0.7% in the intervention period), with an adjusted odds ratio (OR) of 0.3 [95% confidence interval (CI), 0.1-0.7]. There was a decrease in ICU admissions (18.6% in the control versus 13.0% in the intervention period) with an adjusted OR of 0.6 (95% CI, 0.5-0.9). There was no significant change in 30-day mortality (11.2% in the control versus 11.0% in the intervention period, P = 0.901). CONCLUSION: In our physician-staffed prehospital system, use of noninvasive ventilation for acute cardiogenic pulmonary edema decreased both endotracheal intubation and ICU admission rates.
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Serviços Médicos de Emergência/métodos , Intubação Intratraqueal/estatística & dados numéricos , Edema Pulmonar/terapia , Idoso , Idoso de 80 Anos ou mais , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Ventilação não Invasiva , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Acute pain is the most common complaint of patients presenting to emergency departments (EDs). Effective pain management is a core ED mission, but numerous studies have pointed to insufficient pain treatment or oligoanalgesia. According to a 1997 national survey in Swiss EDs, a validated pain scale was used in only 14%, an analgesia protocol in <5%, and 1.1% had a nurse-initiated pain protocol. Since then, numerous societal and health care factors have led to improved ED pain care. The aim of this study was to assess the state of ED pain management in Switzerland. METHODS: Hospital-based Swiss EDs open 24 hours a day and 7 days a week in 2013 were surveyed using a questionnaire. Data from 2013 were collected. Questions queried the pain management process by nurses and physicians in each ED. RESULTS: The response rate was 115 of 137 eligible EDs (84%). Pain intensity was assessed with a validated instrument in 71% of waiting rooms and in 99% of treatment areas. A nurse-initiated analgesia protocol was available in 56% of waiting rooms and in 70% of treatment areas. Physician pain protocols were available in 75%, and analgesia-sedation protocols in 51%. CONCLUSION: The pain management processes in Swiss EDs have improved over the last 17 years, and are now equivalent to other western countries. Our study did not, however, assess if these improvements resulted in better analgesia at the bedside, an important topic that will require further study.
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Manejo da Dor/métodos , Dor , Analgesia/métodos , Serviço Hospitalar de Emergência , Política de Saúde , Humanos , Enfermeiras e Enfermeiros , Dor/diagnóstico , Dor/tratamento farmacológico , Inquéritos e Questionários , SuíçaRESUMO
BACKGROUND: Plain abdominal radiography (PAR) is routinely performed in emergency departments (EDs). This study aimed to (1) identify the indications for PAR in EDs and compare them against international guidelines, (2) uncover predictors of non-compliance with guidelines, and (3) describe the use of additional radiological examinations in EDs. METHODS: Retrospective cohort study in the EDs of two hospitals in Geneva, Switzerland, including all adult patients who underwent PAR in the EDs. Indications were considered "appropriate" if complying with guidelines. Predictors of non-compliance were identified by univariate and multivariate analyses. RESULTS: Over 1 year, PAR was performed in 1997 patients (2.2% of all admissions). Their mean age was 59.7 years, with 53.1% of female patients. The most common indications were constipation (30.8%), suspected ileus (28.9%), and abdominal pain (15.3%). According to the French and American guidelines, only 11.8% of the PARs were indicated, while 46.2% of them complied with the Australian and British guidelines. On multivariate analysis, admission to the private hospital ED (odds ratio [OR] 3.88, 95% CI 1.78-8.45), female gender (OR 1.95, 95% CI 1.46-2.59), and an age > 65 years (OR 2.41, 95%CI 1.74-3.32) were associated with a higher risk of inappropriate PAR. Additional radiological examinations were performed in 73.7% of patients. CONCLUSIONS: Most indications for PAR did not comply with guidelines and elderly women appeared particularly at risk of being exposed to inappropriate examination. PAR did not prevent the need for additional examinations. Local guidelines should be developed, and initiatives should be implemented to reduce unnecessary PARs. TRIAL REGISTRATION: ClinicalTrials.gov , identifier NCT02980081 .
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Serviço Hospitalar de Emergência/estatística & dados numéricos , Radiografia Abdominal/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Utilização de Equipamentos e Suprimentos , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , SuíçaRESUMO
BACKGROUND: Acute abdominal pain accounts for about 10% of emergency department visits and has progressively become the primary indication for CT scanning in most centers. The goal of our study is to identify biological or clinical variables able to predict or rule out significant pathology (conditions requiring urgent medical or surgical treatment) on abdominal CT in patients presenting to an emergency department with acute abdominal pain. METHODS: This was a retrospective cohort study performed in the emergency department of an academic center with an annual census of 60'000 patients. One hundred and-nine consecutive patients presenting with an acute non-traumatic abdominal pain, not suspected of appendicitis or renal colic, during the first semester of 2013, who underwent an abdominal CT were included. Two medical students, completing their last year of medical school, extracted the data from patients' electronic health record. Ambiguities in the formulations of clinical symptoms and signs in the patients' records were solved by consulting a board certified emergency physician. Nine clinical and biological variables were extracted: shock index, peritonism, abnormal bowel sounds, fever (> 38 °C), intensity and duration of the pain, leukocytosis (white blood cell count >11G/L), relative lymphopenia (< 15% of total leukocytes), and C-reactive Protein (CRP). These variables were compared to the CT results (reference standard) to determine their ability to predict a significant pathology. RESULTS: Significant pathology was detected on CT in 71 (65%) patients. Only leukocytosis (odds ratio 3.3, p = 0.008) and relative lymphopenia (odds ratio 3.8, p = 0.002) were associated with significant pathology on CT. The joint presence of these two anomalies was strongly associated with significant pathology on CT (odds ratio 8.2, p = 0.033). Leukocytosis with relative lymphopenia had a specificity of 89% (33/37) and sensitivity of 48% (33/69) for the detection of significant pathology on CT. CONCLUSION: The high specificity of the association between leukocytosis and relative lymphopenia amongst the study population suggests that these parameters would be sufficient to justify an emergency CT. However, none of the parameters could be used to rule out a significant pathology.
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Abdome Agudo/diagnóstico por imagem , Leucocitose/complicações , Linfopenia/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Contagem de Leucócitos , Leucocitose/sangue , Linfopenia/sangue , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
OBJECTIVES: No general emergency department triage scale has been evaluated for prehospital triage. The objective of this study was to evaluate the reliability and the performance of the Swiss Emergency Triage Scale (SETS) used by paramedics to determine the emergency level and orientation of simulated patients. PATIENTS AND METHODS: In a prospective cross-sectional study, 23 paramedics evaluated 28 clinical scenarios with the SETS using interactive computerized triage software simulating real-life triage. The primary outcome was inter-rater reliability regarding the triage level among participants measured by intraclass correlation coefficient (ICC). Secondary outcomes were the accuracy of triage level and the reliability and accuracy of orientation of patients of at least 75 years to a dedicated geriatric emergency centre. RESULTS: Twenty-three paramedics completed the evaluation of the 28 scenarios (644 triage decisions). Overall, ICC for triage level was 0.84 (95% confidence interval: 0.77-0.99). Correct emergency level was assigned in 89% of cases, overtriage rate was 4.8%, and undertriage was 6.2%. ICC regarding orientation in the subgroup of simulated patients of at least 75 years was 0.76 (95% confidence interval: 0.61-0.89), with 93% correct orientation. CONCLUSION: Reliability of paramedics rating simulated emergency situations using the SETS was excellent, and the accuracy of their rating was very high. This suggests that in Switzerland, the SETS could be safely used in the prehospital setting by paramedics to determine the level of emergency and guide patients to the most appropriate hospital.
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Pessoal Técnico de Saúde/educação , Competência Clínica , Treinamento por Simulação/métodos , Triagem/métodos , Idoso , Estudos Transversais , Serviços Médicos de Emergência , Feminino , Humanos , Masculino , Variações Dependentes do Observador , Estudos Prospectivos , Reprodutibilidade dos Testes , SuíçaRESUMO
Acute ethanol intoxication (AEI) is frequent in emergency departments (EDs). These patients are at risk of mistriage, and to leave the ED without being seen. This study's objective was to describe the process and performance of triage and trajectory for patients with suspected AEI. Retrospective, observational study on adults admitted with a suspected AEI within 1 year at the ED of an urban teaching hospital. Data on the triage process, patients' characteristics, and their ED stay were extracted from electronic patient records. Predictors for leaving without being seen were identified using logistic regression analyzes. Of 60,488 ED patients within 1 year, 776 (1.3%) were triaged with suspected AEI. This population was young (mean age 38), primarily male (64%), and professionally inactive (56%). A large proportion were admitted on weekends (45%), at night (46%), and arrived by ambulance (85%). The recommendations of our triage scale were entirely respected in a minority of cases. In 22.7% of triage situations, a triage reason other than "alcohol abuse/intoxication" (such as suicidal ideation, head trauma or other substance abuse) should have been selected. Nearly, half of the patients (49%) left without being seen (LWBS). This risk was especially high amongst men (OR 1.56, 95% CI 1.12-2.19), younger patients (< 26 years of age; OR 1.97, 95% CI 1.16-3.35), night-time admissions (OR 1.97, 95% CI 1.16-3.35), and patients assigned a lower emergency level (OR 2.32, 95% CI 1.58-3.42). Despite a standardized triage protocol, patients admitted with suspected AEI are at risk of poor assessment, and of not receiving optimal care.
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Intoxicação Alcoólica/complicações , Triagem/normas , Adolescente , Adulto , Idoso , Intoxicação Alcoólica/psicologia , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Triagem/métodos , Triagem/tendênciasRESUMO
OBJECTIVE: To evaluate the prevalence of isolated femoral head impactions associated with acetabular fractures and to assess whether impactions may be predictive of the development of delayed major complications requiring total hip arthroplasty. MATERIALS AND METHODS: A total of 128 consecutive adult patients with acetabular fracture and no femoral head fracture were included. Admission CTs were re-interpreted for the presence of hip dislocation and femoral head impactions. Radiological and clinical reports were reviewed in patients in whom conservative management of the femoral head was attempted, to determine if total hip arthroplasty was eventually required over a 48-month follow-up period. Univariate and multivariate analyses were performed to assess whether impaction is an independent predictor of failure of conservative management. RESULTS: Impaction was found in 40% of all patients (51 out of 128), in 58% of those with dislocation (19 out of 33), and in 34% of those without dislocation (32 out of 95; p < 0.05). One hundred and five patients underwent conservative management of the femoral head; 12.5% of them (13 out of 105) eventually required total hip arthroplasty. An impaction was present in 77% of the latter (10 out of 13) and in 33% of patients with successful conservative management (30 out of 92; p = 0.0042). At multivariate analysis, impaction and dislocation were significantly and independently associated with a higher risk for delayed total hip arthroplasty (odds ratio of 4.8 and 4.0 respectively). CONCLUSION: Femoral head impactions are frequently seen on CT of patients with acetabular fractures; they are independent predictive factors for the need for delayed total hip arthroplasty. They should be systematically mentioned in the CT report.
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Acetábulo/lesões , Cabeça do Fêmur/lesões , Luxação do Quadril/diagnóstico por imagem , Fraturas do Quadril/diagnóstico por imagem , Fraturas do Quadril/terapia , Tomografia Computadorizada por Raios X , Acetábulo/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador , Feminino , Cabeça do Fêmur/diagnóstico por imagem , Luxação do Quadril/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
OBJECTIVES: To evaluate non-intravenously enhanced low-dose computed tomography with oral contrast (LDCT) for the assessment of pregnant women with right lower quadrant pain, when magnetic resonance imaging (MRI) is not immediately available. METHODS: One hundred and thirty-eight consecutive pregnant women with acute abdominal pain were admitted in our emergency centre. Thirty-seven (27%) of them, with clinical suspicion of acute appendicitis, underwent abdominal ultrasonography (US). No further examination was recommended when US was positive for appendicitis, negative with low clinical suspicion or showed an alternative diagnosis which explained the clinical presentation. All other patients underwent LDCT (<2.5 mSv). Standard intravenously enhanced CT or MRI was performed when LDCT was indeterminate. RESULTS: Eight (22%) of 37 US exams were reported normal, 25 (67%) indeterminate, 1 (3%) positive for appendicitis, 3 (8%) positive for an alternative diagnosis. LDCT was obtained in 29 (78%) patients. It was reported positive for appendicitis in 9 (31%), for alternative diagnosis in 2 (7%), normal in 13 (45%) and indeterminate in 5 (17%). Further imaging (standard CT or MRI) showed appendicitis in 2 of these 5 patients, was truly negative in 1, indeterminate in 1 and falsely positive in 1. An appendicitis was confirmed at surgery in 12 (32%) of the 37 patients. The sensitivity and the specificity of the algorithm for appendicitis were 100% (12/12) and 92% (23/25), respectively. CONCLUSIONS: The proposed algorithm is very sensitive and specific for detection of acute appendicitis in pregnant women; it reduces the need of standard CTs when MRI is not available as second-line imaging. KEY POINTS: ⢠In pregnant women, US is limited by an important number of indeterminate results ⢠Low-dose CT can be used after an inconclusive US for the diagnosis of appendicitis in pregnant women ⢠An algorithm integrating US and low-dose CT is highly sensitive and specific for appendicitis in pregnant women.
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Algoritmos , Apendicite/diagnóstico , Meios de Contraste/administração & dosagem , Complicações na Gravidez/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia/métodos , Doença Aguda , Administração Oral , Adolescente , Adulto , Diagnóstico Diferencial , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Adulto JovemRESUMO
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.
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Eficiência Organizacional/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Tempo de Internação/estatística & dados numéricos , Relações Médico-Paciente , Listas de Espera , Estudos de Coortes , Aglomeração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Background: Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism (PE) are limited, and guidelines provide inconsistent recommendations on use of diagnostic tests. Objective: To prospectively validate a diagnostic strategy in pregnant women with suspected PE. Design: Multicenter, multinational, prospective diagnostic management outcome study involving pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb compression ultrasonography (CUS), and computed tomography pulmonary angiography (CTPA). (ClinicalTrials.gov: NCT00740454). Setting: 11 centers in France and Switzerland between August 2008 and July 2016. Patients: Pregnant women with clinically suspected PE in emergency departments. Intervention: Pulmonary embolism was excluded in patients with a low or intermediate pretest clinical probability and a negative D-dimer result. All others underwent lower limb CUS and, if results were negative, CTPA. A ventilation-perfusion (V/Q) scan was done if CTPA results were inconclusive. Pulmonary embolism was excluded if results of the diagnostic work-up were negative, and untreated pregnant women had clinical follow-up at 3 months. Measurements: The primary outcome was the rate of adjudicated venous thromboembolic events during the 3-month follow-up. Results: 441 women were assessed for eligibility, and 395 were included in the study. Among these, PE was diagnosed in 28 (7.1%) (proximal deep venous thrombosis found on ultrasonography [n = 7], positive CTPA result [n = 19], and high-probability V/Q scan [n = 2]) and excluded in 367 (clinical probability and negative D-dimer result [n = 46], negative CTPA result [n = 290], normal or low-probability V/Q scan [n = 17], and other reason [n = 14]). Twenty-two women received extended anticoagulation during follow-up, mainly for previous venous thromboembolic disease. The rate of symptomatic venous thromboembolic events was 0.0% (95% CI, 0.0% to 1.0%) among untreated women after exclusion of PE on the basis of negative results on the diagnostic work-up. Limitation: There were several protocol deviations, reflecting the difficulty of performing studies in pregnant women with suspected PE. Conclusion: A diagnostic strategy based on assessment of clinical probability, D-dimer measurement, CUS, and CTPA can safely rule out PE in pregnant women. Primary Funding Source: Swiss National Foundation for Scientific Research, Groupe d'Etude de la Thrombose de Bretagne Occidentale, and International Society on Thrombosis and Haemostasis.
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Complicações Cardiovasculares na Gravidez/diagnóstico , Embolia Pulmonar/diagnóstico , Adulto , Anticoagulantes/uso terapêutico , Angiografia por Tomografia Computadorizada , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/diagnóstico por imagem , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico por imagem , Complicações Cardiovasculares na Gravidez/prevenção & controle , Estudos Prospectivos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/prevenção & controle , Ultrassonografia , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/prevenção & controleRESUMO
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 manÅuvre 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.
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Reanimação Cardiopulmonar , Medicina de Emergência , Dor Abdominal , Idoso , Emergências , Medicina de Emergência/tendências , HumanosRESUMO
BACKGROUND: The Swiss Emergency Triage Scale (SETS) is a four-level emergency scale that previously showed moderate reliability and high rates of undertriage due to a lack of standardization. It was revised to better standardize the measurement and interpretation of vital signs during the triage process. OBJECTIVE: The aim of this study was to explore the inter-rater and test-retest reliability, and the rate of correct triage of the revised SETS. PATIENTS AND METHODS: Thirty clinical scenarios were evaluated twice at a 3-month interval using an interactive computerized triage simulator by 58 triage nurses at an urban teaching emergency department admitting 60 000 patients a year. Inter-rater and test-retest reliabilities were determined using κ statistics. Triage decisions were compared with a gold standard attributed by an expert panel. Rates of correct triage, undertriage, and overtriage were computed. A logistic regression model was used to identify the predictors of correct triage. RESULTS: A total of 3387 triage situations were analyzed. Inter-rater reliability showed substantial agreement [mean κ: 0.68; 95% confidence interval (CI): 0.60-0.78] and test-retest almost perfect agreement (mean κ: 0.86; 95% CI: 0.84-0.88). The rate of correct triage was 84.1%, and rates of undertriage and overtriage were 7.2 and 8.7%, respectively. Vital sign measurement was an independent predictor of correct triage (odds ratios for correct triage: 1.29 for each additional vital sign measured, 95% CI: 1.20-1.39). CONCLUSION: The revised SETS incorporating standardized vital sign measurement and interpretation during the triage process resulted in high reliability and low rates of mistriage.
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Competência Clínica , Simulação por Computador , Enfermagem em Emergência/métodos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Triagem/métodos , Estado Terminal/terapia , Feminino , Hospitais de Ensino , Humanos , Modelos Logísticos , Masculino , Variações Dependentes do Observador , Estudos Prospectivos , Suíça , Sinais VitaisRESUMO
BACKGROUND: The association between early antibiotic administration and outcomes remains controversial in patients hospitalized for community-acquired pneumonia. METHODS: We performed a secondary analysis of a randomized controlled trial comparing two antibiotic treatment strategies for patients hospitalized for moderately severe CAP. The univariate and multivariate associations between time to antibiotic administration (TTA) and time to clinical stability were assessed using a Cox proportional hazard model. Secondary outcomes were death, intensive care unit admission and hospital readmission up to 90days. RESULTS: 371 patients (mean age 76years, CURB-65 score≥2 in 52%) were included. Mean TTA was 4.35h (SD 3.48), with 58.5% of patients receiving the first antibiotic dose within 4h. In multivariate analysis, number of symptoms and signs (HR 0.876, 95% CI 0.784-0.979, p=0.020), age (HR 0.986, 95% CI 0.975-0.996, p=0.007), initial heart rate (HR 0.992, 95% CI 0.986-0.999, p=0.023), and platelets count (HR 0.998, 95% CI 0.996-0.999, p=0.004) were associated with a reduced probability of reaching clinical stability. The association between TTA and time to clinical stability was not significant (HR 1.009, 95% CI 0.977-1.042, p=0.574). We found no association between TTA and the risk of intensive care unit admission, death or readmission up to 90days after the initial admission. CONCLUSION: In patients hospitalized for moderately severe CAP, a shorter time to antibiotic administration was not associated with a favorable outcome. These findings support the current recommendations that do not assign a specific time frame for antibiotics administration.
Assuntos
Antibacterianos/uso terapêutico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/tratamento farmacológico , Tempo para o Tratamento , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções Comunitárias Adquiridas/mortalidade , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Pneumonia/mortalidade , Modelos de Riscos Proporcionais , Índice de Gravidade de Doença , Suíça , Adulto JovemRESUMO
OBJECTIVES: To determine if radiation dose delivered by contrast-enhanced CT (CECT) for acute abdominal pain can be reduced to the dose administered in abdominal radiography (<2.5 mSv) using low-dose CT (LDCT) with iterative reconstruction algorithms. METHODS: One hundred and fifty-one consecutive patients requiring CECT for acute abdominal pain were included, and their body mass index (BMI) was calculated. CECT was immediately followed by LDCT. LDCT series was processed using 1) 40% iterative reconstruction algorithm blended with filtered back projection (LDCT-IR-FBP) and 2) model-based iterative reconstruction algorithm (LDCT-MBIR). LDCT-IR-FBP and LDCT-MBIR images were reviewed independently by two board-certified radiologists (Raters 1 and 2). RESULTS: Abdominal pathology was revealed on CECT in 120 (79%) patients. In those with BMI <30, accuracies for correct diagnosis by Rater 1 with LDCT-IR-FBP and LDCT-MBIR, when compared to CECT, were 95.4% (104/109) and 99% (108/109), respectively, and 92.7% (101/109) and 100% (109/109) for Rater 2. In patients with BMI ≥30, accuracies with LDCT-IR-FBP and LDCT-MBIR were 88.1% (37/42) and 90.5% (38/42) for Rater 1 and 78.6% (33/42) and 92.9% (39/42) for Rater 2. CONCLUSIONS: The radiation dose delivered by CT to non-obese patients with acute abdominal pain can be safely reduced to levels close to standard radiography using LDCT-MBIR. KEY POINTS: ⢠LDCT-MBIR (<2.5 mSv) can be used to assess acute abdominal pain. ⢠LDCT-MBIR (<2.5 mSv) cannot safely assess acute abdominal pain in obese patients. ⢠LDCT-IR-FBP (<2.5 mSv) cannot safely assess patients with acute abdominal pain.
Assuntos
Abdome Agudo/diagnóstico por imagem , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Abdome Agudo/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Índice de Massa Corporal , Emergências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doses de Radiação , Radiografia Abdominal/métodos , Cintilografia , Tomografia Computadorizada por Raios X/métodos , Adulto JovemRESUMO
AIM: To identify the predictive signs of aortic valve involvement on the non-electrocardiogram (ECG)-gated admission computed tomography (CT) of patients with Type A aortic dissection (AD) according to the Stanford classification. MATERIALS AND METHODS: We retrospectively analyzed the non-ECG-gated CT examinations of patients admitted to the emergency department who underwent surgery for Type A AD over a period of 4 years. The diameter of the following structures was calculated as the mean of the smallest and largest diameters (mm) measured in two different planes: aortic annulus, sinus of Valsalva, sinotubular junction, and proximal ascending aorta. These parameters were compared against operative reports in order to determine whether they were predictive of aortic valve involvement. RESULTS: In total, 20 patients (13 men and 7 women) of a mean age of 59.5 years (29-80) were included, 55% of patients (11/20) having surgically proven valvular involvement. The mean diameters (inmm) of the aortic annulus, sinus of Valsalva, sinotubular junction and proximal ascending aorta in the group with (and without, respectively) valvular involvement was 27.7 (26.7), 44.3 (38.1), 42.6 (36.6), and 47.8 (45.9). Only the measurement of the mean diameter of the sinuses of Valsalva was significantly predictive (p=0.02) of aortic valve involvement. CONCLUSION: Our findings suggest that measuring the diameter of the sinuses of Valsalva on non-ECG-gated admission CT examinations allows for predicting aortic valve involvement in Type A AD patients.
Assuntos
Aneurisma Aórtico/diagnóstico por imagem , Dissecção Aórtica/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Seio Aórtico/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
AIMS OF THE STUDY: Profound hyponatremia (<125 mmol/l) is frequent in the emergency department. Its incidence appears to increase during hot weather. Our objectives were to investigate seasonal variations in the incidence of profound hyponatraemia and identify its risk factors. METHODS: The incidence of profound hyponatremia among patients admitted to the emergency department of a university hospital was compared between summer and winter periods over two successive years. Risk factors for profound hyponatraemia were analysed in a case-control retrospective study. Each adult patient admitted during the study periods with a blood sodium level <125 mmol/l was matched with two patients who had normal blood sodium concentrations. RESULTS: Of 28 734 analysed patients, 264 cases of profound hyponatraemia (0.92%) were identified. The incidence of profound hyponatraemia was higher in summer than in winter (1.29% vs 0.54%; odds ratio [OR] 2.39, 95% confidence interval [CI] 1.83-3.12). In a multivariate analysis, age (OR 1.02, 95% CI 1.01-1.03), psychiatric disorders (OR 2.69, 95% CI 1.86-3.89), and use of thiazide diuretics (OR 7.79, 95% CI 4.73-12.85) or potassium-sparing diuretics (OR 4.69, 95% CI 2.31-9.52) were associated with increased risk. Mortality was higher in cases than in controls (11.7% vs 6.9%, OR 1.75, 95% CI 1.05-2.92). CONCLUSIONS: The incidence of profound hyponatraemia was higher during the summer than the winter and was associated with excess risk of overall mortality. The use of thiazide and potassium-sparing diuretics was associated with the highest risk of hyponatraemia.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hiponatremia/etiologia , Estações do Ano , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Hiponatremia/epidemiologia , Incidência , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Sódio/sangue , Suíça/epidemiologia , Adulto JovemRESUMO
BACKGROUND: There is a growing interest in better defining risk factors associated with increased susceptibility to exacerbation in patients with COPD. INTRODUCTION: The aim of the study was to determine whether identification of a respiratory virus during a severe acute exacerbation of COPD (AECOPD) increases the risk of subsequent exacerbations and mortality during a one-year followup. METHODS: Secondary analysis of 86 COPD patients admitted for AECOPD between June 2007 and December 2008 at Geneva's University Hospital who were followed up for 1 year. Fifty-one percent of index AECOPD were related to viral infection. Rate of AECOPD, time to next AECOPD, and all-cause mortality were compared between patients with vs without viral index AECOPD. RESULTS: Eighty-one cases were included in this secondary follow-up analysis. Mean exacerbation rate was 1.9 AECOPD per person-year for patients with viral index AECOPD vs 4.0 AECOPD per person year for those with non-viral index AECOPD. Incidence rate ratio (IRR) for subsequent AECOPD during one year follow up was lower for patients with viral index AECOPD (IRR 0.57; [CI 95% 0.39-0.84]), after controlling for previous exacerbations, and was strongly associated with the number of exacerbations in the year preceding the index AECOPD. During the one-year follow-up period, 16 patients (19%) died. In a Cox regression model, patients with a proven viral infection did not have a higher mortality (HR 0.56 [CI 95% 0.20 -1.58]). CONCLUSION: Viral AECOPD was not associated with a higher rate of subsequent exacerbations or mortality during the following year.