Moving From CT to MRI Paradigm in Acute Ischemic Stroke: Feasibility, Effects on Stroke Diagnosis and Long-Term Outcomes.

BACKGROUND: The relative value of computed tomography (CT) and magnetic resonance imaging (MRI) in acute ischemic stroke (AIS) is debated. In May 2018, our center transitioned from using CT to MRI as first-line imaging for AIS. This retrospective study aims to assess the effects of this paradigm change on diagnosis and disability outcomes. METHODS: We compared all consecutive patients with confirmed diagnosis of AIS admitted to our center during the MRI-period (May 2018-August 2022) and an identical number of patients from the preceding CT-period (December 2012-April 2018). Univariable and multivariable analyses were performed to evaluate outcomes, including the number and delay of imaging exams, the rate of missed strokes, stroke mimics treated with thrombolysis, undetermined stroke mechanisms, length of hospitalization, and 3-month disability. RESULTS: The median age of the 2972 included patients was 76 years (interquartile range, 65-84), and 46% were female. In the MRI-period, 80% underwent MRI as first acute imaging. The proportion of patients requiring a second acute imaging modality for diagnostic ± revascularization reasons increased from 2.1% to 5% (Punadj <0.05), but it decreased in the subacute phase from 79.0% to 60.1% (Padj <0.05). In thrombolysis candidates, there was a 2-minute increase in door-to-imaging delay (Padj <0.05). The rates of initially missed AIS diagnosis was similar (3.8% versus 4.4%, Padj=0.32) and thrombolysis in stroke mimics decreased by half (8.6% versus 4.3%; Padj <0.05). Rates of unidentified stroke mechanism at hospital discharge were similar (22.8% versus 28.1%; Padj=0.99). The length of hospitalization decreased from 9 (interquartile range, 6-14) to 7 (interquartile range, 4-12) days (Padj=0.62). Disability at 3 months was similar (common adjusted odds ratio for favorable Rankin shift, 0.98 [95% CI, 0.71-1.36]; Padj=0.91), as well as mortality and symptomatic intracranial hemorrhage. CONCLUSIONS: A paradigm shift from CT to MRI as first-line imaging for AIS seems feasible in a comprehensive stroke center, with a minimally increased delay to imaging in thrombolysis candidates. MRI was associated with reduced thrombolysis rates of stroke mimics and subacute neuroimaging needs.

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.

[Emergency medicine: what's new in 2023]. / Médecine d'urgence: ce qui a changé en 2023.

Research in prehospital and in-hospital emergency medicine is essential to the development of this discipline. By calling certain practices into question (thrombolysis for minor strokes, use of coagulation factors for patients with severe polytrauma), providing access to new technologies (video-laryngoscopy, POCT troponins in pre-hospital care) or questioning new practices (double defibrillation, pulmonary US in pneumonia), research enables emergency physicians to adapt their day-to-day practice.

La recherche en médecine d'urgence, tant sur le plan préhospitalier qu'hospitalier, est nécessaire et même indispensable à la fois au développement de cette discipline, mais également à la reconnaissance de ses spécificités. Par la remise en question de certaines pratiques (thrombolyse pour les AVC mineurs, utilisation de facteurs de la coagulation pour le polytraumatisé sévère), l'accès à de nouvelles technologies (vidéo-laryngoscopie, troponines POCT en préhospitalier) ou le questionnement sur de nouvelles pratiques (double défibrillation, US pulmonaire dans la pneumonie), la recherche permet aux urgentistes d'adapter leur pratique quotidienne à l'état de l'art.

[Emergency medicine: what's new in 2022]. / Médecine d'urgence : ce qui a changé en 2022.

Emergency medicine is facing many challenges, particularly related to the consequences of the pandemic on the pressure of patient flows and the lack of human resources. More than ever, our discipline seeks to offer our patients quality care based on several recent studies, of which the following is a section: a) Gender effect in the administration of tranexamic acid; b) External validation of the Canadian Syncope Risk Score; c) Role of neuro-imaging in psychiatric decompensation; d) Choice of analgesia in renal colic; e) Use of carotid ultrasound for pulse control in cardiac arrest and f) The safetyness of performing simple sutures in non-sterile conditions.

La médecine d'urgence est confrontée à de nombreux défis, notamment liés aux conséquences de la pandémie sur la pression des flux patients et du manque de ressources médico-soignantes. Plus que jamais, notre discipline cherche à offrir à nos patients des soins de qualité en s'appuyant sur plusieurs études récentes dont voici une sélection : a) effet de genre dans l'administration d'acide tranexamique ; b) validation externe du Canadian Syncope Risk Score ; c) rôle de l'imagerie cérébrale dans les décompensations psychiatriques ; d) choix de l'antalgie dans la colique néphrétique ; e) utilisation de l'US carotidien dans le contrôle du pouls lors d'ACR et f) possibilité de réaliser des sutures simples sans conditions stériles.

[Updates in emergency medicine]. / Médecine d'urgence.

In 2021, emergency medicine has been impacted by the Covid19 pandemic. The repercussions were both on clinical and scientific aspects specific to our discipline. For this special issue, we have chosen not to insist on the pandemic but to return to some fundamentals of our discipline: cardiovascular emergencies remain the leading cause of death in the world and the aspects of risk stratification of pathologies such as acute coronary syndromes or neurovascular attack remain a daily issue within the framework of the strategies of management and investigation in emergency medicine. In addition, the consideration of alternative treatments in the context of pathologies, ranging from cannabis consumption to cardiac arrest and atrial fibrillation, also remains a daily challenge.

En 2021, la médecine d'urgence a été impactée par la pandémie Covid19. Les répercussions ont autant été cliniques que sur la recherche scientifique spécifique à notre discipline. Pour ce numéro spécial, nous avons fait le choix de ne pas insister sur la pandémie, mais de revenir à certains fondamentaux de notre discipline : l'urgence cardiovasculaire reste la première cause de mortalité dans le monde. Les aspects de stratification du risque pour ces pathologies, telles que les syndromes coronariens aigus ou les AVC, sont toujours un enjeu quotidien dans le cadre des stratégies de prise en charge et d'investigation en urgence. Par ailleurs, la prise en compte d'alternatives thérapeutiques dans des pathologies très variées, allant de la consommation de cannabis à l'arrêt cardiaque en passant par la fibrillation auriculaire, reste également un enjeu au quotidien.

[Emergency medicine†: update 2020]. / Médecine d'urgence.

2020 has seen the birth of several relevant studies in emergency medicine of which the following is a selection : 1) conservative treatment for primary spontaneous pneumothorax may be offered ; 2) tranexamic acid does not provide benefit in gastrointestinal bleeding ; 3) the Canadian Syncope Risk Score is validated for the risk stratification of syncopal patients ; 4) early administration of tranexamic acid does not have a significant effect on the neurological prognosis of patients with moderate to severe trauma brain injury ; 5) the notion of frailty seems to be predictive of mortality in the event of intra-hospital cardiac arrest in elderly patients ; 6) a pharmacological cardioversion strategy followed by electrical cardioversion is as effective as initial electrical cardioversion for atrial fibrillation in the emergency room.

2020 a vu naître plusieurs études pertinentes en médecine d'urgences dont voici une sélection : 1) un traitement conservateur dans les pneumothorax spontanés primaires peut être proposé ; 2) l'acide tranexamique n'apporte pas de bénéfice dans l'hémorragie digestive ; 3) le Canadian Syncope Risk Score est validé pour la stratification du risque des patients syncopaux ; 4) l'administration précoce d'acide tranexamique n'a pas d'effet significatif sur le pronostic neurologique des patients avec un traumatisme craniocérébral modéré à sévère ; 5) la notion de fragilité semble être prédictive de la mortalité en cas d'arrêt cardiaque intrahospitalier chez les patients âgés et 6) une stratégie de cardioversion médicamenteuse suivie d'une cardioversion électrique est aussi efficace qu'une cardioversion électrique d'emblée dans la fibrillation auriculaire aux urgences.

[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.

[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.

Performance of three predictive scores to avoid delayed diagnosis of significant blunt bowel and mesenteric injury: A 12-year retrospective cohort study.

BACKGROUND: Avoiding missed diagnosis and therapeutic delay for significant blunt bowel and mesenteric injuries (sBBMIs) after trauma is still challenging despite the widespread use of computed tomography (CT). Several scoring tools aiming at reducing this risk have been published. The purpose of the present work was to assess the incidence of delayed (>24 hours) diagnosis for sBBMI patients and to compare the predictive performance of three previously published scores using clinical, radiological, and laboratory findings: the Bowel Injury Prediction Score (BIPS) and the scores developed by Raharimanantsoa Score (RS) and by Faget Score (FS). METHODS: A population-based retrospective observational cohort study was conducted; it included adult trauma patients after road traffic crashes admitted to Lausanne University Hospital, Switzerland, between 2008 and 2019 (n = 1,258) with reliable information about sBBMI status (n = 1,164) and for whom all items for score calculation were available (n = 917). The three scores were retrospectively applied on all patients to assess their predictive performance. RESULTS: The incidence of sBBMI after road traffic crash was 3.3% (38 of 1,164), and in 18% (7 of 38), there was a diagnostic and treatment delay of more than 24 hours. The diagnostic performances of the FS, the RS, and the BIPS to predict sBBMI, expressed as the area under the receiver operating characteristic curve, were 95.3% (95% confidence interval [CI], 92.7-97.9%), 89.2% (95% CI, 83.2-95.3%), and 87.6% (95% CI, 81.8-93.3%) respectively. CONCLUSION: The present study confirms that diagnostic delays for sBBMI still occur despite the widespread use of abdominal CT. When CT findings during the initial assessment are negative or equivocal for sBBMI, using a score may be helpful to select patients for early diagnostic laparoscopy. The FS had the best individual diagnostic performance. However, the BIPS or the RS, relying on clinical and laboratory variables, may be helpful to select patients for early diagnostic laparoscopy when there are unspecific CT signs of bowel or mesenteric injury. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: usefulness for tranexamic acid treatment criteria.

BACKGROUND: Tranexamic acid reduces surgical blood loss and reduces deaths from bleeding in trauma patients. Tranexamic acid must be given urgently, preferably by paramedics at the scene of the injury or in the ambulance. We developed a simple score (Bleeding Audit Triage Trauma score) to predict death from bleeding. METHODS: We conducted an external validation of the BATT score using data from the UK Trauma Audit Research Network (TARN) from 1st January 2017 to 31st December 2018. We evaluated the impact of tranexamic acid treatment thresholds in trauma patients. RESULTS: We included 104,862 trauma patients with an injury severity score of 9 or above. Tranexamic acid was administered to 9915 (9%) patients. Of these 5185 (52%) received prehospital tranexamic acid. The BATT score had good accuracy (Brier score = 6%) and good discrimination (C-statistic 0.90; 95% CI 0.89-0.91). Calibration in the large showed no substantial difference between predicted and observed death due to bleeding (1.15% versus 1.16%, P = 0.81). Pre-hospital tranexamic acid treatment of trauma patients with a BATT score of 2 or more would avoid 210 bleeding deaths by treating 61,598 patients instead of avoiding 55 deaths by treating 9915 as currently. CONCLUSION: The BATT score identifies trauma patient at risk of significant haemorrhage. A score of 2 or more would be an appropriate threshold for pre-hospital tranexamic acid treatment.

[Customized management of pericarditis]. / Une prise en charge sur mesure de la péricardite.

Pericarditis is a disease for which clinical criteria can be used to direct ambulatory or hospitalized management. Acute pericarditis is the most frequent form of pericardial disease and recurrence is the most common complication. Current management is largely based on empirical experience but randomized controlled trails are beginning to be appear that have enabled the elaboration of certain recommendations. The use of colchicine is the most recent development in the pharmacological treatment of this affection. Low doses of colchicine, adapted for weight and potential side effects, seem to reduce rates of recurrence. Recommended length of treatment is 3 months for acute pericarditis and 6 months for recurrent pericarditis. Ongoing trials may further clarify the role of this molecule in the management of this condition.

Prehospital use of pelvic circumferential compression devices in a physician-based emergency medical service: A 6-year retrospective cohort study.

Fractures of the pelvic ring are a potential source of significant bleeding. Pelvic circumferential compression devices (PCCDs) can reduce and immobilize unstable fractures, but their hemostatic effect is unproven. Our aim was to assess the current practice of prehospital PCCD application and to identify factors available in the field predictive of significant pelvic ring injuries. All interventions (n = 13,435) in the Lausanne University Hospital Emergency Medical Service (EMS) were screened for PCCD placements from January 2008 to November 2014. Significant pelvic ring injuries (Tile types B or C) were considered as potentially benefitting from a PCCD. Data were extracted from the local prehospital registry. During the study period, 2366 trauma missions were performed. A PCCD was applied to 552/2366 (23%) patients. Significant pelvic ring injuries were present in 105/2366 (4.4%). Factors associated with the presence of significant pelvic ring injury were increased respiratory rate (OR 1.04), prolonged capillary refill time (OR 2.11), increased shock index (OR 3.91), pedestrians hit by a vehicle (OR 2.19), and presenting with falls from more than 2 m (OR 1.91). Among patients with a significant pelvic ring injury, a PCCD was placed in 79 (75%) and omitted in 26 (25%). One sixth of patients with a PCCD had a final diagnosis of significant pelvic ring injury. Further studies are needed to better understand which patient-, or accident-related factors are associated with prehospital PCCD omission among patients with significant pelvic ring injury.

Evaluation of the discriminative performance of the prehospital National Advisory Committee for Aeronautics score regarding 48-h mortality.

OBJECTIVE: The National Advisory Committee for Aeronautics (NACA) score is used by many emergency medical services to assess the severity of prehospital patients. Little is known about its discriminative performance regarding short-term mortality. PARTICIPANTS AND METHODS: We retrospectively included adult missions between 2008 and 2014 in a Swiss ground and air-based emergency medical services. We excluded uninjured or dead-on-scene patients. Primary outcome was assessment of the discriminative performance of the NACA score to classify the 48-h vital status of patients. Overall discrimination was quantified using the area under receiver operating characteristic curve (AUC). We also explored the influence of epidemiological characteristics (age and sex), mechanism (trauma or nontrauma) and clinical parameters (respiratory rate, oxygen saturation, heart rate, systolic blood pressure, capillary refill time, and Glasgow Coma Scale) on its discriminative performance. We then assessed the incremental value of these variables in the classification accuracy of a rule based on these variables in addition to the NACA score. RESULTS: We included 11 567 patients out of 11 639 (72 exclusions for missing data). Overall AUC was 0.86. The score was more discriminant for trauma (AUC = 0.95 vs. 0.83), and for younger patients (AUC = 0.91 for 16-59 vs. 0.78 for 84-104 years). Adding age, sex, mechanism, and clinical parameters resulted in a classification rule with higher discriminative performance than NACA score alone (AUC of 0.92 vs. 0.86; P < 0.001). CONCLUSION: The NACA score is an efficient way to discriminate victims regarding short-term mortality. Its performance can be enhanced by also integrating epidemiological and clinical parameters into an extended classification rule.

Kidney light chain disease in patients with the acquired immunodeficiency syndrome.

Light chain deposit disease (LCDD) is a rare condition caused by deposition of overproduced monoclonal light chains and has been frequently related to multiple myeloma or lymphocytic disorders. LCDD in association with human immunodeficiency virus (HIV) has only been described twice in the literature and is thought to result from HIV direct/indirect effects on B and T-cell populations, leading to chronic immune activation with paraprotein production. We report a renal LCDD case diagnosed at autopsy in a severely immunodepressed HIV patient and analyse renal histopathology of 18 HIV patients who had an autopsy in our department between 2000 and 2010.