Post-mortem changes of the vascular system-a thanatological study using multidetector computed tomography.

Forensic pathologists have to deal with post-mortem changes of the human body. Those post-mortem phenomena are familiar and largely described in thanatology. However, knowledge about the influence of post-mortem phenomena on the vascular system is more limited, except for the apparition and development of cadaveric lividity. The introduction of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) in the forensic field and the expansion of their usage in medico-legal routine, allow for exploring the inside of corpses differently and may play a part in the understanding of thanatological processes. This study aimed to describe post-mortem changes in the vascular system by investigating the presence of gas and collapsed vessels.We investigated post-mortem MDCT data of 118 human bodies. Cases with internal/external bleeding or corporal lesion allowing contamination with external air were excluded. Major vessels and heart cavities were systematically explored and a trained radiologist semi-quantitatively assessed the presence of gas.Collapsed veins were observed in 61.9% of cases (CI95% 52.5 to 70.6) and arteries in 33.1% (CI95% 24.7 to 42.3). Vessels most often affected were for arteries: common iliac (16.1%), abdominal aorta (15.3%), external iliac (13.6%), and for veins: infra-renal vena cava (45.8%), common iliac (22.0%), renal (16.9%), external iliac (16.1%), and supra-renal vena cava (13.6%). Cerebral arteries and veins, coronary arteries, and subclavian vein were unaffected. The presence of collapsed vessels was associated with a minor degree of cadaveric alteration. We observed that arteries and veins follow the same pattern of gas apparition for both the quantity and the location.In post-mortem radiology, collapsed vessels and intravascular gas are frequently visualized and as a result of all post-mortem changes, the assessment of the distribution of blood can be confusing. Therefore, knowledge of thanatological phenomena is crucial to prevent post-mortem radiological misapprehensions and possible false diagnoses.

Assessment of frailty by paramedics using the clinical frailty scale - an inter-rater reliability and accuracy study.

BACKGROUND: Frailty assessment by paramedics in the prehospital setting is understudied. The goals of this study were to assess the inter-rater reliability and accuracy of frailty assessment by paramedics using the Clinical Frailty Scale (CFS). METHODS: This was a cross-sectional study with paramedics exposed to 30 clinical vignettes created from real-life situations. There was no teaching intervention prior to the study and paramedics were only provided with the French version of the CFS (definitions and pictograms). The primary outcome was the inter-rater reliability of the assessment. The secondary outcome was the accuracy, compared with the expert-based assessment. Reliability was determined by calculating an intraclass correlation coefficient (ICC). Accuracy was assessed through a mixed effects logistic regression model. A sensitivity analysis was carried out by considering that an assessment was still accurate if the score differed from no more than 1 level. RESULTS: A total of 56 paramedics completed the assessment. The overall assessment was found to have good inter-rater reliability (ICC = 0.87 [95%CI 0.81-0.93]). The overall accuracy was moderate at 60.6% (95%CI 54.9-66.1) when considering the full scale. It was however much higher (94.8% [95%CI 92.0-96.7] when close assessments were considered as accurate. The only factor associated with accurate assessment was field experience. CONCLUSION: The assessment of frailty by paramedics was reliable in this vignette-based study. However, the accuracy deserved to be improved. Future research should focus on the clinical impact of these results and on the association of prehospital frailty assessment with patient outcomes. REGISTRATION: This study was registered on the Open Science Framework registries ( https://doi.org/10.17605/OSF.IO/VDUZY ).

Time to Reconsider Analgesia in Mass Casualty Incidents.

The provision of analgesia in mass casualty incidents has traditionally been viewed as low-priority and reserved for later stages of care. Poor pain management is commonplace in trauma victims, and inadequate acute pain management can hinder evacuation efforts and may lead to the development of chronic pain and posttraumatic stress disorder. New, safe, and simple methods for administering quality analgesia have proven to be safe and effective in the prehospital setting and, as such, could easily be implemented into mass casualty incident protocols and allow for analgesia at earlier stages in such incidents, thereby improving patient care.

A Short Intervention and an Interactive e-Learning Module to Motivate Medical and Dental Students to Enlist as First Responders: Implementation Study.

BACKGROUND: Prompt and proficient basic life support (BLS) maneuvers are essential to increasing the odds of survival after out-of-hospital cardiac arrest. However, significant time can elapse before the arrival of professional rescuers. To decrease these delays, many countries have developed first responder networks. These networks are composed of BLS-certified lay or professional rescuers who can be dispatched by emergency medical communication centers to take care of those who experience out-of-hospital cardiac arrest. Many systems are, however, limited by a relatively low number of active first responders, and first-year medical and dental students may represent an almost untapped pool of potential rescuers. On top of providing an enhanced BLS coverage to the population, this could also help medical students be better prepared to their future role as certified health care providers and address societal expectations regarding health care students. OBJECTIVE: Our objective was to describe the impact of a short motivational intervention followed by a blended BLS course (e-learning and practice session) designed to motivate first-year medical and dental students to enlist as first responders. METHODS: A short, web-based, motivational intervention presenting this project took place, and first-year University of Geneva, Faculty of Medicine students were provided with a link to the study platform. Those who agreed to participate were redirected to a demographic questionnaire before registering on the platform. The participants were then asked to answer a second questionnaire designed to determine their baseline knowledge prior to following an interactive e-learning module. Upon completion, a web-based booking form enabling them to register for a 1-hour practice session was displayed. These sessions were held by senior medical students who had been trained and certified as BLS instructors. The participants who attended these practice sessions were asked to answer a postcourse questionnaire before receiving the certificate enabling them to register as first responders. RESULTS: Out of the 529 first-year students registered at University of Geneva, Faculty of Medicine on January 14, 2021, 190 (35.9%) initially agreed to participate. Moreover, 102 (19.3%) attended the practice sessions, and 48 (9.1%) had completed all training and enlisted as first responders on the dedicated platform, Save a Life, at 6 months (July 14, 2021). Postcourse confidence in resuscitation skills was associated with a higher likelihood of registering as first responder (P=.03). No association was found between prior BLS knowledge and the probability of registering to a practice session (P=.59), of obtaining a course completion certificate (P=.29), or of enlisting as first responder (P=.56). CONCLUSIONS: This study shows that a motivational intervention associated with a short BLS course can convince medical students to enlist as first responders. Further studies are needed to understand the rather low proportion of medical students finally registering as first responders. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/24664.

Basic Life Support Knowledge among Junior Medical and Dental Students, Communication Channels, and the COVID-19 Pandemic.

Background and objective: The prognosis of cardiac arrest victims strongly depends on the prompt provision of Basic Life Support (BLS) maneuvers. Medical students should therefore be proficient in this area, but many lack essential BLS knowledge. The goal of this prospective, closed web-based study was to determine whether a short intervention designed to motivate first-year medical students to follow a blended BLS course could lead to a significant improvement in BLS knowledge in the following year. Materials and Methods: A fully automated web-based questionnaire was administered to second-year medical students one year after they had been given the opportunity of following a blended BLS course (e-learning and practice session). The primary outcome was the difference, on a 6-question score assessing essential BLS knowledge, between these students and those from the 2020 promotion since the latter had not been offered the optional BLS course. Results: The score was similar between the two study periods (3.3 ± 0.8 in 2022 vs. 3.0 ± 1.0 in 2020, p = 0.114), but no firm conclusion could be drawn since participation was much lower than expected (17.9% in 2022 vs. 43.7% in 2020, p < 0.001). Therefore, a second questionnaire was created and administered to understand the reasons underlying this low participation. Conclusions: There was a lack of improvement in BLS knowledge in second-year medical students after the introduction of an optional introductory BLS course in the first-year curriculum, but the limited participation rate precludes drawing definitive conclusions. Ineffective communication appears to be the cause of this low participation rate, but a lack of motivation in the aftermath of the COVID-19 pandemic cannot be ruled out. Corrective actions should be considered to enhance communication, restore motivation, and ultimately improve BLS knowledge among medical and dental students.

Impact of a Serious Game (Escape COVID-19) on the Intention to Change COVID-19 Control Practices Among Employees of Long-term Care Facilities: Web-Based Randomized Controlled Trial.

BACKGROUND: Most residents of long-term care facilities (LTCFs) are at high risk of complications and death following SARS-CoV-2 infection. In these facilities, viral transmission can be facilitated by shortages of human and material resources, which can lead to suboptimal application of infection prevention and control (IPC) procedures. To improve the dissemination of COVID-19 IPC guidelines, we developed a serious game called "Escape COVID-19" using Nicholson's RECIPE for meaningful gamification, as engaging serious games have the potential to induce behavioral change. OBJECTIVE: As the probability of executing an action is strongly linked to the intention of performing it, the objective of this study was to determine whether LTCF employees were willing to change their IPC practices after playing "Escape COVID-19." METHODS: This was a web-based, triple-blind, randomized controlled trial, which took place between November 5 and December 4, 2020. The health authorities of Geneva, Switzerland, asked the managers of all LTCFs under their jurisdiction to forward information regarding the study to all their employees, regardless of professional status. Participants were unaware that they would be randomly allocated to one of two different study paths upon registration. In the control group, participants filled in a first questionnaire designed to gather demographic data and assess baseline knowledge before accessing regular online IPC guidelines. They then answered a second questionnaire, which assessed their willingness to change their IPC practices and identified the reasons underlying their decision. They were then granted access to the serious game. Conversely, the serious game group played "Escape COVID-19" after answering the first questionnaire but before answering the second one. This group accessed the control material after answering the second set of questions. There was no time limit. The primary outcome was the proportion of LTCF employees willing to change their IPC practices. Secondary outcomes included the factors underlying participants' decisions, the domains these changes would affect, changes in the use of protective equipment items, and attrition at each stage of the study. RESULTS: A total of 295 answer sets were analyzed. Willingness to change behavior was higher in the serious game group (82% [119/145] versus 56% [84/150]; P<.001), with an odds ratio of 3.86 (95% CI 2.18-6.81; P<.001) after adjusting for professional category and baseline knowledge, using a mixed effects logistic regression model with LTCF as a random effect. For more than two-thirds (142/203) of the participants, the feeling of playing an important role against the epidemic was the most important factor explaining their willingness to change behavior. Most of the participants unwilling to change their behavior answered that they were already applying all the guidelines. CONCLUSIONS: The serious game "Escape COVID-19" was more successful than standard IPC material in convincing LTCF employees to adopt COVID-19-safe IPC behavior. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/25595.

Asynchronous Distance Learning of the National Institutes of Health Stroke Scale During the COVID-19 Pandemic (E-Learning vs Video): Randomized Controlled Trial.

BACKGROUND: The COVID-19 pandemic has considerably altered the regular medical education curriculum while increasing the need for health care professionals. Senior medical students are being incrementally deployed to the front line to address the shortage of certified physicians. These students, some of whom will be fast-tracked as physicians, may lack knowledge regarding the initial management of time-critical emergencies such as stroke. OBJECTIVE: Our aim was to determine whether an e-learning module could improve asynchronous distance knowledge acquisition of the National Institutes of Health Stroke Scale (NIHSS) in senior medical students compared to the traditional didactic video. METHODS: A randomized, data analyst-blinded web-based trial was conducted at the University of Geneva Faculty of Medicine between April and June 2020. Fifth year medical students followed a distance learning path designed to teach the NIHSS. The control group followed the traditional didactic video created by Patrick Lyden, while the e-learning group followed the updated version of a previously tested, highly interactive e-learning module. The main outcome was the score on a 50-question quiz displayed upon completion of the learning material. The difference in the proportion of correct answers for each specific NIHSS item was also assessed. RESULTS: Out of 158 potential participants, 88 started their allocated learning path and 75 completed the trial. Participants who followed the e-learning module performed better than those who followed the video (38 correct answers, 95% CI 37-39, vs 35 correct answers, 95% CI 34-36, P<.001). Participants in the e-learning group scored better on five elements than the video group: key NIHSS concepts (P=.02), the consciousness - global item (P<.001), the facial palsy item (P=.04), the ataxia item (P=.03), and the sensory item (P=.04). CONCLUSIONS: Compared to the traditional didactic video, a highly interactive e-learning module enhances asynchronous distance learning and NIHSS knowledge acquisition in senior medical students.

Differences in Basic Life Support Knowledge Between Junior Medical Students and Lay People: Web-Based Questionnaire Study.

BACKGROUND: Early cardiopulmonary resuscitation and prompt defibrillation markedly increase the survival rate in the event of out-of-hospital cardiac arrest (OHCA). As future health care professionals, medical students should be trained to efficiently manage an unexpectedly encountered OHCA. OBJECTIVE: Our aim was to assess basic life support (BLS) knowledge in junior medical students at the University of Geneva Faculty of Medicine (UGFM) and to compare it with that of the general population. METHODS: Junior UGFM students and lay people who had registered for BLS classes given by a Red Cross-affiliated center were sent invitation links to complete a web-based questionnaire. The primary outcome was the between-group difference in a 10-question score regarding cardiopulmonary resuscitation knowledge. Secondary outcomes were the differences in the rate of correct answers for each individual question, the level of self-assessed confidence in the ability to perform resuscitation, and a 6-question score, "essential BLS knowledge," which only contains key elements of the chain of survival. Continuous variables were first analyzed using the Student t test, then by multivariable linear regression. Fisher exact test was used for between-groups comparison of binary variables. RESULTS: The mean score was higher in medical students than in lay people for both the 10-question score (mean 5.8, SD 1.7 vs mean 4.2, SD 1.7; P<.001) and 6-question score (mean 3.0, SD 1.1 vs mean 2.0, SD 1.0; P<.001). Participants who were younger or already trained scored consistently better. Although the phone number of the emergency medical dispatch center was well known in both groups (medical students, 75/80, 94% vs lay people, 51/62, 82%; P=.06), most participants were unable to identify the criteria used to recognize OHCA, and almost none were able to correctly reorganize the BLS sequence. Medical students felt more confident than lay people in their ability to perform resuscitation (mean 4.7, SD 2.2 vs mean 3.1, SD 2.1; P<.001). Female gender and older age were associated with lower confidence, while participants who had already attended a BLS course prior to taking the questionnaire felt more confident. CONCLUSIONS: Although junior medical students were more knowledgeable than lay people regarding BLS procedures, the proportion of correct answers was low in both groups, and changes in BLS education policy should be considered.

Association between prehospital arterial hypercapnia and mortality in acute heart failure: a retrospective cohort study.

BACKGROUND: Acute Heart Failure (AHF) is a potentially lethal pathology and is often encountered in the prehospital setting. Although an association between prehospital arterial hypercapnia in AHF patients and admission in high-dependency and intensive care units has been previously described, there is little data to support an association between prehospital arterial hypercapnia and mortality in this population. METHODS: This was a retrospective study based on electronically recorded prehospital medical files. All adult patients with AHF were included. Records lacking arterial blood gas data were excluded. Other exclusion criteria included the presence of a potentially confounding diagnosis, prehospital cardiac arrest, and inter-hospital transfers. Hypercapnia was defined as a PaCO2 higher than 6.0 kPa. The primary outcome was in-hospital mortality, and secondary outcomes were 7-day mortality and emergency room length of stay (ER LOS). Univariable and multivariable logistic regression models were used. RESULTS: We included 225 patients in the analysis. Prehospital hypercapnia was found in 132 (58.7%) patients. In-hospital mortality was higher in patients with hypercapnia (17.4% [23/132] versus 6.5% [6/93], p = 0.016), with a crude odds-ratio of 3.06 (95%CI 1.19-7.85). After adjustment for pre-specified covariates, the adjusted OR was 3.18 (95%CI 1.22-8.26). The overall 7-day mortality was also higher in hypercapnic patients (13.6% versus 5.5%, p = 0.044), and ER LOS was shorter in this population (5.6 h versus 7.1 h, p = 0.018). CONCLUSION: Prehospital hypercapnia is associated with an increase in in-hospital and 7-day mortality in patient with AHF.

Prehospital arterial hypercapnia in acute heart failure is associated with admission to acute care units and emergency room length of stay: a retrospective cohort study.

BACKGROUND: Acute Heart Failure (AHF) is a common condition that often presents with acute respiratory distress and requires urgent medical evaluation and treatment. Arterial hypercapnia is common in AHF and has been associated with a higher rate of intubation and non-invasive ventilation in the Emergency Room (ER), but its prognostic value has never been studied in the prehospital setting. METHODS: A retrospective study was performed on the charts of all patients taken care of by a physician-staffed prehospital mobile unit between June 2016 and September 2019 in Geneva. After approval by the ethics committee, charts were screened to identify all adult patients with a diagnosis of AHF in whom a prehospital arterial blood gas (ABG) sample was drawn. The main predictor was prehospital hypercapnia. The primary outcome was the admission rate in an acute care unit (ACU, composite of intensive care and high-dependency units). Secondary outcomes were ER length of stay (LOS), orientation from ER (intensive care unit, high-dependency unit, general ward, discharge home), intubation rate at 24 h, hospital LOS and hospital mortality. RESULTS: A total of 106 patients with a diagnosis of AHF were analysed. Hypercapnia was found in 61 (58%) patients and vital signs were more severely altered in this group. The overall ACU admission rate was 48%, with a statistically significant difference between hypercapnic and non-hypercapnic patients (59% vs 33%, p = 0.009). ER LOS was shorter in hypercapnic patients (5.4 h vs 8.9 h, p = 0.016). CONCLUSIONS: There is a significant association between prehospital arterial hypercapnia, acute care unit admission, and ER LOS in AHF patients.

Association between Prehospital Hypoxemia and Admission to Intensive Care Unit during the COVID-19 Pandemic: A Retrospective Cohort Study.

Background and Objectives: The aim of this study was to assess the association between prehospital peripheral oxygen saturation (SpO2) and intensive care unit (ICU) admission in confirmed or suspected coronavirus disease 19 (COVID-19) patients. Materials and Methods: We carried out a retrospective cohort study on patients requiring prehospital intervention between 11 March 2020 and 4 May 2020. All adult patients in whom a diagnosis of COVID-19 pneumonia was suspected by the prehospital physician were included. Patients who presented a prehospital confounding respiratory diagnosis and those who were not eligible for ICU admission were excluded. The main exposure was "Low SpO2" defined as a value < 90%. The primary outcome was 48-h ICU admission. Secondary outcomes were 48-h mortality and 30-day mortality. We analyzed the association between low SpO2 and ICU admission or mortality with univariable and multivariable regression models. Results: A total of 145 patients were included. A total of 41 (28.3%) patients had a low prehospital SpO2 and 21 (14.5%) patients were admitted to the ICU during the first 48 h. Low SpO2 was associated with an increase in ICU admission (OR = 3.4, 95% CI = 1.2-10.0), which remained significant after adjusting for sex and age (aOR = 5.2, 95% CI = 1.8-15.4). Mortality was higher in low SpO2 patients at 48 h (OR = 7.1 95% CI 1.3-38.3) and at 30 days (OR = 3.9, 95% CI 1.4-10.7). Conclusions: In our physician-staffed prehospital system, first low prehospital SpO2 values were associated with a higher risk of ICU admission during the COVID-19 pandemic.

Teaching the National Institutes of Health Stroke Scale to Paramedics (E-Learning vs Video): Randomized Controlled Trial.

BACKGROUND: Prompt and accurate identification of stroke victims is essential to reduce time from symptom onset to adequate treatment and to improve neurological outcomes. Most neurologists evaluate the extent of neurological deficit according to the National Institutes of Health Stroke Scale (NIHSS), but the use of this scale by paramedics, the first healthcare providers to usually take care of stroke victims, has proven unreliable. This might be, at least in part, due to the teaching method. The video used to teach NIHSS lacks interactivity, while more engaging electronic learning (e-learning) methods might improve knowledge acquisition. OBJECTIVE: This study was designed to evaluate whether a highly interactive e-learning module could enhance NIHSS knowledge acquisition in paramedics. METHODS: A randomized controlled trial comparing a specially designed e-learning module with the original NIHSS video was performed with paramedics working in Geneva, Switzerland. A registration number was not required as our study does not come into the scope of the Swiss federal law on human research. The protocol was nevertheless submitted to the local ethics committee (Project ID 2017-00847), which issued a "Declaration of no objection." Paramedics were excluded if they had prior knowledge of or previous training in the NIHSS, or if they had worked in a neurology or neurosurgery ward. The primary outcome was overall performance in the study quiz, which contained 50 questions. Secondary outcomes were performance by NIHSS item, time to course and quiz completion, user satisfaction regarding the learning method, user perception of the course duration, and probability the user would recommend the course to a colleague. RESULTS: The study was completed by 39 paramedics. There was a better overall median score (36/50 vs 33/50, P=.04) and a higher degree of satisfaction regarding the learning method in the e-learning group (90% vs 37%, P=.002). Users who had followed the e-learning module were more likely to recommend the course to a colleague (95% vs 63%, P=.02). Paramedics in the e-learning group took more time to complete the course (93 vs 59 minutes, P<.001), but considered the duration to be more adequate (75% vs 32%, P=.01). Time to quiz completion was similar between groups (25 vs 38 minutes, P=.12). CONCLUSIONS: Use of an e-learning module shows promising results in teaching the NIHSS to paramedics.

Effect of an E-Learning Module on Personal Protective Equipment Proficiency Among Prehospital Personnel: Web-Based Randomized Controlled Trial.

BACKGROUND: To avoid misuse of personal protective equipment (PPE), ensure health care workers' safety, and avoid shortages, effective communication of up-to-date infection control guidelines is essential. As prehospital teams are particularly at risk of contamination given their challenging work environment, a specific gamified electronic learning (e-learning) module targeting this audience might provide significant advantages as it requires neither the presence of learners nor the repetitive use of equipment for demonstration. OBJECTIVE: The aim of this study was to evaluate whether a gamified e-learning module could improve the rate of adequate PPE choice by prehospital personnel in the context of the coronavirus disease (COVID-19) pandemic. METHODS: This was an individual-level randomized, controlled, quadruple-blind (investigators, participants, outcome assessors, and data analysts) closed web-based trial. All emergency prehospital personnel working in Geneva, Switzerland, were eligible for inclusion, and were invited to participate by email in April 2020. Participants were informed that the study aim was to assess their knowledge regarding PPE, and that they would be presented with both the guidelines and the e-learning module, though they were unaware that there were two different study paths. All participants first answered a preintervention quiz designed to establish their profile and baseline knowledge. The control group then accessed the guidelines before answering a second set of questions, and were then granted access to the e-learning module. The e-learning group was shown the e-learning module right after the guidelines and before answering the second set of questions. RESULTS: Of the 291 randomized participants, 176 (60.5%) completed the trial. There was no significant difference in baseline knowledge between groups. Though the baseline proportion of adequate PPE choice was high (75%, IQR 50%-75%), participants' description of the donning sequence was in most cases incorrect. After either intervention, adequate choice of PPE increased significantly in both groups (P<.001). Though the median of the difference in the proportion of correct answers was slightly higher in the e-learning group (17%, IQR 8%-33% versus 8%, IQR 8%-33%), the difference was not statistically significant (P=.27). Confidence in the ability to use PPE was maintained in the e-learning group (P=.27) but significantly decreased in the control group (P=.04). CONCLUSIONS: Among prehospital personnel with an already relatively high knowledge of and experience with PPE use, both web-based study paths increased the rate of adequate choice of PPE. There was no major added value of the gamified e-learning module apart from preserving participants' confidence in their ability to correctly use PPE.

[Emergency medicine†: update 2019]. / Médecine d'urgence.

At a time when «â€…Smarter medicine ¼ and «â€…Choosing Wisely ¼ campains become increasingly important, emergency medicine is no exception. Many recent studies lead us to reconsider our practices and to change our work-up and treatement strategies, to ultimately use only the ones with a real clinical benefit for emergency departement patients.

À l'heure où le concept de smarter medicine s'applique de plus en plus à la pratique médicale, la médecine d'urgence ne fait pas exception et de nombreux travaux récents nous amènent à revoir nos pratiques, à changer nos stratégies de prise en charge pour finalement ne retenir que les examens ou traitements ayant un réel bénéfice pour les patients en situation d'urgence.

[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.

[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.