Post-traumatic symptoms in patients with acute coronary syndrome: Maybe an outcome predictor after the ED visit!

OBJECTIVES: We aimed to assess the patients' experience of threat during management of an acute coronary syndrome (ACS) in the Emergency Department (ED) and to analyze the impact of this acute stress on day-30 outcomes. STUDY DESIGN: This is a prospective study. METHODS: We included patients with ACS in the ED. After discharge, the perceived stress (Perceived Stress Scale (PSS); Visual Analogic Scale (VAS) in stress evaluation; Patient Health Questionnaire (PHQ); and Posttraumatic Stress Disorder Checklist Scale (PCLS) were used. RESULTS: 35 patients have developed PTSD on day-30 (31.8%). The independent predictors of developing PTSD at day-30 were high PSS score on admission (OR = 1.4; CI = 1.1-1.8; p = 0.004) and/or elevated PHQ-9 score at day-30 (OR = 1.5; CI = 1.2-1.9; p < 0.001). The recurrence of the chest pain was more frequent in the PTSD group of patients. Patients with PTSD symptoms were more likely to report a non-therapeutic adherence to their cardiovascular medication. CONCLUSION: Stress management in EDs should become a systematic step in the management of patients with ACS. This study emphasizes the importance of multidisciplinary follow-up and early screening of patients at risk of PTSD to improve their outcomes after discharge.

Update on the Epidemiology of Scorpion Envenomation in the South of Tunisia.

INTRODUCTION: Scorpion envenomation is still a frequent occurance in tropical and subtropical regions. In Tunisia, multiple studies on scorpion envenoming have contributed to an improved understanding of cardiac dysfunction and factors predictive of poor prognosis. These previous studies have contributed to the current standardized management of envenomed patients. However, the epidemiology of scorpion envenoming in Tunisia has not been updated for more than 10 years. The aim of this study was to report an update of the epidemiological features of scorpion envenomation in the southern region of Tunisia. METHODS: This is a retrospective monocentric study including all patients admitted in the emergency room for scorpion envenomation. Cases were collected from emergency medical files during a 3-year period (2013-2015). The diagnosis of scorpion envenomation was made by history of a scorpion sting. All files in which scorpion envenomation was not certain were excluded. Data are presented as mean±SD with range or percentages, as appropriate. RESULTS: We enrolled 282 patients aged 27.4±22.8 years with a 1:1 sex ratio. During surveillance in the emergency room, 39 patients developed cardiac dysfunction. Overall, 42 patients (14.9%) were at stage 3 of severity, and 240 patients (85.1%) had moderate scorpion envenomation (stage 2). Only 1 patient died a few hours after admission. In the remaining cases, the outcome was good. Our results show the improvement in mortality rates even in severe presentations. CONCLUSION: This study found that the outcome of scorpion-stung patients has clearly improved. This enhancement can be explained by early medical consultation and standardized management of patients with predictive factors for cardiac dysfunction.

Epidemiological features of stress hyperglycemia in elderly at emergency department.

UNLABELLED: Background : Stress hyperglycemia among patients having an acute pathology is frequently described in recent studies. AIMS: The objectives of this work were to describe epidemiologic features of elderly patients hospitalized in the emergency department and having a hyperglycemia due to stress. METHODS: A retrospective chart review identified patients older than 65 years with obtained serum glucose levels. Patients with diabetes were excluded. Two levels of serum glucose were considered (>6,9 mmol/l and ≤ 6,9 mmol/l).   RESULTS: We included 165.  There were 94 patients with high level of serum glucose level (56,9%). Multivariate analysis found that only cardio-vascular pathologies were more predictive of having stress hyperglycemia (p=0,014, odds-ratio=2,8, IC=1,2-6,4). There were no correlation between serum glucose levels and mortality. CONCLUSION: Stress hyperglycemia is a fairly common disorder but underestimated in emergency department. Its impact on the prognosis of elderly patients remains to be studied.

Does change of catecholamine use improve the outcome of patients with shock admitted to intensive care unit?

Up to 2008, dopamine was the catecholamine that was the most recommended in our intensive care unit (ICU) after fluid resuscitation. However, recently, norepinephrine has become the catecholamine that was most recommended in our ICU after fluid resuscitation. The aim of this study was to determine if there was an efficacy or safety benefit to this protocol therapeutic change in patients with shock admitted to our ICU. The primary outcome variable was ICU mortality. This is a prospective observational study conducted in 2 periods in our ICU (Habib Bourguiba University Hospital, Sfax, Tunisia). During the 2 study periods, 251 patients were included. There were 130 patients in group 1 and 121 patients in group 2. There were no significant differences between the 2 groups with regard to most of the baseline characteristics. The comparison between the 2 groups showed that in the first period, dopamine was the catecholamine that was the most used. However, in the second period, norepinephrine is the catecholamine that was most used. When we analyzed the catecholamine prescription in septic shock, we concluded that in the first study period, dopamine was used as the catecholamine as the first choice in 85.7% of cases (P < 0.001), and norepinephrine is the first choice in 100% of cases in the second period. In cardiogenic shock, in the first study period, dobutamine was used as the catecholamine as the first choice in 61% of cases (P < 0.001) and norepinephrine is the first choice in 43% of cases in the second period. Finally, in hypovolemic shock, dopamine was used as the catecholamine as the first choice in 68% of cases in group 1 and norepinephrine is the first choice in 88% of cases in the second period (P < 0.001). During the ICU stay, some adverse events related to catecholamine use were observed. The occurrence of arrhythmias was significantly more frequent in the first group. Mortality rate was at 51% in the first group and 44% in the second group (P = 0.27). The mortality rate was not significantly different for each type of shock (septic, cardiogenic, and hypovolemic) in both groups (P > 0.05 for all), although the occurrence of arrhythmias was significantly more frequent in the first group, in clinical practice, our study confirms that the rate of death did not differ significantly between the 2 groups of patients mostly treated with dopamine (group 1) and the group mostly treated with norepinephrine.

Reliability of the rapid antigen test for diagnosis of SARS-CoV-2 in Tunisia.

Background: Early and accurate diagnosis is crucial for preventing the spread of SARS-CoV-2 infection. The rapid antigen test was developed for testing infection, and it was necessary to assess its performance before widespread use in Tunisia. Aim: To evaluate the effectiveness of a rapid antigen test for the detection of SARS-CoV-2 in nasopharyngeal swabs in Tunisia. Methods: Nasopharyngeal samples were taken from COVID-19 suspected cases between October and December 2020 and tested using the Standard Q COVID-19 Ag test (SD-Biosensor, Republic of Korea) and real-time reverse transcription polymerase chain reaction (RT­PCR). Results: Overall, 4539 patients were tested. Of the total study population (N = 4539), 82.5% of positive samples remained positive with the rapid antigen test, while 20.2% (470/2321) of samples that were negative with rapid antigen test were confirmed positive with RT-PCR, giving a negative predictive value of 79.8% for the rapid antigen test. The sensitivity and negative predictive value of the rapid antigen test were 70.2% and 65.8%, respectively. These results improved to 96.4% and 92.8%, respectively, when considering the cycle threshold value by RT-PCR below 25. Conclusion: Although the rapid antigen test was less sensitive than RT-PCR, its ability to rapidly detect individuals with high viral loads makes it suitable for use during an epidemic.

Catheterized chicken for training on ultrasound-guided vascular access: A simple, cost-effective, and effective model.

Ultrasound-guided vascular access is a medical procedure that is becoming increasingly common in daily practice and is recommended to avoid iatrogenic complications. One of the procedures with a high-risk rate of complications is the vascular puncture. However, training on this technique can be challenging due to the limited availability of simulation models. We propose a simple, cost-effective, and effective ultrasound-guided vascular access simulation model that utilizes chicken breast and a urine catheter to address this need.

Prediction value of the Canadian CT head rule and the New Orleans criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma: a multicenter external validation study.

STUDY OBJECTIVE: The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention after mild head injury. METHODS: This was an observational cohort study performed between 2008 and 2011 on patients with mild head injury who were aged 10 years or older. We collected prospectively clinical head CT scan findings and outcome. Primary outcome was need for neurosurgical intervention, defined as either death or craniotomy, or the need of intubation within 15 days of the traumatic event. Secondary outcome was the presence of traumatic lesions on head CT scan. New Orleans Criteria and Canadian CT Head Rule decision rules were compared by using sensitivity specifications and positive and negative predictive value. RESULTS: We enrolled 1,582 patients. Neurosurgical intervention was performed in 34 patients (2.1%) and positive CT findings were demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%) and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative predictive values for the above-mentioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively, for the Canadian CT Head Rule and New Orleans Criteria. Sensitivity and specificity for clinical significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62% to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95% CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was found in the subgroup of patients with a Glasgow Coma Scale score of 15. CONCLUSION: For patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value. The question of whether the use of the Canadian CT Head Rule would have a greater influence on head CT scan reduction requires confirmation in real clinical practice.

Man-O-War simulator: a Low-cost manikin for training on chest tube management.

Simulation-based medical education is becoming a cornerstone in health education. Simulators are commonly expensive and not available in developing countries. We propose a very low-cost simulator that any educator can realize. We describe here the steps to follow to develop this proposed simulator.

[Use of catecholamines for shock. A continuous debate!]. / L'utilisation des Catecholamines dans les etats de choc. Le debat continue!

BACKGROUND: Hypotension and shocks are frequently observed in patients requiring admission in ICU. However, the optimal adrenergic support in shock is controversial. AIM: To perform a descriptive approach of the current use of catecholamine in a medico-surgical ICU in patients with schoks. METHODS: Our study is prospective over 3 month period. Were included all patients admitted in our ICU during the study period's. We compared the populations with and without catecholamine, we analysed the catecholamine selected in various clinical settings and we studied the impact of the use of catecholamine on the patient outcomes. RESULTS: During the study's period, 226 patients were hospitalized in our service and were the subject of this study. The median age (± SD) was of 47± 24 years. During their hospitalization in the ICU, 132 patients (58.4%) presented a shock. The cardiogenic shock and the hypovolemic shock were the most observed (37.8% and 35.6% respectively). Hundred thirty patients (57.5%) received catecholamines during their stay in ICU. Eighty four patients (64.6% of the patients having received catecholamines) had received dopamine. Sixty two patients (47.7% of the patients having received catecholamines) had received dobutamine, 63 patients (48.5%) had received epinephrine and 22 patients (16.9%) had received norepinephrine. The mean's period of catecholamines use was 5 ± 4 days. Among drugs proposed in order to manage patients with cardiogenic shock, dobutamine was chosen as the first choice agent in 62% of the cases. Among drugs proposed in order to manage patients with septic shock, Dopamine was chosen as the first choice agent in 85.7 % of the cases. In our study the patients of the class C or D in the Knauss classification are significantly predisposed to receive catecholamines during their ICU stay (OR: 5.3 ; IC 95% : 1.7 - 5.7).Moreover, the needing of catecholamine use is strongly associated with high mortality (OR: 16,8; IC 95% : 16.4 - 49.2). CONCLUSION: The choice of catecholamines is a matter of debate for critically ill patients. The use of catecholamines is a clinical marker of severity and provider of mortality.

Evidence of SARS-CoV-2 symptomatic reinfection in four healthcare professionals from the same hospital despite the presence of antibodies.

OBJECTIVES: Since the onset of the COVID-19 pandemic, cases of reinfection with SARS-CoV-2 have been reported, raising additional public health concerns. SARS-CoV-2 reinfection was assessed in healthcare workers (HCWs) in Tunisia because they are at the greatest exposure to infection by different variants. METHODS: We conducted whole-genome sequencing of the viral RNA from clinical specimens collected during the initial infection and the suspected reinfection from 4 HCWs, who were working at the Habib Bourguiba University Hospital (Sfax, Tunisia) and retested positive for SARS-CoV-2 through reverse transcriptase-polymerase chain reaction (RT-PCR) after recovery from a first infection. A total of 8 viral RNAs from the patients' respiratory specimens were obtained, which allowed us to characterize the differences between viral genomes from initial infection and positive retest. The serology status for total Ig, IgG, and IgM against SARS-CoV-2 was also determined and followed after the first infection. RESULTS: We confirmed through whole-genome sequencing of the viral samples that all 4 cases experienced a reinfection event. The interval between the 2 infection events ranged between 45 and 141 days, and symptoms were milder in the second infection for 2 patients and more severe for the remaining 2 patients. Reinfection occurred in all 4 patients despite the presence of antibodies in 3 of them. CONCLUSION: This study adds to the rapidly growing evidence of COVID-19 reinfection, where viral sequences were used to confirm infection by distinct isolates of SARS-CoV-2 in HCWs. These findings suggest that individuals who are exposed to different SARS-CoV-2 variants might not acquire sufficiently protective immunity through natural infection and emphasize the necessity of their vaccination and the regular follow-up of their immune status both in quantitative and qualitative terms.

Clinical characteristics and outcomes of critically ill COVID-19 patients in Sfax, Tunisia.

BACKGROUND: Africa, like the rest of the world, has been impacted by the coronavirus disease 2019 (COVID-19) pandemic. However, only a few studies covering this subject in Africa have been published. METHODS: We conducted a retrospective study of critically ill adult COVID-19 patients-all of whom had a confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection- admitted to the intensive care unit (ICU) of Habib Bourguiba University Hospital (Sfax, Tunisia). RESULTS: A total of 96 patients were admitted into our ICU for respiratory distress due to COVID-19 infection. Mean age was 62.4±12.8 years and median age was 64 years. Mean arterial oxygen tension (PaO2)/fractional inspired oxygen (FiO2) ratio was 105±60 and ≤300 in all cases but one. Oxygen support was required for all patients (100%) and invasive mechanical ventilation for 38 (40%). Prone positioning was applied in 67 patients (70%). Within the study period, 47 of the 96 patients died (49%). Multivariate analysis showed that the factors associated with poor outcome were the development of acute renal failure (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.75-25.9), the use of mechanical ventilation (OR, 5.8; 95% CI, 1.54-22.0), and serum cholinesterase (SChE) activity lower than 5,000 UI/L (OR, 5.0; 95% CI, 1.34-19). CONCLUSIONS: In this retrospective cohort study of critically ill patients admitted to the ICU in Sfax, Tunisia, for acute respiratory failure following COVID-19 infection, the mortality rate was high. The development of acute renal failure, the use of mechanical ventilation, and SChE activity lower than 5,000 UI/L were associated with a poor outcome.

Stroke knowledge among emergency centre visitors: A cross-sectional multicenter survey.

INTRODUCTION: Stroke is a public health problem worldwide. Community stroke knowledge is crucial to guide the prevention approach. We aimed to evaluate the level of stroke knowledge among the visitors to Emergency Centres (ECs) in the southern region of Tunisia concerning factors of risk, symptoms, and treatment of stroke. METHODS: A multicenter cross-sectional survey about stroke knowledge; conducted in five ECs for 10 days. All the visitors to these ECs were invited to participate in this survey. In each center, one investigator had to conduct the questionnaire. We used the stroke knowledge test (SKT). RESULTS: We enrolled 839 participants aged at 44 ± 7 years and with an M/F sex-ratio at 0.9. Relatives and mass media were the most reported sources of information about stroke. In 32.3% of cases, the participants had a university schooling level. The upper quartile had an SKT score of 55% or over (n = 247; 29.4%). The SKT score was significantly higher in young, female participants, in rural centers, with a university level of schooling and with no reported chronic diseases. Receiving information about stroke through the medium of television or via relatives was an independent predictor of a high SKT score compared with other knowledge sources. CONCLUSION: This study emphasises the urgent need for improving the population's knowledge about stroke in Tunisia. These findings may reflect the lack of government policies for education and training on stroke. A national educating program is necessary to implement to increase stroke knowledge.

Risk factors and outcomes of intensive care unit-acquired infections in a Tunisian ICU.

BACKGROUND: ICU-acquired infections constitute an important world-wide health problem. Our aim was to determine the incidence, predictive factors and impact of ICU-AIs in ICU patients in Tunisia. MATERIAL/METHODS: We conducted a prospective observational cohort study over a 3 month period in the medical surgical intensive care unit of Habib Bourguiba University Hospital (Sfax-Tunisia). RESULTS: During the study period 261 patients were surveyed; 44 of them (16.9%) developed 55 episodes of ICU-AI (34.7 ICU-AI/1000 days of hospitalization). The most frequently identified infections were ventilator-associated pneumoniae (58.2%), and primary bloodstream infection (18.2%). The most frequently isolated organisms were multidrug-resistant P. aeruginosa (44.7%), and A. baumannii (21.3%). The initial antibiotic prescription for ICU-AI was inadequate in 9 cases (16.4% of episodes of ICU-AI). At ICU discharge, overall mortality was 29.9%. Independent risk factors for acquiring infection in ICU were the use of central venous catheter (p=0.014) and antibiotic prescription on admission for more than 24 hours (p=0.025), those of mortality in ICU were SAPS II of more than 35 points (p<0.001) and ICU-AI (p=0.002), and those of mortality at 28 days after an episode of ICU-AI were septic shock (p=0.004) and inadequate initial antimicrobial treatment (p=0.011). CONCLUSIONS: We conclude that the occurrence of ICU-AI is significantly related to increased mortality, and that focusing interventions on better use of antibiotics would have a benefit in terms of prevention and consequences of ICU-AI.

Microbiological characteristics of catheter-related bacteremia in a Tunisian intensive care unit.

BACKGROUND: Prevalence of catheter-related bacteremia in intensive care units is increasing as central venous catheters (CVC) are used more frequently. In the most of the published literature, Gram positive cocci are the leading cause of catheter-related bacteremia and the systemic empiric treatment recommended include the administration of glycopeptides. AIM: To search for the microbiological characteristics of catheter-related bacteremia in a Tunisian ICU. METHODS: Prospective observational cohort survey conducted in the ICU of the Habib Bourguiba university hospital, Tunisia (a 22 bed medical-surgical intensive care unit). We had included all patients admitted to the unit over the study period (from August 1st, 2001 to March 31st, 2002), and who submitted to a central venous catheter for more than 24 hours. Catheter-tip specimens were cultured using a semiquantitative method. RESULTS: During the study period 218 central venous catheters (CVC) were assessed. The mean length of time the catheter was kept in place was 8±6.7 days (range; 2 and 46 days). The CVC insertion site was the subclavian vein in 156 cases (71.6%), the jugular vein in 35 cases (16%), and the femoral vein in 27 cases (12.4%). Seventy four catheters (33.9%) were removed because of suspicion of catheter-related sepsis. The catheter-related bacteremia rate was 6.1 infections/1000 days-CVC. Unlike Gram-positive cocci which caused only one case of catheter-related bacteremia, Gram-negative rods, namely Klebsiella pneumoniae and Serratia marcescens were responsible for 91.7% of cases of catheter-related bacteremia. CONCLUSION: Our findings translate a specific microbiological flora in our Tunisian intensive care unit and highlight the importance of a treatment strategy based on local epidemiology in patients with catheter related bacteremia.

Ricin poisoning after oral ingestion of castor beans: A case report and literature review.

INTRODUCTION: >1000 ricin poisoning cases secondary to intentional castor bean consumption have been reported in the literature since the late 1800s. The lethality of ricin poisoning after oral ingestion is determined by a few factors. CASE REPORT: We present a case that highlights the erratic absorption of ricin after accidental oral ingestion. On admission, the physical examination found a somnolent patient, with miosis, and a generalized abdominal tenderness. Her blood tests showed metabolic acidosis. Thanks to her early management, the discharge was possible three days later. DISCUSSION: The toxicity of ricin is dependent on the dose delivered and the route of the exposure. Supportive care is the mainstay of treatment. As shown in our case, early management is crucial for a good outcome.

Frailty screening of Tunisian older adults: feasibility and usefulness in the Emergency Department.

INTRODUCTION: Frail older adults are at an increased risk for adverse outcomes after an Emergency Department (ED) visit. Several tools exist for the screening of frailty among these patients. However, no tool has been validated in Tunisia. This study aims to evaluate the usefulness of frailty screening in predicting the outcome of older adults presenting to the ED. METHODS: This is a prospective, monocentric study. We evaluated the eligible patients at the ED and after their discharge. Follow-up phone calls were scheduled at 1, 2, 3, and 6 months after the ED visit. All patients aged 65 years or older; and visiting the ED during the inclusion period were involved. We used the ADL index and ISAR scale for assessing frailty. RESULTS: We enrolled 184 patients; they were living alone in 25% of cases. Half of them had medical care insurance. The ADL index was maximum (6 = total dependency) in 20% of cases. The ISAR score was above 1 point in 38%. Unplanned hospitalizations have accounted for 34%. In univariate analysis, the ADL index and ISAR score were statistically higher in the group of "unplanned hospitalization". In multivariate analysis, the ISAR score and ADL index have not been associated with unplanned hospitalization. CONCLUSION: Our results did not demonstrate the relevance of the ISAR or ADL scales in predicting the mortality or the need for unplanned hospitalization in multivariate analysis. This study did indicate an increased mortality in the "frail" patients in the univariate analysis. Further studies with larger samples and different tools are necessary.

[Prognostic factors for mortality due to acute arterial stroke in a North African population]. / Facteurs pronostiques de mortalité par accident vasculaire cérébral artériel à la phase aiguë dans une population nord-africaine.

INTRODUCTION: cerebrovascular accident (stroke) constitutes a major public health problem due to the number of people affected and to its medical social and economic consequences. This study aims to identify poor vital prognostic factors for survival in patients with acute arterial stroke. METHODS: we conducted a prospective study of patients with symptoms suggestive of stroke at the two University Hospitals of Sfax, Tunisia over a period of 4 months. Patients were followed-up for a period of 1 month. RESULTS: we collected data from 200 patients. After one month of follow-up, mortality was 19.9%. Poor prognostic factors were: male sex, consumption of tobacco, a history of stroke, low Glasgow score, high NIHSS, headaches, acute symptomatic epileptic seizures, Babinski's sign, mydriasis, aphasia, combined deviation of the head and the eyes, high PAS, PAD and PAM, hyperthermia, hyperglycaemia, leukocytosis, high concentration of CRP, creatinine, urea and troponin T, haemorrhagic stroke, perilesional oedema, a mass effect, commitment, total middle cerebral artery topography of ischemia, early signs of ischemia, meningeal hemorrhage, ventricular flood, hydrocephalus, the recourse to respiratory support, to anti-edematous treatment and to antihypertensive therapy, hemorrhagic transformation, vascular epilepsy, infectious, metabolic complications, complications of bed sores. CONCLUSION: the identification of the predictive factors for survival allows for optimisation of therapeutic procedures and better implementation of patient' management. A comparative study will be considered to measure the impact of the corrective measures.

[Traumatic head injury in children in south Tunisia epidemiology, clinical manifestations and evolution. 454 cases]. / Traumatismes crâniens chez l'enfant dans le sud Tunisien profil epidémiologique, manifestations cliniques et evolution. A propos de 454 cas.

AIM: To determine epidemiological, causes, clinical and Para clinical manifestations and outcome in children with traumatic head injury in south Tunisia. METHODS: A retrospective study over a 8 year period (1997-2004) of 454 children's with head injury admitted to the Intensive Care Unit (ICU) of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. RESULTS: Mean age (+/- SD) was of 7.2 +/-3.8 years. The main cause of trauma was traffic accidents (69.4%). There were a predominance of male patient's with a sex-ratio of 2.21. The Score of coma of Glasgow adapted to the child, was on average from 8 +/- 3 points. Extra-cranial pathology was present were observed in 38.9%. The cerebral CT-Scan performed on admission for all patients was pathological in 86.3% of the cases. The most observed lesions were meningeal Haemorrhage (35.2%) and the cerebral contusion (34.5%). According to the "Traumatic Coma Dated Bank classification" we noted a high proportion of type 2 group (46%). Secondary systemic insults were observed in 377 children (83%). Evolution was marked by the death of 82 children (18%). Among survivors, a good recovery was observed in 229 children (50.4%). CONCLUSION: In Tunisia, head injury is a frequent cause of hospitalization. It is essentially involved in traffic accidents. The short term prognosis is poor with a high (18%) mortality. Prevention is highly advised.

Benefits of the tranexamic acid in head trauma with no extracranial bleeding: a prospective follow-up of 180 patients.

INTRODUCTION: Tranexamic acid (TXA) is one of the debated therapies in the management of traumatic brain injury (TBI). We conducted this study to evaluate the benefits of TXA in TBI on the mortality and its safety in these patients. METHODS: This was a prospective randomized open-label trial including all patients, aged at 18 years or older, hospitalized in the emergency room during a 13-month period, for TBI. After the realization of the body CT scan, the patients were included if they had intracranial bleeding, and were then randomized according to their medical file number to receive or not the TXA. The eligibility criteria were based on the uncertainty principle, patients with significant extracranial bleeding were excluded since there was evidence that TXA improve their outcome. RESULTS: We enrolled 180 patients aged at 42 ± 20 years, with an 88% men-proportion. Subarachnoid haemorrhage was the most frequent lesion in the brain CT-scan (67.5%). After randomization, 96 patients were in the TXA group (53%). Demographic data, clinical, biological and radiological features were statistically comparable in the two groups of patients ('TXA' and 'noTXA'). The needs of transfusion or neurosurgery, the mortality rate, the in-hospital length of stay and the dependency at 28-post-traumatic day were similar in the two groups of patients. However, pulmonary embolism was statistically more frequent in 'TXA' group (11.5 versus 2.4%, p = 0.02). CONCLUSION: TXA is an interesting treatment in haemorrhagic shock. Its efficiency in head trauma is still debated and controversial. Its impact on the mortality and the needs of transfusion or surgery were not demonstrated in this study. Nevertheless, its safety worth to be studied in larger samples as we found a higher rate of pulmonary embolism in the treated group.

Epidemiological, clinical characteristics and outcome of severe scorpion envenomation in South Tunisia: multivariate analysis of 951 cases.

The aim of this retrospective descriptive study was to describe both epidemiologically and clinically manifestations following severe scorpion envenomation and to define simple predictive factors which can be used in routine practice in general Intensive Care Units (ICU) as an indicator of poor prognosis. Cases were collected from hospital patients' files during 13-year (1990-2002) period in the medical Intensive Care Unit of a university hospital (Sfax - Tunisia). The diagnosis of scorpion envenomation was based on a history of scorpion sting. Nine hundred fifty-one patients, who were admitted for a scorpion sting, were analyzed. There were 769 patients (80.8%) in the grade III group (with cardiogenic shock and/or pulmonary edema or severe neurological manifestation (coma and/or convulsion)) and 182 patients (19.2%) in the grade II group (with systemic manifestations). Scorpion envenomation is more frequent in summer; indeed 82.3% of our patients were admitted between June and September. The mean age (+/-SD) was 14.7 +/- 17.4 years, ranging from 0.5 to 90 years. In this study 739 patients (77.8%) had neuromuscular signs, 700 patients (73.6%) had gastrointestinal signs and 585 patients (61.5%) had a pulmonary edema, while 195 patients (20.5%) had a cardiogenic shock. The mean blood sugar on admission was at 11.32 +/- 5.66 mmol/l, a high blood sugar level (>11 mmol/l) was observed in 39% of cases. The mean blood urea was at 7.1 +/- 3.2 mmol/l, it was above 10 mmol/l in 10.7% of cases. The mean of leucocytes was at 17 418 +/- 7833 cells/mm(3), it was above 11 000/mm(3) in 80% of cases. In the end of the stay in ICU, evolution was marked by the improvement of 879 patients (92.5%) while 72 patients (7.5%) died. A multivariate analysis found the following factors to be correlated with a poor outcome: age less than 5 years (OR = 2.27), fever >38.5 degrees C (OR = 2.79), coma with Glasgow coma score < or =8/15 (OR = 9.87), pulmonary edema (OR = 8.46), leucocytes >25 000 cells/mm3 (OR = 2.35) and blood urea >8 mmol/l (OR = 4.02). Moreover, in children group, a significant association was found between PRISM score and mortality rate, this model had a high discriminative power with an area under the ROC curve at 0.93. In the adult patients a significant association was found between SAPS II score and mortality rate, this model had a high discriminative power with an area under the ROC curve at 0.82. In summary, in severe scorpion envenomation, age less than 5 years, fever >38.5 degrees C, coma with Glasgow coma score < or =8/15, pulmonary edema, leucocytes >25 000 cells/mm3 and blood urea >8 mmol/l were associated with a poor outcome.