Predictors of acute coronary syndrome in pre hospital patients with chest pain.

BACKGROUND: Non-traumatic chest pain is a common cause in pre hospital emergency medicine. The objective of our study was to identify predictive factors of STEMI in patients with acute chest pain, on telephone interview. METHODS: We conducted a prospective observational study over a period of one year (december 2017 to november 2018) in the Emergency Care System of the North Est (SAMU 01) of Tunisia. We included all adults patients aged more than 18 years old, calling the emergency dispatch center for acute non traumatic chest pain (CP). The demographic and clinical data were collected and studied to identify the predictive factors for STEMI. RESULTS: We included 368 patients. The average age was 56 ± 15 years, the sex ratio was 2.7. Smoking was the most common cardiovascular risk factor (41%) followed by hypertension (31%) and coronary artery disease (20%). Half of calls were made by doctors and 43% of them were made within the first two hours of onset of the CP. Clinical examination showed cardio respiratory arrest in 10 patients, 6 of them were related to STEMI. On the arrival of our emergency mobile teams, an elevation of ST segment was identified in 118 patients (32%) of which 37% were admitted directly into the catheterization room. In multivariate analysis, the independent predictive factors of STEMI were: diabetes (OR = 5.25; CI [1.61 - 17.06]), smoking (OR = 2.78, CI [1.03 - 7.5]), typical CP (OR = 4.68, CI [1.09 - 21.67]), CP persistence of more than 30 min (OR = 63.31, CI [13.51 - 29.49]). CONCLUSION: History of diabetes, smoking, typical and persistent CP were the main factors associated with STEMI in patients calling the emergency dispatch center for an acute CP. The early identification of these factors by the emergency physician will improve the management of acute CP since the medical regulation.

Simulation training for continuing professional development of nurses in cardiology and cardiovascular surgery.

BACKGROUND:   Nurses play a key role in cardiac arrest management, especially those assigned to cardiac intensive care units, where they are often actively involved in cardiopulmonary resuscitation. AIM: To evaluate the effect of simulation training in in continuing professional development of nurses in this setting. METHODS: A comparative study using paired samples (where the candidate was his own control with repeated measures before and after intervention), was conducted among nurses working in the cardiology and cardiovascular surgery division of our institution. The primary endpoint was the change in skills judged on the basis of competency score of 20 assessed before and after simulation training. RESULTS: 32 nurses participated in the training session. Despite a median job seniority of 8.5 years [4.0 - 12.5], only 44% of nurses had already participated in a simulation session. Although most of the candidates (84%) had previously performed chest compressions, only 34% had delivered an electrical defibrillation during their exercise. We showed a significant increase in overall scores from 8.0 [5.0 - 9.8] to 17.5 [17.0 - 19.0] after the simulation training session (p<0.0001). All the criteria judged in the evaluation grid (basic life support, manual electrical defibrillation) were significantly improved and the most positive effect was observed in the manual defibrillation where the prior experience of the participants was limited. CONCLUSIONS: Simulation learning had a major positive impact on the development of nurses' skills in terms of cardiopulmonary resuscitation.

Out of hospital cardiac arrest: when to resuscitate.

INTRODUCTION: This study explores why resuscitation is withheld when mobile emergency medical team arrive at the scene of a cardiac arrest. METHODS: We conducted a prospective, observational study in pre hospital emergency services. We included adults' patients, with a suspicion of non-traumatic cardiac arrest (CA) in an out of hospital environment, who received or not cardiopulmonary resuscitation (CPR) by our mobile emergency medical service teams. An analytic study was conducted in order to identify independent factors that could influence the decision to resuscitate OHCA. RESULTS: During study, 228 patients were enrolled, the mean age was 64 +/- 14 years and 59% were men. Eighteen patients (8%) received bystander CPR by witnesses. The median time elapsed to arrive at the scene was 13 [8-25] min. The median "noflow" was 22 [10-34] min. The resuscitation decision was taken by the mobile EMS staff for 106 patients (46.5%). For other patients, the decision not to resuscitate was motivated solely by the finding of a confirmed state of death in an elderly patient (p = 0.045). The predictive decision factor for resuscitation was the no flow time less than 18.5 min, Odds Ratio adjusted with 95% confidence interval to: 1.38 (1.24 - 3.55) (p <0.001). Overall out of hospital survival rate was 17% of resuscitated patients. CONCLUSION: The decision to resuscitate a cardiac arrest outside of the hospital depends more on the "no flow" time than on the presumed etiologies.

Pulmonary embolism mimicking acute myocardial infarction: a case report and review of literature.

The diagnosis of pulmonary thromboembolism (PTE) with changes shown by electrocardiography (ECG) is a challenge in the clinical practice due to rare pathognomonic findings. We report the case of a 37-year old woman managed in out of hospital sitting for a chest pain. Electrocardiogram was suggestive of antero-septal acute myocardial infarction (AMI). Catheterization revealed non occlusive coronary disease. Transthoracic echocardiography showed an elevated pulmonary and right heart pressures. Computed tomography pulmonary angiography confirmed the diagnosis of bilateral pulmonary embolism. PTE with ECG changes should be considered in the differential diagnosis of AMI, particularly in young patients with chest pain and ST segment elevation suggestive of acute coronary syndrome.

Observatory of elderly people cared in pre-hospital.

INTRODUCTION: Emergency medical services (EMS) supports an increasing number of elderly patients. AIM: To evaluate outcome and autonomy of patients aged 65 and older who  managed in the prehospital theater. METHODS: We conducted a prospective observational multicenter study over one year (October 2015 -September 2016). We included patients aged 65 or older managed in the pre hospital setting. We studied: demographic criteria, pre-hospital care, severity (IGSA score and GCS), baseline and 3-month autonomy was assessed using the Katz score. Multivariate analysis was performed to identify predictive factors of mortality at 24 hours. RESULTS: we included 385 patients. Average age was 81 ± 8 years and sex ratio was equal to 1.08. Thirty eight (10%) patients were in cardiac arrest at the arrival of EMS team and 50% of them were resuscitated without recuperation. The IGSA score was 7 [5-10] on the initial examination versus 6  [4-7] on the arrival at the hospital (p<0.01). Baseline autonomy was 2 [0-6] versus 3 [0-6] at 3 months with p = 0.02. Ninety four patients (33%) regained their  baseline autonomy after the acute episode. At 24 hours the mortality rate was 9% (n=32). In multivariate analysis, the independent predictor factor of  mortality was GCS <8 with an adjusted OR=9,22 ;95%CI[3,44-24,70] ; p<0.001. CONCLUSION: Except out of hospital cardiac arrest, the survival of elderly subjects managed by EMS teams was encouraging. In the medium term, one-third of them regained their autonomy after the acute episode. These elements suggest successful integration into the emergency system.

[Emergencies and humanitarian aid in cases of armed conflict]. / Urgences et aide humanitaire en cas de conflit armé.

The Libyan revolution which began in February 2011 caused a massive influx of refugees of different nationalities into Tunisia. A refugee camp was gradually set up by the Tunisian authorities in collaboration with civil society and international humanitarian organisations. The refugees' health care and emergency treatment became a necessity.

[Cardio respiratory arrest out of the hospital at the eldest]. / Arrêt cardiorespiratoire du sujet âgé en pré hospitalier.

BACKGROUND: The management of the older constituted a problematic that will be more attractive in the future because of the population's advanced age. AIM: To evaluate the management of the older more than 75 years that presented an arrest chest. METHODS: Retrospective study during 12 months (from the first January 2004 to 31 December 2004) and interested 15 regulation's documents; we studied demographic parameters, the cause and the time of called the evolution after cardio-respiratory resuscitation. RESULTS: We had 9276 called cases: 320 concerned patients more than 75 years (3, 45%) among 15 (4, 68%) had a chest arrest, the ratio sex was 0, 5 and the middle age: 78, 4 years. In the most cases; the called arrived by night (40%). The principal symptomatology was respiratory troubles (33, 33%); the outcome was fatal in all cases. CONCLUSION: The older over than 75 years had many pathologies that is why the prognostic of the chest arrest was very bad (mortality 100%), the gravity of the chest arrest was seen on this study so we must take seriously all the pathology presented by the older, multiplied the medical consultations to detect the complications earlier and to improve the life's quality.

[Anaesthetic security: evolution of ideas]. / La sécurité anesthésique: evolution des concepts.

BACKGROUND: The concept of risk has not clear neither in the media nor in the medical field. It appears important to us to bring details relating some definitions in the field of anaesthesia safety. AIM: This work aims to clarify the concepts of safety, of risk in a medical activity like the Anaesthesia. METHODS: A search was carried out on Medline with the following key words: Risk anaesthetic, anaesthetic Safety, anaesthetic mortality. RESULTS: The definitions of risk, of acceptable risk taking account of social and economic considerations are brought in this text. The ways to evaluate safety and the methods to achieve it was developed. DISCUSSION: The indicator of quality more used to evaluate safety is anaesthetic mortality. Many difficulties exist with the interpretation of data on mortality. The standards of care are normally established according to the degree of necessary safety. Concurrently to these standards exist certainly the human error which is a phenomenon towards which must direct all the efforts of improvement of safety but more especially the errors of system which are found regularly in the analysis of accidents and incident. CONCLUSION: The identification of the failures is the mandatory step to achieve safety.

[Predictive factors of morbidity and mortality after surgery in the elderly]. / Facteurs prédictifs de morbidité et de mortalité de la chirurgie du vieillard.

UNLABELLED: The aim of the study was to determine prognostic factors of post operative morbidity and mortality for patients aged 80 years and older. We compared two groups of patients aged 80 and over operated to determine predictive factors of morbidity and mortality: group of patients who presented post operative complication within 30 days after surgery and group of patients without any complication. Comparison of the two groups for global morbidity using univariate analysis showed only one prognostic factor: surgery of diabetic foot (p = 0.034). Predictive factors of mortality according to univariate analysis were: pre-operative shock (p = 0.001), abdominal wall pathology (p = 0.027), gastric or duodenal ulcer diseases (p = 0.011) and global morbidity (p = 0.006). After logistic regression, only pre-operative shock was an independent predictive factor of mortality (p = 0.0023). CONCLUSION: Risk for morbidity after surgery in the elderly 80 years and over is linked with type of surgery and not with soil. Likewise, risk for mortality is linked with advanced stage of disease that is presence of pre-operative shock and not with soil.

Neuroendocrine tumours of the digestive tract report of two cases and literature review.

Neuroendocrine tumors (NET) of the digestive system are rare. They comprise only 1% of all the tumors of the gastrointestinal tract. The aim of this study is to report two cases of exceptional localization of non secretary neuroendocrine tumors. Their difficulty in diagnosis, treatment and controversy in chemotherapy merit their study in depth. These are two patients that were treated in the department of general surgery (Beau Séjour) in Charles Nicolle Hospital for non secretary (NET) of the pancreas and stomach. The first was presented as a painless epigastria mass with frequent diarrhea. The second was presented as a painful mass in the left hypochondriac area without any other symptoms. Biochemical evaluation confirmed their non secretary properties. Surgery remains the first line of treatment. It was possible for the gastric, but not for the pancreatic tumor. Both were very advanced and had metastasis. Histopathological evaluation and immunohistochemical study using the method of peroxydase antiperoxydase (PAP) complexes for some special monoclonal antibodies confirmed the diagnosis. Chemotherapy of both cases was mal tolerated and was discussed in details.

[Prognostic study of liver abscess]. / Etude pronostique des abcès du foie.

The objective of this work is to study factors of prognostic of mortality of abscesses of the liver. We have treated between 1990 and 2000 in our service, 38 patient for abscess of the liver. The symptoms are dominated by the pain of the right hypochondria (37 cases) and the fever (34 cases). An unique abscess has been recovered in 25 cases. Some multiple localizations have been observed in 12 cases. 21 patients have been operated. The bacteriological study at all patients revealed the presence of germ in 27 cases. In 6 cases, there were two germs. It was a bacillus negative gram in 26 cases and a cocci positive gram in 7 cases. Six complications have been observed at the operated patients. In 5 cases, it was a septic shock having leads to the death. After survey univariate and multivariate the only factor of bad prognostic recovered is the septic shock. The aetiology was identified in only 9 cases; it was abscess cholangiotis.

[Abdomino-pelvic actinomycosis: a case report]. / Actinomycose abdomino-pelvienne: à propos d'un cas.

The actinomycosis is a chronic suppurative granulomatosis disease. It is owed to a bacillus gram positive; actinomycès israelli. The cervical and thoracic localizations are most frequent. The digestive localization represents 20% of cases. It interest very rarely the pelvis and the genital tracts. We bring back the observation of a patient old of 30 years admitted for mass abdominal. To the exam, the patient had a sensibility of the left hypochondriac area and we found a mass of 6 cm of diameter. To the rectal touch, we found a mass in the bag of Douglas. The echography and the computed tomography revealed a collection under the spleen and a pelvic collection. A rectotomy is performed. The bacteriological study isolates actinomycès israelli. The collection under the spleen is drained under radiological control. Actinomycès israelli is also recovered in the pus brought back by the puncture. The patient is treated by Penicillin. The patient had a favourable evolution. No etiology is found at this patient. For this observation, the collection was accessible to a drainage permitting the diagnosis and the treatment of the actinomycosis while avoiding a mutilated surgery.

[Prognostic factors for splenectomy for hematologic diseases]. / Facteurs pronostiques des splenectomies pour rate hematologique.

The aim of this study was to identify the prognostic factors of intraoperative haemorrhage, perioperative blood transfusions and morbidity. We collected 120 splenectomies in Beau Séjour department of surgery, Charles' Nicolle Hospital, Tunis, Tunisia between 1979 and 1999. The descriptive analysis showed sex-ratio 0.82 with mean age (+/- standard deviation) 30.6 +/- 15 year. Idiopathic thrombopenic purpura was the principal disease indicating splenectomy. Morbidity was defined as occurrence of post operative peritoneal sepsis or bleeding. The mortality and morbidity rates were respectively 0.8% and 6.6%. The prognostic analysis didn't identify predictive factors of intraoperative haemorrhage, however it identified two independent predictive actors of specific morbidity: intraoperative haemorrhage (p = 0.03) and preoperative rate of haemoglobin (p = 0.0049).