Incidence and outcomes of emergency department patients requiring emergency general surgery: a 5-year retrospective cohort study.

AIMS: Patients undergoing emergency general surgery are at high risk of complications and death. Our objectives were to estimate the incidence of emergency general surgery in a Swiss University Hospital, to describe the characteristics and outcomes of patients undergoing such procedures, and to study the impact of age on clinical outcomes. METHODS: This was a retrospective cohort study of adult patients who visited the emergency department (ED) of Geneva University Hospitals between January 2015 and December 2019. Routinely collected data were extracted from electronic medical records. The primary outcome was the incidence of emergency general surgery among patients visiting the emergency department, defined as general surgery within three days of emergency department admission. We also assessed demographic characteristics, mortality, intensive care unit admission and patient disposition. Multivariable log-binomial regression was used to study the associations of age with intensive care unit (ICU) admission, one-year mortality and dependence at discharge. Age was modelled as a continuous variable using restricted cubic splines and we compared older patients (75th percentile) with younger patients (25th percentile). RESULTS: Between January 2015 and December 2019, a total of 310,914 emergency department visits met our inclusion criteria. Among them, 3592 patients underwent emergency general surgery within 3 days of emergency department admission, yielding an annual incidence of 116 events per 10,000 emergency department visits (95% CI: 112-119), with a higher incidence in females and young patients. Overall, 5.3% of patients were admitted to ICU, 7.8% were dependent on rehabilitation or assisted living at discharge and 4.8% were dead after one year. Older patients had a higher risk of ICU admission (adjusted risk ratio (aRR) 2.9 [1.5-5.4]), dependence at discharge (aRR 15.3 [5.5-42.4]) and one-year mortality (aRR 5.4 [2.2-13.4]). CONCLUSION: Emergency department visits resulting in emergency general surgery are frequent, but their incidence decreases with patient age. Mortality, ICU admission and dependence at discharge following emergency general surgery are more frequent in older patients. Taking into account the increased risk for older patients, a shared process is appropriate for making more informed decisions about their options for care.

Risk of neonatal hypothyroidism in newborns from mothers exposed to CTPA during pregnancy: Ancillary data from a prospective outcome study.

BACKGROUND: Neonatal hypothyroidism is often raised as a potential concern for the use of computed tomography pulmonary angiography (CTPA) in pregnant women with suspected pulmonary embolism (PE). OBJECTIVES: To assess the incidence of neonatal hypothyroidism among newborns from mothers exposed to CTPA. PATIENTS/METHODS: Pregnant women with clinically suspected PE were included in a multicenter, multinational prospective diagnostic management outcome study, based on pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb venous compression ultrasonography, and CTPA. Results of Guthrie tests were systematically collected for newborns of all women who required CTPA as part of the diagnostic strategy. A thyroid-stimulating hormone (TSH) level above 15 U/ml was used to define hypothyroidism. RESULTS: Out of the 166 women included in the Swiss participating centers, 149 underwent a CTPA including 14 with twin pregnancies. Eight women suffered a pregnancy loss and results of the Guthrie test could not be retrieved for four newborns. All TSH levels were reported as being below 15 U/ml. The incidence of neonatal hypothyroidism was 0/151 (0.0%, 95% confidence interval: 0.0%-2.5%). CONCLUSIONS: We did not identify any cases of neonatal hypothyroidism in our cohort of 149 pregnant women investigated for suspected PE using a CTPA. Along with previous literature data, this provides further reassuring data regarding the use of CTPA in this indication.

[Interdisciplinarity and critical care in emergency medicine]. / Interdisciplinarité et urgences vitales en médecine d'urgence.

Cardiorespiratory arrest, stroke and severe trauma have serious consequences if untreated with strict procedures in a timely manner. This temporal imperative implies the implementation of a succession of actions coordinated by healthcare providers with diverse expertise, and operating according to known, mastered and trained standards of care. Simple and clear communication principles ensure the consistency and fluidity of these actions. Competent and inclusive leadership promotes the achievement of set objectives and allows the team to adapt to demanding or unforeseen situations. Interdisciplinarity as it is practiced in the emergency setting for critical pathways such as those mentioned, then takes on its full meaning.

L'arrêt cardiorespiratoire, l'accident vasculaire cérébral et le traumatisé grave sont grevés de lourdes conséquences s'ils ne sont pas traités avec des procédures strictes dans des délais adéquats. Cet impératif temporel implique la mise en œuvre d'une succession d'actions coordonnées par des intervenants à l'expertise diverse et opérant selon des standards de soins connus, maîtrisés et entraînés. Des principes de communication simples et clairs assurent la cohérence et la fluidité de ces actions. Un leadership, compétent et inclusif, favorise l'atteinte des objectifs fixés et permet l'adaptation de l'équipe aux situations exigeantes ou imprévues. L'interdisciplinarité telle qu'elle est pratiquée pour ces filières de soins critiques prend alors tout son sens.

Fatal diving: could it be an immersion pulmonary edema? Case report.

Immersion pulmonary edema is a rare, underrecognized, and potentially lethal pathology developing during scuba diving and other immersion-related activities (swimming or apnoea). Physiopathology is complex and not fully understood, but its mechanisms involve an alteration of the alveolo-capillary barrier caused by transcapillary pressure elevation during immersion, leading to an accumulation of fluid and blood in the alveolar space. Diagnosis remains a challenge for clinicians and forensic practionner. The symptoms begin during ascent, with cough, frothy sputum, and hemoptysis. Auscultation reveals signs of pulmonary edema. Pulmonary CT scan, which is the radiological exam of choice, shows ground glass opacities and interlobular thickening, eventually demonstrating a patterned distribution, likely in the anterior segments of both lungs. Apart from the support of vital functions, there is no specific treatment and hyperbaric oxygen therapy is not systematically recommended. We present a case of fatal IPE occurring in a recreational diver who unfortunately died shortly after his last dive. Diagnosis was made after complete forensic investigations including post-mortem-computed tomography, complete forensic autopsy, histological examination, and toxicological analysis.

Eight versus 28-point lung ultrasonography in moderate acute heart failure: a prospective comparative study.

Lung ultrasonography (LUS) is an accurate method of estimating lung congestion but there is ongoing debate on the optimal number of scanning points. The aim of the present study was to compare the reproducibility (i.e. interobserver agreement) and the feasibility (i.e. time consumption) of the two most practiced protocols in patients hospitalized for acute heart failure (AHF). This prospective trial compared 8- and 28-point LUS protocols. Both were performed by an expert-novice pair of sonographers at admission and after 4 to 6 days on patients admitted for AHF. A structured bio-clinical evaluation was simultaneously carried out by the treating physician. The primary outcome was expert-novice interobserver agreement estimated by kappa statistics. Secondary outcomes included time spent on image acquisition and interpretation. During the study period, 43 patients underwent a total of 319 LUS exams. Expert-novice interobserver agreement was moderate at admission and substantial at follow-up for 8-point protocol (weighted kappa of 0.54 and 0.62, respectively) with no significant difference for 28-point protocol (weighted kappa of 0.51 and 0.41; P value for comparison 0.74 at admission and 0.13 at follow-up). The 8-point protocol required significantly less time for image acquisition at admission (mean time difference - 3.6 min for experts, - 5.1 min for novices) and interpretation (- 6.0 min for experts and - 6.3 min for novices; P value < 0.001 for all time comparisons). Similar differences were observed at follow-up. In conclusion, an 8-point LUS protocol was shown to be timesaving with similar reproducibility when compared with a 28-point protocol. It should be preferred for evaluating lung congestion in AHF inpatients.

[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.

Confidence and use of physical examination and point-of-care ultrasonography for detection of abdominal or pleural free fluid. A cross-sectional survey.

Physical examination (PE) has always been a corner stone of medical practice. The recent advances in imaging and fading of doctors' ability in performing it, however, raised doubts on PE usefulness. Point-of-care ultrasonography (POCUS) is gaining ground in medicine with the detection of free fluids being one of its main applications. To estimate physicians' confidence and use of PE and POCUS for the detection of abdominal or pleural free fluid, we conducted a cross-sectional survey. In all, 246 internal and emergency medicine physicians answered to the survey (197 in-hospital physicians and 49 general practitioners; response rate 28.5%). Almost all declared to perform PE in case of suspected ascites or pleural effusion (88% and 90%, respectively). The highest rates of confidence were observed in conventional PE signs (91% for diminished breath sounds, 80% for dullness to thorax percussion, and 66% for abdominal flank dullness). For the remaining signs, rates of confidence were less than 53%. Physicians with > 15 years of experience and POCUS-naïve doctors reported higher confidence in PE. Most of emergency and almost half of internal medicine physicians (78% and 44%, respectively) attended a structured POCUS course. POCUS use was higher among trained physicians for both ascites (84% vs 50%, p < 0.001) and pleural effusion (80% vs 34%, p < 0.001). Similarly, higher POCUS use was observed in younger physicians. In conclusion, PE is frequently performed and rates of confidence are low for most PE signs, especially among young doctors and POCUS users. This detailed inventory suggests an ongoing shift towards POCUS integration in clinical practice.

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.

Assessing the clinical probability of pulmonary embolism during pregnancy: The Pregnancy-Adapted Geneva (PAG) score.

BACKGROUND: The diagnosis of pulmonary embolism (PE) in pregnant women represents an ongoing challenge. As in the general population, the first step in pregnant women with suspected PE consists of assessing clinical pre-test probability (PTP). However, no dedicated clinical decision rule has been developed in this population. OBJECTIVE: To propose a new version of the Geneva score adapted to pregnant women with suspected PE. METHODS: Data from a multicenter, prospective management outcome study including 395 women with suspected PE, in whom PTP was assessed using the Geneva score, were used. We first removed items which were present in none of the patients (cancer, age >65 years). Receiver operating characteristic (ROC) curve analysis was then performed for quantitative variables and the optimal threshold defined. The obtained Pregnancy-Adapted Geneva Score (PAG Score) comprised seven items, including an age 40 years or older and a heart rate >110 beats per minute. RESULTS: The PAG Score showed a high discriminative power to identify patients with a low, intermediate, or high PTP, associated with increasing prevalence of PE, 2.3%, 11.6%, and 61.5%, respectively. The ROC curves showed an area under the curve of 0.795 for the PAG Score compared to 0.684 for the Geneva score. CONCLUSION: In pregnant women with suspected PE, the PAG Score shows a high discriminative power to identify patients at low, intermediate, or high PTP. It has the strength of being a fully objective decision rule, is clinically relevant, easy to compute, and should now be tested in a prospective outcome study.

Learning process of ultrasound-guided Ilio-fascial compartment block on a simulator: a feasibility study.

BACKGROUND: Ultrasound-guided fascia iliaca compartment block (US-FICB) is not part of the learning curriculum of the emergency physicians (EP) and is usually performed by anesthesiologists. However, several studies promote EP to use this procedure. The goal of this study was to assess the feasibility of a training concept for non-anesthesiologists for the US-FICB on a simulator based on a validating learning path. METHOD: This was a feasibility study. Emergency physicians and medical students received a 1-day training with a learning phase (theoretical and practical skills), followed by an assessment phase. The primary outcome at the assessment phase was the number of attempts before successfully completing the procedure. The secondary outcomes were the success rate at first attempt, the length of procedure (LOP), and the stability of the probe, corresponding to the visualization of the needle tip (and its tracking) throughout the procedure, evaluated on a Likert scale. RESULTS: A total of 25 participants were included. The median number of attempts was 2.0 for emergency physicians and 2.5 for medical students, and this difference was not significant (p = 0.140). Seven participants (28%) succeeded at the first attempt of the procedure; the difference between emergency physicians and medical students was not significant (37% versus 21%; p = 0.409). The average LOP was 19.7 min with a significant difference between emergency physicians and medical students (p = 0.001). There was no significant difference regarding the stability of the probe between the two groups. CONCLUSION: Our 1-day training for non-anesthesiologists with or without previous skills in ultrasound seems to be feasible for learning the US-FICB procedure on a simulator.

Point of care ultrasonography from the emergency department to the internal medicine ward: current trends and perspectives.

The advent of portable devices in the early 80s has brought ultrasonography to the patient's bedside. Currently referred to as 'point of care ultrasonography' (POCUS), it has become an essential tool for clinicians. Initially developed in the emergency and critical care settings, POCUS has gained increasing importance in internal medicine wards in the last decade, with both its growing diagnostic accuracy and portability making POCUS an optimal instrument for everyday clinical assessment and procedures. There is large body of evidence to confirm POCUS' superiority when compared to clinical examination and standard X-ray imaging in a variety of clinical situations. On the contrary, only few indications, such as procedural guidance, have a proven additional benefit for patients. Since POCUS is highly user-dependent, pre- and post-graduate curricula are needed and the range of use should be clearly defined. This review focuses on trends and perspectives of POCUS in the management of diseases frequently encountered in emergency and internal medicine. In addition, questions are raised regarding the teaching and supervision of POCUS needing to be addressed in the near future.

[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.

Impact of a patient-flow physician coordinator on waiting times and length of stay in an emergency department: A before-after cohort study.

OBJECTIVE: Overcrowding is common in most emergency departments (ED). Despite the use of validated triage systems, some patients are at risk of delayed medical evaluation. The objective of this study was to assess the impact of a patient-flow physician coordinator (PFPC) on the proportion of patients offered medical evaluation within time limits imposed by the Swiss Emergency Triage Scale (SETS) and on patient flow within the emergency department of a teaching urban hospital. METHODS: In this before-after retrospective cohort study, we compared the proportions of patients who received their first medical contact within SETS-imposed time limits, mean waiting times before first medical consultation, mean length of stay, and number of patients who left without being seen by a physician, between two periods before and after introducing a PFPC. The PFPC was a senior physician charged with quickly assessing in the waiting area patients who could not immediately be seen and managing patient flow within the department. RESULTS: Before introducing the PFPC position, 33,605 patients were admitted, versus 36,288 after. Introducing a PFPC enabled the department to increase the proportion of patients seen within the SETS-imposed time limits from 60.1% to 69.0% (p <0.0001). Waiting times until first medical consultation were reduced on average by 27.7 minutes (95% confidence interval [95% CI]: 25.9-29.5, p < .0001). No significant differences were observed as to length of stay or number of patients who left without being seen between the two study periods. CONCLUSIONS: Introducing a physician dedicated to managing patient flow enabled waiting times until first medical consultation to be reduced, yet had no significant benefit for patient flow within the ED, nor did it reduce the number of patients who left without being seen.

Design of InterFACE: A Tool to Improve Collaborative Work and Decision Making During Rescucitation.

Successful resuscitation requires good teamwork, communication and quick decision-making. The complexity of the situation makes the communication often erratic. As a consequence, improper decisions can be taken and errors can occur, endangering patients. In order to support the resuscitation team in their work, we developed an innovative product named Interconnected and Focused Mobile Applications on Patients Care Environment (InterFACE), enhancing team situational awareness, and improving the team communication process. To develop our solution, we relied on a user-centred design process involving caregivers from both adult and paediatric emergency departments. The process started with interviews and observations, followed by an iterative development approach validated at each step by end-users. The resulting intervention is composed of a tablet app interacting with a large screen, visible to each members of the resuscitation team, presenting real time information about the resuscitation. Resuscitations are very complex and challenging situations involving many actors. Designing a support tool for such situations requires a strong involvement of end users to understand how people work together and what information they share.

[Emergency medicine : update 2017]. / Médecine d'urgence.

Emergency medicine is part of the current stream of efficient and qualitative medicine : 1) the modified Valsava maneuver results in the resolution of almost 50% of supra-ventricular tachycardia without any drug; 2) lung echography performed by emergency physicians is a very sensitive and specific diagnostic tool for most thoracic emergencies; 3) cardiopulmonary resuscitation initiated by lay-rescuers improves short and long-term outcome; 4) no anticoagulant treatment is warranted in distal deep vein thrombosis and 5) systematic unenhanced abdominal CT might improve evaluation of elderly patients with acute abdominal pain.

Dans le courant actuel d'une médecine de qualité visant l'efficience, la médecine d'urgence n'est pas en reste : 1) la manœuvre de Valsalva modifiée permet une cardioversion dans près de 50 % des tachycardies supraventriculaires paroxystiques sans aucun autre traitement ; 2) l'échographie pulmonaire pratiquée par l'urgentiste est rapide avec de très bonnes sensibilité et spécificité dans plusieurs pathologies thoraciques ; 3) une réanimation initiée par des témoins permet une meilleure survie et améliore le pronostic à long terme ; 4) un traitement anticoagulant n'est pas nécessaire lors de thrombose veineuse profonde sous-poplitée et 5) un scanner abdominal non injecté systématique pourrait améliorer la prise en charge de patients âgés souffrant de douleurs abdominales aiguës.