Spontaneous intrahepatic gas gangrene and fatal septic shock.

Gas gangrene of the liver is a rare clinical syndrome associated with a high rate of mortality. It is mostly associated with malignancy and immunosuppression. We report on a male patient who presented at the department of emergency medicine with high fever but no localised complaints. CT scan revealed a cavitary lesion filled with air in the liver. Clostridium perfringens was proved to be present in the hepatic lesion and the blood, and clostridium perfringens sepsis with gas gangrene of the liver was diagnosed. Despite early diagnosis and treatment the patient died. The importance of "an aggressive treatment policy" in this kind of life-threatening disease is emphasised.

Fatal intentional poisoning cases admitted to the University Hospitals of Leuven, Belgium from 1993 to 1996.

Between January 1993 and July 1996, a total of 2827 intentional cases of poisoning were registered in the University Hospitals of Leuven, Belgium. Ten of these cases were fatal. This study was set up to evaluate the substances involved, the circumstances, the features and the characteristics of the patients who died due to intentional poisoning. The male to female ratio of these fatal cases was 9 : 1. The median age was 43 years. Two groups of substances were revealed to be associated with fatal outcome. The first group consisted of chemicals (seven lethal cases): cholinesterase inhibitors ( =3), methanol ( =2) and paraquat ( =2). The second group consisted of benzodiazepines (three lethal cases). In the cases of poisoning with chemicals, death was directly related to product toxicity and the severity of the poisoning, whilst with benzodiazepines, which are considered to be relatively safe drugs even when taken in overdose, there was a clear relationship between a fatal outcome and a delay between ingestion and medical support. Product toxicity, complications and a delay in medical support may be considered as predictors for the effectiveness and efficacy of treatment and may influence which medical treatments need to be administered.

Chest pain in the emergency department: the broad spectrum of causes.

We performed a prospective study to describe the broad spectrum of causes of chest pain in patients presenting to the emergency department and to compare the diagnoses in referred patients, self-referred patients and patients rushed in by ambulance. The final diagnosis in a consecutive case series of 578 chest pain patients was established after discharge from the hospital. The underlying disorders were grouped into cardiac, respiratory, gastro-oesophageal disorders, musculoskeletal pathology, somatization disorders, other diseases and unknown. For comparison of the frequencies of the disease categories the Chi-squared test was used. Out of 578 patients, 161 (27.9%) were self-referred, 369 (63.8%) were referred by the general practitioner and 48 (8.3%) were rushed in by ambulance. Cardiac diseases represented 51.7% of the cases, myocardial infarction and unstable angina 19% and 12.8% respectively Cardiac diseases were statistically significantly less common in self-referred patients (p<0.0005). Pulmonary diseases encompassed 14.2% of the population, followed by somatization disorders (9.2%), musculoskeletal pathology (7.1%) and other causes (4.3%). In 11.1% of the cases no definite final diagnosis could be established. Somatization disorders were significantly more frequent in self-referred and ambulance patients. Cardiac and pulmonary problems are the most frequent underlying disorders in acute chest pain patients in the emergency department. Somatization disorders and musculoskeletal pathology represented respectively 19.1% and 14.8% of the non-cardiac causes. The referral pattern influenced significantly the distribution of the disease categories with more cardiac and less psychiatric disorders in referred patients.

Chest pain in general practice or in the hospital emergency department: is it the same?

OBJECTIVE: The aim of the present study was to provide a description of the impact of setting on the diagnostic case mix that is identified in consecutive patients presenting with chest pain. METHODS: A cross-sectional study was carried out of patients presenting with chest pain according to setting: general practice, self-referred, referred or arriving by ambulance at the hospital emergency department (ED). GPs from 25 general practices situated in the Flemish part of Belgium were recruited, and the hospital involved was a major teaching hospital in the same area. A total of 320 patients in general practice and 580 patients in the hospital ED were studied. The difference in prevalence rates for the major diagnostic categories was the main outcome measure. RESULTS: Gastrointestinal disorders, musculoskeletal problems and psychopathology are identified more frequently in general practice; and serious lung diseases and cardiovascular diseases in the hospital ED. Within the hospital, there is a strong trend towards increasing frequency of serious cardiovascular diseases including unstable angina (P = 0.01) from self-referred to referred patients and those rushed in by ambulance. The opposite trend was identified for respiratory (P = 0.02) and musculoskeletal (P = 0.07) diseases. The diagnostic case mix in self-referred patients tends to be more similar to the other groups of hospital patients than to patients in general practice. CONCLUSIONS: There is a large difference between the diagnostic case mix presented in general practice compared with the ED and among referral-related subgroups within the hospital emergency department.

A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients.

OBJECTIVES: To develop and test the effect of a nurse-led interdisciplinary intervention program for delirium on the incidence and course (severity and duration) of delirium, cognitive functioning, functional rehabilitation, mortality, and length of stay in older hip-fracture patients. DESIGN: Longitudinal prospective before/after design (sequential design). SETTING: The emergency room and two traumatological units of an academic medical center located in an urban area in Belgium. PARTICIPANTS: 60 patients in an intervention cohort (81.7% females, median age = 82, interquartile range (IQR) = 13) and another 60 patients in a usual care/nonintervention cohort (80% females, median age = 80, IQR = 12). INTERVENTION: (1) Education of nursing staff, (2) systematic cognitive screening, (3) consultative services by a delirium resource nurse, a geriatric nurse specialist, or a psychogeriatrician, and (4) use of a scheduled pain protocol. MEASUREMENTS: All patients were monitored for signs of delirium, as measured by the Confusion Assessment Method (CAM). Severity of delirium was assessed using a variant of the CAM. Cognitive and functional status were measured by the Mini-Mental State Examination (MMSE) (including subscales of memory, linguistic ability, concentration, and psychomotor executive skills) and the Katz Index of activities of daily living (ADLs), respectively. RESULTS: Although there was no significant effect on the incidence of delirium (23.3% in the control vs 20.0% in the intervention cohort; P =.82), duration of delirium was shorter (P =.03) and severity of delirium was less (P =.0049) in the intervention cohort. Further, clinically higher cognitive functioning was observed for the delirious patients in the intervention cohort compared with the nonintervention cohort. Additionally, a trend toward decreased length of stay postoperatively was noted for the delirious patients in the intervention cohort. Despite these positive intervention effects, no effect on ADL rehabilitation was found. Results for risk of mortality were inconclusive. CONCLUSIONS: This study demonstrated the beneficial effects of an intervention program focusing on early recognition and treatment of delirium in older hip-fracture patients and confirms the reversibility of the syndrome in view of the delirium's duration and severity.

Telehealth and communication technologies in health: summary and action plan.

INTRODUCTION: Rapid innovations and improvements in communication technologies have opened many new channels for health education and delivery, as well as disaster management. Theme 2 examined the role and applicability of these technologies to Disaster Medicine and Management and the various issues involved in their use. METHODS: Details of the methods used are provided in the introductory paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The chairs then presided over a workshop that resulted in the generation of a set Action Plans that then were reported to the collective group of all delegates. RESULTS: Main points developed during the presentations and discussion included harnessing convergence, seeking interoperability, building partnerships and making it appropriate. This group identified four Principles of Action underlying its plan: (1) investigate possibilities, (2) identify stakeholders, (3) invite participation, and (4) involve discussants in activities. DISCUSSION: Action plans were categorized into three areas that included "thinking globally, acting regionally", forming a telehealth advisory group, and increasing corporate partnerships. CONCLUSIONS: Technology is opening many opportunities that have applications in disaster management. To optimize benefits, goals and standards must be agreed upon and implemented.

Systematic triage in the emergency department using the Australian National Triage Scale: a pilot project.

The objective of this study was to evaluate the validity in Belgium of the National Triage Scale for judgement of the urgency of a patient's condition and making a case-mix description of the patient profiles in the different urgency categories. The study is of a descriptive retrospective and descriptive correlational design and was carried out in the emergency department at the University Hospital Gasthuisberg in Leuven, Belgium. The urgency of patients arriving at the emergency department was evaluated during one randomly selected shift a day over 12 weeks in 1997 by one of the four triage-educated nurses, using an instrument based on the National Triage Scale. Patient identification and outcome parameters were retrieved from the existing computer system. The data were mainly analysed using the Ridit analysis. Overall 3650 patients were evaluated: Category 1, 4.19%; Category 2, 24.44%; Category 3, 39.32%; Category 4, 27.97%; Category 5, 4.08%. Any similarity between sentinel diagnoses as well as between the admission percentages in this pilot study and the reference from Australia (Z = 0.827; p > 0.05) was noted. Different aspects influenced the triage nurses while determining the degree of urgency. Urgency categories profiles revealed a significant effect of age (Kruskall-Wallis = 530.5; p = 0.000). Higher categories of urgency resulted in a higher degree of admission (t (df = 3640) = 643.45; p = 0.000). It is concluded that a resemblance between the pilot study and the reference confirms the predictive validity of the scale used. Patient profiles in the different urgency categories give a description of the emergency department population.

Planning recommendations for international emergency medicine and out-of-hospital care system development.

OBJECTIVES: To present suggestions on planning for development of emergency medicine (EM) and out-of-hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already familiar with EM. METHODS: The techniques and programs used by the authors and others in assisting in EM development in other countries to date are described. CONCLUSIONS: Some aspects of EM system development have applicability to most countries, but other aspects must be decided by planners based on country-specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the efficacy of these efforts. Further studies are needed on the relative effectiveness and cost-benefit of different EM development efforts.

The 'three in one' block as locoregional analgesia in an emergency department.

The 'three in one' block is a well-known locoregional technique for per- and post-operative anaesthesia. This 'three in one' block was investigated in an emergency department with three combinations of local anaesthetics as a locoregional way of pain relief for patients with fractures of the upper femur. A double-blind prospective study was conducted with 61 consecutive patients. A good regression of the linear visual analogue scale (LVAS), good haemodynamic stability and great patient satisfaction were found for all groups of patients at different times after installation of the block. Side effects were few and are avoidable by reducing the amount of local anaesthetic given to elderly patients with a low bodyweight. The technique failed in only four patients due to technical reasons. It was concluded that the 'three in one' block is a fast, safe, reliable and easy technique for pain relief in an emergency department. Good analgesia was achieved for patients with fractures of the upper femur with no need to change the position of the patient.

"Recommendations for uniform reporting of data following major trauma--the Utstein style" (as of July 17, 1999). An International Trauma Anaesthesia and Critical Care Society (ITACCS).

Basic and advanced care of trauma patients has always been an important aspect of prehospital and immediate in-hospital emergency medicine, involving a broad spectrum of disciplines, specialties and skills delivered through Emergency Medical Services Systems which, however, may differ significantly in structure, resources and operation. This complex background has, at least in part, hindered the development of a uniform pattern or set of criteria and definitions. This in turn has hitherto rendered data incompatible, with the consequence that such differing systems or protocols of care cannot be readily evaluated or compared with acceptable validity. Guided by previous consensus processes evolved by the ERC, the AHA and other International Organizations--represented in ILCOR--on 'Uniform reporting of data following out-of-hospital and in-hospital cardiac arrest--the Utstein style' an international working group of ITACCS has drafted a document, 'Recommendations for uniform reporting of data following major trauma--the Utstein style'. The reporting system is based on the following considerations: A structured reporting system based on an "Utstein style template" which would permit the compilation of data and statistics on major trauma care, facilitating and validating independent or comparative audit of performance and quality of care (and enable groups to challenge performance statistics which did not take account of all relevant information). The recommendations and template should encompass both out-of-hospital and in-hospital trauma care. The recommendations and template should further permit intra- and inter-system evaluation to improve the quality of delivered care and identification of the relative benefits of different systems and innovative initiatives. The template should facilitate studies setting out to improve epidemiological understanding of trauma; for example such studies might focus on the factors that determine survival. The document is structured along the lines of the original Utstein Style Guidelines publication on 'prehospital cardiac arrest'. It includes a glossary of terms used in the prehospital and early hospital phase and definitions, time points and intervals. The document uses an almost identical scheme for illustrating the different process time clocks--one for the patient, one for the dispatch centre, one for the ambulance and, finally, one for the hospital. For clarity, data should be reported as core data (i.e. always obtained) and optional data (obtained under specific circumstances). In contrast to the graphic approach used for the Utstein template for pre- or in-hospital cardiac arrest, respectively, the present template introduces, for the time being, at least, a number of terms and definitions and a semantic rather than a graphic report form. The document includes the following sections: The Section Introduction and background The Section on Trauma Data Structure Development: presents a general outline of the development of structured data using object-orientated modelling (which will be discussed in due course) and includes a set of explanatory illustrations. The Section on Terms and Definitions: outlines terms and definitions in trauma care, describing different types of trauma (blunt, penetrating, long bone, major/combined, multiple/polytrauma and predominant trauma). The Section on Factors relating to the circumstances of the injury describes the following items: cause of injury (e.g. type of injury (blunt or penetrating), burns, cold, crush, laceration, amputation, radiation, multiple, etc. Severity of Injury e.g. prehospital basic abbreviated injury score developed by the working group. The score contains anatomical and physiological disability data, with the anatomical scale ranging ordinally from 1. Head to 9. External; the physiological disability scale ranging ordinally from 0--unsurvivable. Mechanism of injury recording for transportation incidents etc. e.g. the type of impact, po

Monitoring the circulatory responses of shocked patients during fluid resuscitation in the emergency department.

OBJECTIVES: To assess the feasibility of constructing left ventricular response curves non-invasively during the fluid resuscitation of critically ill patients in the emergency department (ED) using a portable suprasternal Doppler ultrasound (PSSDU) device. DESIGN: Prospective case series. SETTING: Emergency department, Catholic University of Leuven, Belgium. PATIENTS: Shocked patients in the ED were diagnosed by predefined criteria. Only those thought to require standardised intravenous colloid challenges were observed i. e., sequential boluses of 3.5 ml/kg/10 min titrated against changes in stroke distance (Doppler surrogate for left ventricular stroke volume). RESULTS: A total of 50 shocked patients were studied. Stroke distance was measurable in 45 patients. 35 patients were fluid responders in terms of stroke distance. Group mean stroke distance increased during resuscitation (8.6 +/- 4.1 cm to 19.5 +/- 4.6 cm, P < 0.001) and then reached a plateau value (19.6 +/- 4.6 cm, P = 0.488). No response to fluid was seen in nine patients of which eight had severe sepsis. Alternative therapeutic approaches increased stroke distance for all of these patients. Evidence for right ventricular dysfunction was found as a cause for fluid non-response in the majority of patients with sepsis. CONCLUSIONS: Previous experimental work has shown that changes in central blood flow can be derived using the PSSDU device. This clinical feasibility study suggests that the PSSDU can help tailor haemodynamic therapy for an individual patient and give an early indication of treatment failure in the ED.

Is there an evolution in the epidemiology and follow-up of carbon monoxide poisoning victims?

A retrospective study was conducted to investigate for potential changes in the epidemiology of acute carbon monoxide (CO) poisoning and to evaluate the recommendations within the emergency department (ED) on therapy and neurological and social follow-up of these patients. One hundred and sixty-seven patients with a non-intentional CO poisoning in the time period from 1995 to 1997 were reviewed and compared with data of a similar patient population between 1988 and 1990. Both patient groups were matched for age, sex and comorbidity. Comparing the epidemiological data of the two groups, three main evolutions were observed: (1) there is a global reduction in ED admissions for CO poisoning; (2) the number of young victims has a tendency to decrease; (3) the most common CO source has become an insufficiently functioning stove instead of a defective gas water heater. Regarding treatment and follow-up strategies three conclusions could be drawn: (1) the recommendations for hyperbaric-oxygen therapy were strictly followed; (2) the neurological follow-up was poor and has to be ameliorated and revisited; (3) the systematic follow-up by the social worker on the other hand resulted in immediate actions to prevent a second CO poisoning. This recently elaborated protocol for social evaluation emphasizes the important function of the social worker in the ED and the importance of transmural follow-up organized by the ED.

Harris or axis ring: an aid in diagnosing low (type 3) odontoid fractures.

OBJECTIVE: To present our experience of diagnosing fractures of the odontoid process on lateral radiographs of the cervical spine that show the Harris (axis) ring. DESIGN: Retrospective study. SETTING: Teaching hospital, Belgium. SUBJECTS: 12 patients with multiple injuries, including cervical spine, 8 of them unconscious or uncooperative. INTERVENTIONS: Cross table lateral view of the cervical spine. MAIN OUTCOME MEASURE: Identification of otherwise hidden type 3 axial fractures. RESULTS: Diagnosis of low odontoid fractures in all cases. CONCLUSION: The Harris ring is disrupted in low odontoid fractures and intact in fractures of the odontoid process. Awareness of this sign will allow diagnosis of otherwise hidden axial fractures.