[Forensic risk in emergency medicine]. / Risque médico-judiciaire en médecine d'urgence.

Activities in the emergency departments increase in all countries for many reasons: medical, social, economic, etc. In the same time, it is logical to observe an increase in claims; this is confirmed by the insurance companies. In this review, we describe the typology of claims according to the Reason model, also named Swiss cheese model. Thus weseparate the risk situations, the taking risk and the lack of information. When the three factors are associated, claims occur. Then it is easy to propose a method of prevention based on the compliance to the recommandations of good pratices written by the scientific societies.

Nurses' understanding influences comprehension of patients admitted in the observation unit.

Comprehension is poor in patients admitted in the emergency observation unit. Teamwork communication gaps could contribute to patients' misunderstanding of their health condition. To determine in patients admitted in the emergency observation unit whether comprehension of diagnosis, prognosis, and management depended on nurses' comprehension, the authors conducted a prospective observational study in a busy adult emergency department of a tertiary teaching hospital in Paris over 2 months. Consecutive patients admitted in the emergency observation unit were included. Patients' and nurses' comprehension of diagnosis, prognosis, and management was compared with the statements of the emergency department attending physicians for these items. The authors observed whether patients' misunderstanding was associated with nurses' misunderstanding. A total of 544 patients were evaluated. For each patient, nurses' and patients' comprehension was available. Patients understood severity in 40%, organ involved in 69%, medical wording in 57%, reason for admission in 48%, and discharge instruction in 67%. In comparison with patients, nurses better understood each item except for discharge instruction. The authors observed that patients' comprehension was better when nurses understood diagnosis (p <.0001), reasons for admission (p =.032) and discharge instructions (p =.002). Nurses' understanding of severity did not modify patients' comprehension. These results support the conclusions that communication gaps in teamwork alter patients' comprehension and that nurses' and patients' misunderstandings are associated. Therefore, improving communication by nurses and physicians to patients may improve patients' understanding.

[The Sino-French emergency and disaster medicine training center]. / Le centre franco-chinois de formation a la médecine d'urgence et de catastrophe (CFCFMUC). Un exemple de coopération entre la France et la Chine.

French (AP-HP) and Chinese (Beijing Health Office) hospitals, with support from the French company Total, collaborated in order to improve Chinese doctors' knowledge of emergency and disaster medicine prior to the Beijing Olympic Games. A Sino-French emergency and disaster medicine training center was subsequently opened in Beijing in 2008, with the aim of providing high-level continuous medical training for Chinese specialists in emergency medicine. Teaching in the management of critical situations was based on the use of a latest-generation simulator (Sim 3G; Laerdal). This collaboration has had both pedagogical and diplomatic benefits.

Bacteremia and MR-proANP changes in mild community-acquired pneumonia.

BACKGROUND: Mid-regional pro-atrial natriuretic peptide (MR-proANP) increases with severity in community-acquired pneumonia (CAP). We investigated whether changes of MR-proANP correlated to bacteremia. METHODS: 392 adult patients with CAP visiting emergency department from a prospective observational multicenter study. RESULTS: MR-proANP levels increased in patients with positive bacteremia (92.8 pmol/L vs. 84.3 pmol/L, p = 0.04). Performance of MR-proANP to detect bacteremia (0.60) was equivalent to CRP (0.59) but less accurate than PCT (0.69). CONCLUSION: MR-ANP poorly predicts bacteremia in CAP patients.

Prevalence of neuropathic pain in emergency patients: an observational study.

OBJECTIVE: Neuropathic pain (NP) in acute conditions has been poorly investigated. A diagnostic score, the DN4 scale (DN4), has been developed to help physicians to detect and treat NP appropriately. DN4 is a 10-item questionnaire. If you have 4 or more positive responses out of 10 items, the answer to the questionnaire is positive and you have a neuropathic pain. We aimed to determine the prevalence of NP in emergency department (ED) patients and to describe this population. METHODS: We used the DN4 in the patients with NP visiting the adult ED of a university hospital. Patients were asked about the characteristics of their pain using a face-to-face questionnaire. RESULTS: Among 533 patients with a DN4 score, 114 (21.4%) had NP. Neuropathic pain was independently negatively associated with age of 65 years of older (odds ratio [OR], 0.2, 95% confidence interval [CI], 0.05-0.8) and positively associated with intense pain (OR, 5.2; 95% CI, 1.5-18.2), located to the limbs (OR, 2.3; 95% CI, 1.2-4.0). CONCLUSION: Neuropathic pain was common in ED patients and associated to a higher level of pain.

Midregional pro-atrial natriuretic peptide for the diagnosis of cardiac-related dyspnea according to renal function in the emergency department: a comparison with B-type natriuretic peptide (BNP) and N-terminal proBNP.

BACKGROUND: Although renal dysfunction influences the threshold values of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in diagnosis of cardiac-related dyspnea (CRD), its effects on midregional pro-atrial natriuretic peptide (MR-proANP) threshold values are unknown. We evaluated the impact of renal function on MR-proANP concentrations and compared our results to those of BNP and NT-proBNP. METHODS: MR-proANP, BNP, and NT-proBNP concentrations were measured in blood samples collected routinely from dyspneic patients admitted to the emergency department. Patients were subdivided into tertiles based on their estimated glomerular filtration rate [eGFR, in mL · min(-1) · (1.73 m(2))(-1)]: tertiles 1 (<44.3), 2 (44.3-58.5), and 3 (≥58.6). RESULTS: Of 378 patients studied, 69% (n = 260) had impaired renal function [<60 mL · min(-1) · (1.73 m(2))(-1)] and 30% (n = 114) had CRD. MR-proANP, BNP, and NT-proBNP concentrations were significantly increased in patients with impaired renal function. In each tertile, all peptides remained significantly increased in CRD patients by comparison with non-CRD patients. By ROC analysis, MR-proANP, BNP, and NT-proBNP threshold values for the diagnosis of CRD increased as eGFR decreased from tertile 3 to tertile 1. Areas under the ROC curve for all peptides were significantly lower in tertile 1. Using adapted thresholds, MR-proANP, BNP, and NT-proBNP remained independently predictive of CRD, even in tertile 1 patients. CONCLUSIONS: Renal function influences optimum cutoff points of MR-proANP for the diagnosis of CRD. With use of an optimum threshold value adapted to the eGFR category, MR-proANP remains as effective as BNP and NT-proBNP in independently predicting a diagnosis of CRD in the emergency department.

Febrile neutropenia in French emergency departments: results of a prospective multicentre survey.

INTRODUCTION: Febrile neutropenia (FN) is common in cancer patients receiving myelotoxic therapy. The procedures to treat FN are well established in oncology, but it is unclear whether management is adequate in the emergency department (ED). METHODS: This prospective, multicentre, observational study was carried out in 47 French EDs for 6 months. Patients were adults presenting at the ED with FN after myelotoxic treatment for cancer. Severity of infection was defined according to Bone criteria for severe sepsis and septic shock (SS/SSh) and risk was determined according to Multinational Association of Supportive Care in Cancer (MASCC) criteria. The end point was the implementation of guidelines. Management of patients with SS/SSh required: (i) adequate intravenous (IV) antimicrobial therapy for the first 90 min (broad-spectrum beta-lactam with or without an aminoglycoside); (ii) fluid challenge (500 mL); (iii) lactate measurement; (iv) at least one blood culture; and (v) hospitalization. Management of patients without SS/SSh required: (1) no initiation of granulocyte - cell stimulating factor (G-CSF); (2) adequate IV antimicrobial therapy (broad-spectrum beta-lactam) and hospitalization if the patient was high-risk according to MASCC criteria; (3) adequate oral antimicrobial therapy (quinolone or amoxicillin/clavulanate or cephalosporin) and hospital discharge if the patient was low-risk. RESULTS: 198 patients were enrolled; 89 patients had SS/SSh, of whom 19 received adequate antimicrobial therapy within 90 min and 42 received appropriate fluid challenge. Blood cultures were obtained from 87 and lactate concentration was measured in 29. Overall, only 6 (7%) patients with SS/SSh received adequate management. Among 108 patients without SS/SSh, 38 (35%) were high-risk and 70 (65%) low-risk. In the high-risk group, adequate antimicrobial therapy was given to 31 patients, G-CSF was initiated in 4 and 35 were hospitalized. In the low-risk group, 4 patients received adequate oral antimicrobial therapy, IV antimicrobial therapy was prescribed in 59, G-CSF was initiated in 12 and six patients were discharged. Adequate management was given to 26/38 (68%) high-risk and 1/70 low-risk patients. Factors associated with adequate management were absence of SS/SSh (P = 0.0009) and high-risk according to MASCC criteria (P < 0.0001). CONCLUSIONS: In this French sample of cancer patients presenting to the ED with FN, management was often inadequate and severity was under-evaluated in the critically ill.

Blood cocaine and metabolite pharmacokinetics after cardiac arrest in a body-packer case.

INTRODUCTION: Cocaine body packing, the internal concealment of cocaine for transportation between countries, may expose to life-threatening intoxications. No data is currently available on the pharmacokinetics of cocaine and its metabolites when a packet rupture occurs in a body packer. CASE REPORT: We report the first pharmacokinetic data associated with a severe cocaine intoxication in a body packer, resulting in cardiac arrest. Massive concentrations of cocaine (observed maximal concentration: 1.66 mg/L, 1 hour after the cardiac arrest) were measured in plasma up to about 15 hours, suggesting a prolonged absorption due to a slow-release in the gastrointestinal tract despite surgical extraction of the packets. Apparent cocaine elimination half-life was 7.6 hours. CONCLUSION: A prolonged apparent cocaine elimination half-life has been observed. Further pharmacokinetic studies are needed to understand better the pathophysiology of acute cocaine intoxication in body packers.

[New missions for emergency department]. / De nouvelles missions pour les services d'urgences?

There are more than 16 millions emergency department visits per year, 15 millions calls to SAMU and 600,000 mobile intensive care unit interventions. The knowledge of the sum of all these medical problems represents an incomparable database offering the possibility of numerous studies and programs of education. The emergency physicians do not routinely offer screening and brief intervention as part of their current clinical practice. However, for the next years, the strikes will be to develop, besides the mission of care, epidemiologic studies, programs of screening and prevention. Concerning epidemiologic interventions, the preventive actions in ED have be proven efficient as well as in prevention of tobacco addiction, falls in older patients, HIV contamination more specifically in teenagers. This strategy prevents those who are infected from entering treatment before serious complications occur. In the same time, it prevents them from taking measures to avoid transmitting the virus. Syndromic surveillance must be implemented in order to prevent epidemic phenomena or bioterrorism attacks. Simultaneously, the problem of overcrowding must be resolved.

[Misuse of psychotropic medications in a population of subjects held for custody in the city of Paris]. / Mésusage de médicaments psychotropes au sein d'une population de gardés à vue à Paris.

OBJECTIVE: Identify which psychotropic medications are misused and peddled in a population of subjects held for custody in the city of Paris. METHODS: Subjects held for custody in the Medico-Legal Emergency Unit of the Paris Hôtel-Dieu hospital were examined and interrogated between March 2006 and March 2007 in order to assess their consumption of psychotropic medications. RESULTS: Sixty one of the 659 subjects (9.2%) interrogated were included in the study. Their main source of psychotropic medications was street dealers. The most frequently misused psychotropic agent was clonazepam (42.6%), followed by buprenorphine (30.65%) and methadone (21.3%). Clonazepam appears to have replaced flunitrazepam which now only comes in fifth position (11.4%). The finding that methadone is the third most misused drug should lead us to query this medication's dispensing method. CONCLUSIONS: Practitioners should remain vigilant regarding the potential misuse of psychotropic medications, particularly since they may induce severe undesirable events (addiction, neurological disorders, possibly lethal overdosage).

Acute appendicitis, an unusual presentation of Streptococcus pyogenes infection.

The incidence of invasive streptococcal pyogenic infections has been on a worldwide increase. The most frequent clinical manifestations start with cutaneous septicemias. We report an unusual case of Streptococcus pyogenes-based septicemia, secondary to appendicitis with rapidly evolving peritonitis.

[Drug-facilitated crimes: prospective data collection in a forensic unit in Paris]. / Soumission chimique: administration de psychotropes à l'insu d'une victime à des fins d'agression Etude prospective de 52 cas au sein d'une unité médico-judiciaire.

INTRODUCTION: Little is known about the rate of crimes that are facilitated by the administration of psychoactive products without the victim's knowledge. This study analyzes the cases collected over a two-year period in a forensic unit in Paris. MATERIAL AND METHODS: The study covers the period from January 1, 2005 and December /31, 2006. It includes crime victims who consulted for toxicological testing in the forensic unit of the Hôtel Dieu in Paris, after filing a criminal complaint describing symptoms suggestive of chemical submission (amnesia, impaired vigilance or behavior) and whose toxicological tests indicated the presence of a psychoactive product that they had not been aware of taking. The tests used chromatographic techniques on blood, urine, hair, and food or drink residue. RESULTS: Toxicological testing identified 52 cases of drug-facilitated crimes, primarily for theft and sexual abuse (including rape). The psychoactive products were most often incorporated in drinks, half of them alcoholic beverages. Benzodiazepines accounted for 77% of the cases. Other substances, found more rarely, included antihistamines, neuroleptics, and GHB. CONCLUSION: Appropriate samples must be taken from victims rapidly to enable toxicological analysis. Chromatographic analysis must supplement immunological analysis, which is not sufficiently specific or sensitive. The collection of this information must continue in order to quantify the phenomenon and monitor the emergence of new products.