FRENCH versus ESI: comparison between two nurse triage emergency scales with referent scenarios.

OBJECTIVES: Acute triage is needed to prioritize care and achieve optimal resource allocation in busy emergency departments. The main objective is to compare the FRench Emergency Nurse Classification in Hospital scale (FRENCH) to the American scale Emergency Severity Index (ESI). Secondary objectives are to compare for each scale the over and under-triage, the triage matching to the gold standard and the inter-individual sorting reproducibility between the nurses. METHODS: This is a prospective observational study conducting among the nursing staffs and nursing students, selected from Caen University College Hospital and Lisieux Hospital Center emergency departments between two months. Each group individually rank 60 referent clinical cases composed by scales designers. An assessment of scale practicality is collected after for each tool. The collected parameters are analyzed by a Cohen kappa concordance test (κ). RESULTS: With 8151 triage results of gold standard scenarios sorting in two scales by the same nurses, the FRENCH scale seems to give better triage results than the US ESI scale (nurse: FRENCH 60% and ESI 53%, p = 0.003 ; nursing students: FRENCH 49% and ESI 42%, p < 0.001). In the two groups ESI has also a big tendency to under-sort (p = 0.01), particularly for the most severe patients (p < 0.01). The interobserver sorting concordance for any experience gives good results for the FRENCH and the ESI without any difference (nurses : FRENCH KPQ=0.72 ESI KPQ=0.78; p = 0.32 ; students KPQ=0.44 KPQ=0.55; p = 0.22). CONCLUSION: The ESI and FRENCH scales comparison on 8151 sorting results shows direct validity in favor of FRENCH one and similar interobserver agreement for both scales.

Assessment of general emergency medicine physicians' medical education regarding management of pediatric emergencies in western Normandy, France.

OBJECTIVES: General emergency medicine physicians sometimes have to deal with acute management of pediatric emergencies. The objectives of this study were to assess the pediatric medical education background of emergency physicians, how often they encounter pediatric emergencies, as well as the knowledge and organizational gaps regarding the management of children in general emergency departments. METHODS: A survey was conducted from March 25 to June 25, 2017, by emailing an anonymized questionnaire to all senior emergency physicians of the 22 general emergency departments of western Normandy public hospitals. RESULTS: A total of 81 responses were analyzed. In all, 83% percent of respondents had previously worked in a pediatric department. In total, 90% of the respondents reported caring for children within their emergency department and 93% out-of-hospital (100% of them during primary interventions and 39% during secondary interventions such as inter-hospital transfers). Fourteen percent of the respondents considered that the pediatric medical education they received was adapted to their current practice, while 73% reported experiencing difficulties during management of pediatric emergencies (technical difficulties, unsuitable material and therapeutics, relational problems, personal apprehension, disease- or age-specific difficulties, especially with children under the age of 2-3 years). CONCLUSION: Most general emergency physicians report caring for children despite a lack of medical education in pediatrics. Pediatric medical education as well as collaborations between general practitioners and specialized pediatric teams should be enhanced to better match the needs of general emergency departments and improve the quality of primary and acute care for children.

Unique blood culture for diagnosis of bloodstream infections in emergency departments: a prospective multicentre study.

Detection of microorganisms by blood cultures (BCs) is essential in managing patients with bacteraemia. Rather than the number of punctures, the volume of blood drawn is considered paramount in efficient and reliable detection of microorganisms. We performed a 1-year prospective multicentre study in adult emergency departments of three French university hospitals comparing two methods for BCs: a unique blood culture (UBC) collecting a large volume of blood (40 mL) and the standard method of multiple blood cultures (MBC). The performances of both methods for bacterial contamination and efficient microbial detection were compared, each patient serving as his own control. Amongst the 2314 patients included, three hundred were positive for pathogens (n=245) or contaminants (n=55). Out of the 245 patients, 11 were positive for pathogens by UBC but negative by MBC and seven negative by UBC but positive by MBC (p 0.480). In the subgroup of 137 patients with only two BCs, UBC was superior to MBC (p 0.044). Seven and 17 patients had contaminated BCs by UBC and MBC only, respectively (p 0.062). Considering the sums of pathogens missed and contaminants, UBC significantly outperformed MBC (p 0.045). Considering the complete picture of cost savings, efficient detection of microorganisms and decrease in contaminations, UBC offers an interesting alternative to MBC.

Accuracy of a transcutaneous carbon dioxide pressure monitoring device in emergency room patients with acute respiratory failure.

PURPOSE: Transcutaneous CO(2) monitors are widely used in neonatal ICUs. Until recently, these devices performed poorly in adults. Recent technical modifications have produced transcutaneous CO(2) monitors that have performed well in adults with chronic illnesses. We evaluated the accuracy of one of these devices, the TOSCA(®) 500, in adults admitted to an emergency department for acute respiratory failure. METHODS: We prospectively collected 29 pairs of simultaneous transcutaneous arterial CO(2) (PtcCO(2)) and arterial CO(2) (PaCO(2)) values in 21 consecutive adults with acute respiratory failure (acute heart failure, n = 6; COPD exacerbation, n = 8; acute pneumonia, n = 6; and pulmonary embolism, n = 1). Agreement between PaCO(2) and PtcCO(2) was evaluated using the Bland-Altman method. RESULTS: Mean arterial oxygen saturation was 90%, arterial oxygen tension ranged from 32 to 215 mmHg, and PaCO(2) ranged from 23 to 84 mmHg. The mean difference between PaCO(2) and PtcCO(2) was 0.1 mmHg, and the Bland-Altman limits of agreement (bias ± 1.96 SD) ranged from -6 to 6.2 mmHg. None of the patients experienced adverse effects from heating of the device clipped to the earlobe. CONCLUSION: PtcCO(2) showed good agreement with PaCO(2) in adults with acute respiratory failure.

Investigation of the ability of the Pneumonia Severity Index to accurately predict clinically relevant outcomes: a European study.

In order to confirm the validity of the Pneumonia Severity Index (PSI) for patients in Europe, data from adults with pneumonia who were enrolled in two prospective multicentre studies, conducted in France (Pneumocom-1, n = 925) and Spain (Pneumocom-2, n = 853), were compared with data from the original North American study (Pneumonia PORT, n = 2287). The primary outcome was 28-day mortality; secondary outcomes were subsequent hospitalisation for outpatients, and intensive care unit admission and length of stay for inpatients. All outcomes within individual risk classes, and mortality rates in low-risk (PSI I-III) and higher-risk patients, were compared across the three cohorts. Overall mortality rates were 4.7% in Pneumonia PORT, 6.3% in Pneumocom-2 and 10.6% in Pneumocom-1 (p <0.01), ranging from 0.4% to 1.6% (p 0.06) for low-risk patients and from 13.0% to 19.1% (p 0.24) for high-risk patients. Despite significant differences in baseline patient characteristics, none of the study outcomes differed within the low-risk classes. The sensitivity and negative predictive value of low-risk classification for mortality exceeded 93% and 98%, respectively. Thus, in two independent European cohorts, the PSI predicted patient outcomes accurately and reliably, particularly for low-risk patients. These findings confirm the validity of the PSI when applied to patients from Europe.

[Management of adult abdominal pain in the Emergency Room]. / Prise en charge des douleurs abdominales de l'adulte aux Urgences.

Abdominal pain is a commonplace reason for surgical consultation in the emergency department and is the the most common symptom which the digestive surgeon on-call must evaluate. He must understand the pathophysiologic basis of visceral pain and referred pain in order to appreciate its diverse manifestations. Abdominal pain can stem from many causes intestinal and non-intestinal, medical and surgical. Evaluation and management in the emergency department must be rapid and pragmatic; clinical history and physical examination should define the gravity of the case, direct the first diagnostic procedures and complementary examinations, and guide the therapeutic direction. Ultrasonography is a quick and effective diagnostic procedure in the diagnosis of biliary, urologic, and gynecologic pathologies; it can be useful for other digestive problems as well. The new generation spiral CT scanner gives excellent definition of digestive and vascular pathologies. The initial evaluation and management of the acute abdomen may determine the prognosis of the patient; it should lead to prompt symptomatic relief and to a well-directed treatment appropriate to the diagnosis.

Campylobacter fetus meningitis in a diabetic adult cured by imipenem.

Reported here is the successful management of a severe case of Campylobacter fetus subspecies fetus meningitis, complicated by septic shock, in a patient without overt immunosuppression who was cured by imipenem. Meningitis caused by C. fetus has rarely been reported in adults, and only exceptionally in non-immunocompromised patients, and septic shock has not previously been reported as a complication of such meningitis. The best antibiotic regimen for treating this condition remains to be determined. Imipenem has displayed high in vitro activity against C. fetus but has been used rarely in clinical practice. It was administered in this case with good results.

Significance of the changes in the respiratory system pressure-volume curve during acute lung injury in rats.

UNLABELLED: The hypothesis that the changes in the respiratory system pressure- volume (PV) curve during pulmonary edema mainly reflect distal airway obstruction was investigated in rats. Normal rats had a well-defined upper inflection point (UIP) at low airway pressure. Airway occlusion by liquid instillation decreased compliance (Crs) and the volume (Vuip) of the UIP, and increased end-inspiratory pressure. The same changes were observed during the progression of edema produced by high volume ventilation (HV). Changes in Vuip and in Crs produced by HV were correlated with edema severity in normal rats or rats with lungs preinjured with alpha-naphthylthiourea. Vuip and Crs changes were proportional, reflecting compression of the PV curve on the volume axis and suggesting reduction of the amount of ventilatable lung at low airway pressure. In keeping with this explanation, the lower Vuip and Crs were before HV, the more severe HV-induced edema was in alpha-naphthylthiourea-injected rats. When edema was profuse, PV curves displayed a marked lower inflection point (LIP), the UIP at low pressure disappeared but another was seen at high volume above the LIP, and the correlation between Vuip changes and edema severity was lost. These observations may have clinical relevance in the context of the "open lung" strategy. KEYWORDS: ventilator-induced lung injury; respiratory mechanics; acute respiratory distress syndrome

Patients' preferences concerning medical information and surrogacy: results of a prospective study in a French emergency department.

OBJECTIVE: To study the wishes of a sample of French patients about medical information and surrogacy, at a time when the French Ministry of Health is supporting increased patient autonomy. DESIGN: A cohort of competent patients with non-critical illnesses or injuries completed an intention-to-act questionnaire on the amount of medical information they would want to receive should they be hospitalized or in a life-threatening situation. The percentage of patients who would want to have a surrogate if they were in a coma was determined, as well as the identity of the preferred surrogate. The subgroup of patients who were married or living with a partner was evaluated separately to determine how often the spouse/partner was the preferred surrogate. Associations were looked for between patients' wishes and age, sex, educational level, occupation, hierarchical order in the family, and level of confidence in medicine. SETTING: The emergency room of a teaching hospital in the Paris area (France). RESULTS: Of the 1089 patients included in the study, 5. 5 % reported that they would not want any information, 25.3 % that they would want to participate actively in all decisions about their care, and 87.3 % that they would want to be fully informed if they were in a life-threatening situation. Slightly less than one-third of the patients (29.6 %) believed they would not want a surrogate if they developed a coma. Among the patients living with a spouse/partner, 40.6 % (229/561) indicated they would want their spouse/partner to be their surrogate. A significant correlation was observed between wanting more information and wanting a surrogate. Younger patients with a higher educational level were significantly more likely to predict a desire for information and for a surrogate than the other patients. CONCLUSION: Our patients expressed a strong desire to receive extensive information should they become seriously ill, and two-thirds of them reported they would want a surrogate. However, only 40.6 % of the patients living with a spouse/partner would want their spouse/partner to be their surrogate. These data suggest that the time has probably come to propose a nation-wide public hearing on medical information and surrogacy in France.

[Urinary tract infections in the elderly]. / Infections urinaires du sujet âgé.

DEFINITIONS: Age over 65 years is generally used to define the elderly population. Urinary tract infections are increasingly frequent after this age. Comorbidity and living conditions in the elderly have a particular incidence on the clinical expression and the bacterial flora involved. Besides these elements, altered cognitive capacity and abnormal urinary function prior to the infection and lead to an atypical clinical presentation. ASYMPTOMATIC BACTERIURIA: Systematic screening has produced a large body of literature on asymptomatic bacteriuria. Our review of the literature leads to the conclusion that systematic bacteriology tests are not warranted in the elderly population in general due to the subsequent risk of germ selection and erroneous diagnosis. PRACTICAL ATTITUDE: The diagnosis of urinary infection must be evidence-based, taking into account the patient's history and ruling out other diagnoses. In all cases, antibiotics must be carefully adapted to the patient's situation and titrated to kidney function.

Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients. SRLF Collaborative Group on Mechanical Ventilation. Société de Réanimation de Langue Française.

OBJECTIVE: To evaluate the prevalence and outcome of the acute respiratory distress syndrome (ARDS) among patients requiring mechanical ventilation. DESIGN: A prospective, multi-institutional, initial cohort study including 28-day follow-up. SETTINGS: Thirty-six French intensive care units (ICUs) from a working group of the French Intensive Care Society (SRLF). PATIENTS: All the patients entering the ICUs during a 14-day period were screened prospectively. Hypoxemic patients, defined as having a PaO(2)/FIO(2) ratio (P/F) of 300 mmHg or less and receiving mechanical ventilation, were classified into three groups, according to the Consensus Conference on ARDS: group 1 refers to ARDS (P/F: 200 mmHg or less and bilateral infiltrates on the chest X-ray); group 2 to acute lung injury (ALI) without having criteria for ARDS (200 < P/F

Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal Volume reduction in ARDS.

Because animal studies have demonstrated that mechanical ventilation at high volume and pressure can be deleterious to the lungs, limitation of airway pressure, allowing hypercapnia if necessary, is already used for ventilation of acute respiratory distress syndrome (ARDS). Whether a systematic and more drastic reduction is necessary is debatable. A multicenter randomized study was undertaken to compare a strategy aimed at limiting the end-inspiratory plateau pressure to 25 cm H2O, using tidal volume (VT) below 10 ml/kg of body weight, versus a more conventional ventilatory approach (with regard to current practice) using VT at 10 ml/kg or above and close to normal PaCO2. Both arms used a similar level of positive end-expiratory pressure. A total of 116 patients with ARDS and no organ failure other than the lung were enrolled over 32 mo in 25 centers. The two groups were similar at inclusion. Patients in the two arms were ventilated with different VT (7.1 +/- 1.3 versus 10.3 +/- 1.7 ml/kg at Day 1, p < 0.001) and plateau pressures (25.7 +/- 5. 0 versus 31.7 +/- 6.6 cm H2O at Day 1, p < 0.001), resulting in different PaCO2 (59.5 +/- 15.0 versus 41.3 +/- 7.6 mm Hg, p < 0.001) and pH (7.28 +/- 0.09 versus 7.4 +/- 0.09, p < 0.001), but a similar level of oxygenation. The new approach did not reduce mortality at Day 60 (46.6% versus 37.9% in control subjects, p = 0.38), the duration of mechanical ventilation (23.1 +/- 20.2 versus 21.4 +/- 16. 3 d, p = 0.85), the incidence of pneumothorax (14% versus 12%, p = 0. 78), or the secondary occurrence of multiple organ failure (41% versus 41%, p = 1). We conclude that no benefit could be observed with reduced VT titrated to reach plateau pressures around 25 cm H2O compared with a more conventional approach in which normocapnia was achieved with plateau pressures already below 35 cm H2O.

[Myocardial infarct in the admissions and emergency service: a particular entity or predominant atypia?...]. / L'infarctus du myocarde au service d'accueil et d'urgences: une entité particulière ou la prédominance des atypies?...

The diagnosis of myocardial infarction in patients seen in the emergency ward warrants special attention. As demonstrated by Leconte et al. in this issue of La Presse Médicale, only 61% of them have typical chest pain. Nearly 7% have no pain and even 1.1% have no recognizable symptoms of myocardial infarction at all! These authors also observed that the frequency of atypical presentations increases with age. Emergency ward patients with myocardial infarction are indeed a particular population simply due to the mere fact that their symptoms did not lead to pre-hospital care by a mobile emergency unit. Considering the flow of patients in the emergency ward (myocardial infarction accounts for only 0.4% of diagnoses) and the percentage of patients in cardiac intensive care units referred from the emergency ward (23% in our unit) it is clear that special attention should be given to entertaining the diagnosis of myocardial infarction more widely in the emergency ward, particularly in older patients.

Intensive care use in a developing country: a comparison between a Tunisian and a French unit.

OBJECTIVES: To compare the variations in intensive care (ICU) outcome in relation to variations in resources utilization and costs between a developed and a developing country with different medical and economical conditions. DESIGN AND SETTING: Prospective comparison between a 26-bed French ICU and an 8-bed Tunisian ICU, both in university hospitals. PATIENTS: Four hundred thirty and 534 consecutive admissions, respectively, in the French and Tunisian ICUs. MEASUREMENTS: We prospectively recorded demographic, physiologic, and treatment information for all patients, and collected data on the two ICU structures and facilities. Costs and ICU outcome were compared in the overall population, in three groups of severity indexes and among selected diagnostic groups. RESULTS: Tunisian patients were significantly younger, were in better health previously and were less severely ill at ICU admission (p < 0.01). French patients had a lower overall mortality rate (17.2 vs 22.5%; p < 0.01) and received more treatment (p < 0.01). In the low severity range, the outcome and costs were similar in the two countries. In the highest severity range, Tunisian and French patients had similar mortality rates, while the former received less therapy throughout their ICU stays (p < 0.05). Conversely, in the mid-range of severity, mortality was higher among Tunisian patients, and a difference in management was identified in COPD patients. CONCLUSION: Although the Tunisian ICU might appear more cost-effective than the French one in the highest severity group of patients, most of this difference appeared in relation to shorter lengths of ICU stay, and a poorer efficiency and cost-effectiveness was suggested in the mid-range severity group. Differences in economical constraints may partly explain differences in ICU performances. These results indicate where resource allocation could be directed to improve the efficiency of ICU care.

Lower respiratory tract colonization and infection during severe acute respiratory distress syndrome: incidence and diagnosis.

Ventilator-associated pneumonia (VAP) is difficult to detect and is often unsuspected during adult respiratory distress syndrome (ARDS). We prospectively evaluated lower respiratory tract (LRT) colonization and infection in 30 patients with severe ARDS (PaO2/FIO2 ratio < 150 mm Hg), using repeated quantitative cultures of plugged telescopic catheter (PTC) specimens taken blindly via the endotracheal tube every 48 to 72 h after onset of ARDS. All patients except one were receiving antibiotics. When VAP was suspected on the presence of clinical criteria for infection, a repeated PTC and, when possible, a bronchoalveolar lavage (BAL) were obtained before any new antimicrobials were administered; samples growing > or = 10(3) cfu/ml (PTC) or > or = 10(4) cfu/ml (BAL) were considered diagnostic of infection. Twenty-four VAP episodes were diagnosed in 18 patients (60% of patients or 4.2/100 ventilator-days) a mean of 9.8+/-5.7 d after onset of ARDS. Eighteen LRT colonization episodes were recorded; 16 of 24 (66%) VAP episodes were preceded (by 2 to 6 d) by LRT colonization with the same organism(s), and only two episodes of colonization were not followed by VAP. We conclude that although VAP is of relatively late-onset during severe ARDS, its incidence is much higher than in other conditions and can be underestimated. Lower airways colonization is consistently followed by infection with the same organisms and precedes VAP in two thirds of episodes. Repeated protected specimens taken blindly may provide a useful means to predict infection and therefore allow early antimicrobial therapy in high-risk patients with diffuse lung injury.

Effects of positive end-expiratory pressure and different tidal volumes on alveolar recruitment and hyperinflation.

BACKGROUND: The morphologic effect of positive end-expiratory pressure (PEEP) and of two tidal volumes were studied by computed tomography to determine whether setting the tidal volume (Vt) at the upper inflection point (UIP) of the pressure-volume (P-V) curve of the respiratory system or 10 ml/kg have different effects on hyperinflation and alveolar recruitment. METHODS: Alveolar recruitment and hyperinflation were quantified by computed tomography in nine patients with the acute respiratory distress syndrome (ARDS). First, end expiration was compared without PEEP and with PEEP set at the lower inflection point of the P-V curve; second, at end inspiration above PEEP, a reduced Vt set at the UIP (rVt) and a standard 10 ml/kg Vt (Vt) ending above the UIP were compared. Three lung zones were defined from computed tomographic densities: hyperdense, normal, and hyperinflated zones. RESULTS: Positive end-expiratory pressure induced a significant decrease in hyperdensities (from 46.8 +/- 18% to 38 +/- 15.1% of zero end-expiratory pressure (ZEEP) area; P < 0.02) with a concomitant increase in normal zones (from 47.3 +/- 20.9% to 56.5 +/- 13.2% of the ZEEP area; P < 0.05), and a significant increase in hyperinflation (from 8.1 +/- 5.9% to 17.8 +/- 12.7% of ZEEP area; P < 0.01). At end inspiration, a significant increase in hyperinflated areas was observed with Vt compared with rVt (33.4 +/- 17.8 vs. 26.8 +/- 17.3% of ZEEP area; P < 0.05), whereas no significant difference was observed for both normal and hyperdense zones. CONCLUSIONS: Positive end-expiratory pressure promotes alveolar recruitment; increasing Vt above the UIP seems to predominantly increase hyperinflation.

Pressure-volume curves in acute respiratory failure: automated low flow inflation versus occlusion.

Pressure-volume (P-V) curves of the respiratory system allow determination of compliance and lower and upper inflection points (LIP and UIP, respectively). To minimize lung trauma in mechanical ventilation the tidal volume should be limited to the P-V range between LIP and UIP. An automated low flow inflation (ALFI) technique, using a computer-controlled Servo Ventilator 900C, was compared with a more conventional technique using a series of about 20 different inflated volumes (Pst-V curve). The pressure in the distal lung (Pdist) was calculated by subtraction of resistive pressure drop in connecting tubes and airways. Compliance (Cdist), Pdist(LIP), and Pdist(UIP) were derived from the Pdist-V curve and compared with Cst, Pst(LIP), and Pst(UIP) derived from the Pst-V curve. Nineteen sedated, paralyzed patients (10 with ARDS and 9 with ARF) were studied. We found: Cdist = 2.3 + 0.98 x Cst ml/cm H2O (r = 0.98); Pdist(LIP) = 0.013 + 1.09 x Pst(LIP) cm H2O (r = 0.96). In patients with ARDS: Pdist(UIP) = 4.71 + 0.84 x Pst(UIP) cm H2O (r = 0.94). In ARF, we found differences in UIP between the methods, but discrepancies occurred above tidal volumes and had little practical importance. They may reflect that Pdist comprises dynamic phenomena contributing to pressure in the distal lung at large volumes. Compliance, but not LIP and UIP, could be accurately determined without subtraction of resistive pressure from the pressure measured in the ventilator. We conclude that ALFI, which is fully automated and needing no ventilator disconnection, gives useful clinical information.