External validation of Glasgow-Blatchford, modified Glasgow-Blatchford and CANUKA scores to identify low-risk patients with upper gastrointestinal bleeding in emergency departments: a retrospective cohort study.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a medical emergency with an approximate mortality of 10%, which results in a high hospitalisation rate. The Glasgow-Blatchford score (GBS) is recommended to identify low-risk patients who can be discharged from the emergency department (ED). A modified GBS (mGBS) and CANUKA score have recently been proposed but have not been well studied. The aim of this study was to assess whether the use of GBS, mGBS or CANUKA score could identify patients at low risk of death or need for intervention. METHODS: A single-centre retrospective study was performed including patients with suspected UGIB visiting the ED of Saint-Antoine hospital (Paris, France) from January 2016 to December 2018. Demographic and medical data needed to calculate GBS and CANUKA were collected, as well as outcomes data. Need for intervention was defined as the need for blood transfusion, endoscopic haemostasis or rebleeding within 7 days. In-hospital mortality was also collected. Sensitivity, specificity and predictive values were measured for the score thresholds of interest. RESULTS: A total of 386 patients were included. Median age was 60 years (38-78), 65.3% (n=252) were male and 60% (n=233) were hospitalised. A GBS≤1, mGBS=0 and CANUKA≤2 categorised 24.9%, 18.2% and 18.9% of patients as low risk, respectively. There was a need for intervention in 2.2%, 4.6% and 0% of those patients categorised as low risk by GBS, mGBS and CANUKA, respectively. No deaths occurred in the patients identified as low risk, regardless of the score used. All scores had a high sensitivity and negative predictive value. CONCLUSIONS: In patients with UGIB, the use of a GBS≤1 or CANUKA score ≤2 appears to be safe for identifying patients at low risk of death or need for intervention.

Left atrial compression by a large hiatal hernia: A rare cause of cardiac dysfunction.

Symptomatic hiatal hernia (HH) is most often revealed by gastroesophageal reflux disease, but there are atypical presentations some of which are life-threatening. We report the case of a 57-year-old woman brought to the emergency department with isolated shortness of breath for 24 h. Initial explorations revealed unexplained hyperlactatemia (6.4 mmol/L) without clinical or biological evidence of hypovolemia, distributive, obstructive or cardiogenic shock. Two hours after admission, we observed a decreased of blood pressure and an increase of lactate level to 7.9 mmol/L. A bedside echocardiography revealed an extra-cardiac left atrial compression and thoracoabdominal computed tomography showed a large sliding HH compressing the left atrium. After an upper gastrointestinal endoscopy permitting the aspiration of gastric contents, a repair surgery was performed without complications and patient was discharge three days later. Emergency physicians should be aware that HH can be a rare cause of cardiac symptoms by heart compression and certainly use echocardiography for unexplained hemodynamic failure.

Evaluation of use and identification of predictive factors for nonuse of peripheral venous catheters in the emergency department.

The placement of peripheral venous catheters (PVC) is a frequent procedure in the emergency department (ED), which exposes patients to complications (hematoma, fluid leakage, phlebitis, edema, infection), increases hemolysis of blood samples, is time-consuming and costly. The main aim of this study is to analyze the rate of PVC nonuse in the ED and to identify predictive factors of their nonuse. This prospective single-center observational study was conducted in the ED of the Saint-Antoine Hospital in Paris, France between February and March 2022. Adult patients receiving a PVC were included. In addition to demographic and medical data, the reason for PVC prescription and the prescribing physician's expectation of PVC use were collected. A total of 304 patients were included, with a median age of 61.5 years (IQR: 43-79 years), of whom 152 (50%) were men. PVC were primarily prescribed for intravenous medication administration. Seventy-two (23.7%) PVC were not used. In multivariable analysis, the predictive factors of nonuse were the prescribing physician's expectation of nonuse [OR 6.35, CI 95% (2.64-15.29), for "no" and "not sure" vs. "yes" responses] and the reason for prescribing "just in case" [OR 3.54, CI 95% (1.37-9.17)]. PVC were not used in 23.7% of cases. Predictors of nonuse were the prescribing physician's expectation of nonuse and the reason for prescribing "just in case". A PVC should probably not be prescribed if the prescribing physician thinks it will not be used or prescribes it "just in case".