Abstract: OBJECTIVES: Point of care testing and multimarker panels are rapidly expanding in emergency departments. We determined the reliability of Short-of-Breath SOB panel in patients admitted for acute dyspnea and/or chest pain. DESIGN AND METHODS: SOB D-dimer, BNP, cTnI, CK-MB and myoglobin assays were compared with references in 97 outpatients. RESULTS: The correlation between SOB and references methods was acceptable, but with limited precision and accuracy. CONCLUSIONS: Diagnostic performances and cut-off values should be further validated before clinicians replace traditional cardio-respiratory biomarkers by the new SOB panel.
Abstract: OBJECTIVE: B-type natriuretic peptide (BNP) and N-terminal-pro-BNP (Nt-proBNP) are commonly used for the triage of patients in the emergency department (ED) with dyspnoea and/or chest pain. The aim of our study was to determine the accuracy of N-terminal-pro-ANP (Nt-proANP) in such patients. MATERIAL AND METHODS: Nt-proANP was measured by home-made radioimmunoassay in 137 ED patients admitted with cardiovascular and/or pulmonary disorders. BNP and Nt-pro-BNP were determined with automated assays. Final diagnosis was confirmed at discharge or after follow-up. RESULTS: Nt-proANP levels were significantly influenced by the diagnostic subgroups (ANOVA: p<0.001) and were [geometric mean (range)]: 19727 ng/L (5260-45200) in congestive heart failure (CHF, n=31), 6575 ng/L (1350-36000) in coronary artery disease (CAD, n=19), 5324 ng/L (1710-13150) in pulmonary embolism (PE, n=20), 5035 ng/L (1510-16600) in pulmonary diseases (PD, n=24) and 3001 ng/L (750-11860) in patients without cardiopulmonary diseases (n=43). Pairwise comparisons demonstrated that CHF patients had Nt-pro-ANP values higher than all other groups (p<0.05) and that patients without cardiopulmonary diseases had the lowest values (p<0.05). For diagnosis of CHF, the area under the ROC curve of Nt-proANP was 0.94 (95 % CI: 0.89-0.98) and was equivalent to Nt-proBNP (0.91; p=0.284) and BNP (0.93; p=0.572). CONCLUSIONS: The diagnostic accuracy of Nt-proANP was equivalent to BNP and Nt-proBNP in the present cohort of patients admitted to ED with dyspnoea and/or chest pain.
Abstract: BACKGROUND: Multislice CT (MSCT) combined with D-dimer measurement can safely exclude pulmonary embolism in patients with a low or intermediate clinical probability of this disease. We compared this combination with a strategy in which both a negative venous ultrasonography of the leg and MSCT were needed to exclude pulmonary embolism. METHODS: We included 1819 consecutive outpatients with clinically suspected pulmonary embolism in a multicentre non-inferiority randomised controlled trial comparing two strategies: clinical probability assessment and either D-dimer measurement and MSCT (DD-CT strategy [n=903]) or D-dimer measurement, venous compression ultrasonography of the leg, and MSCT (DD-US-CT strategy [n=916]). Randomisation was by computer-generated blocks with stratification according to centre. Patients with a high clinical probability according to the revised Geneva score and a negative work-up for pulmonary embolism were further investigated in both groups. The primary outcome was the 3-month thromboembolic risk in patients who were left untreated on the basis of the exclusion of pulmonary embolism by diagnostic strategy. Clinicians assessing outcome were blinded to group assignment. Analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00117169. FINDINGS: The prevalence of pulmonary embolism was 20.6% in both groups (189 cases in DD-US-CT group and 186 in DD-CT group). We analysed 855 patients in the DD-US-CT group and 838 in the DD-CT group per protocol. The 3-month thromboembolic risk was 0.3% (95% CI 0.1-1.1) in the DD-US-CT group and 0.3% (0.1-1.2) in the DD-CT group (difference 0.0% [-0.9 to 0.8]). In the DD-US-CT group, ultrasonography showed a deep-venous thrombosis in 53 (9% [7-12]) of 574 patients, and thus MSCT was not undertaken. INTERPRETATION: The strategy combining D-dimer and MSCT is as safe as the strategy using D-dimer followed by venous compression ultrasonography of the leg and MSCT for exclusion of pulmonary embolism. An ultrasound could be of use in patients with a contraindication to CT.
Abstract: All over the world, transplant teams are looking for ways to increase and improve the donor pool. Non-heart-beating donation may increase the number of donors, even if some technical, logistical, and emotional problems are still encountered. The results obtained by our team should stimulate other centers to implement this kind of donation in their hospitals. Herein we have described our experience with non-heart-beating donation.
Abstract: Objective. B-type natriuretic peptide (BNP) and N-terminal-pro-BNP (Nt-proBNP) are commonly used for the triage of patients in the emergency department (ED) with dyspnoea and/or chest pain. The aim of our study was to determine the accuracy of N-terminal-pro-ANP (Nt-proANP) in such patients. Material and methods. Nt-proANP was measured by home-made radioimmunoassay in 137 ED patients admitted with cardiovascular and/or pulmonary disorders. BNP and Nt-pro-BNP were determined with automated assays. Final diagnosis was confirmed at discharge or after follow-up. Results. Nt-proANP levels were significantly influenced by the diagnostic subgroups (ANOVA: p<0.001) and were [geometric mean (range)]: 19727 ng/L (5260-45200) in congestive heart failure (CHF, n = 31), 6575 ng/L (1350-36000) in coronary artery disease (CAD, n = 19) , 5324 ng/L (1710-13150) in pulmonary embolism (PE, n = 20), 5035 ng/L (1510-16600) in pulmonary diseases (PD, n = 24) and 3001 ng/L (750-11860) in patients without cardiopulmonary diseases (n = 43). Pairwise comparisons demonstrated that CHF patients had Nt-pro-ANP values higher than all other groups (p<0.05) and that patients without cardiopulmonary diseases had the lowest values (p<0.05). For diagnosis of CHF, the area under the ROC curve of Nt-proANP was 0.94 (95 % CI: 0.89-0.98) and was equivalent to Nt-proBNP (0.91; p = 0.284) and BNP (0.93; p = 0.572). Conclusions. The diagnostic accuracy of Nt-proANP was equivalent to BNP and Nt-proBNP in the present cohort of patients admitted to ED with dyspnoea and/or chest pain.
Abstract: Continuous positive airway pressure (CPAP) is frequently used in patients attending emergency units. Its combination with nebulization is sometimes necessary in those patients presenting with a CPAP dependency. STUDY OBJECTIVE: To compare lung deposition of amikacin delivered by a classical jet nebulizer (SideStream; Medic-Aid; West Sussex, UK) used alone (SST) or coupled to a CPAP device (Boussignac; Vygon; Belgium). METHOD: Amikacin (1g) was nebulized with both devices in six healthy subjects during 5 min on spontaneous breathing. A 1-week wash-out period between each nebulization was applied. Lung deposition was indirectly assessed by urinary monitoring of excreted amount of amikacin. RESULTS: Total daily amount of amikacin excreted in the urine was significantly lower with CPAP than with SST (1.97% initial dose versus 4.88% initial dose, p<0.001) with a corresponding mean ratio CPAP/SST of 0.41. The residual amount of amikacin in the nebulizer was higher with CPAP than with SST (607 mg versus 541 mg) but the difference was not significant (p=0.35). CONCLUSION: These data suggest that the amount of amikacin delivered to healthy lungs is 2.5-fold lower with CPAP than with SST for the same nebulization time and that the nebulization time when using CPAP should be increased to reach the same amount of drug delivered with a classical jet nebulizer.
Abstract: In this observation, we report a novel use of noninvasive positive pressure ventilation in the operating room to support ventilation in an acidotic hypercapnic patient with severe acute chronic respiratory failure refuted for general anaesthesia, operated under spinal anaesthesia for a femoral fracture. The feasibility of noninvasive ventilatory assistance during surgery performed under regional anaesthesia is reported here. In selected cases, noninvasive ventilation can be used in the management of patients with acute or chronic respiratory failure requiring an urgent surgical intervention but in whom the respiratory status excluded a general anaesthesia.
Abstract: Compared to other hospital units, the emergency department presents some distinguishing characteristics of its own. Emergency health-care delivery is a collaborative process involving the contribution of several individuals who accomplish their tasks while working autonomously under pressure and sometimes with limited resources. Effective computerization of the emergency department information system presents a real challenge due to the complexity of the scenario. Current computerized support suffers from several problems, including inadequate data models, clumsy user interfaces, and poor integration with other clinical information systems. To tackle such complexity, we propose an approach combining three points of view, namely the transactions (in and out of the department), the (mono and multi) user interfaces and data management. Unlike current systems, we pay particular attention to the user-friendliness and versatility of our system. This means that intuitive user interfaces have been conceived and specific software modeling methodologies have been applied to provide our system with the flexibility and adaptability necessary for the individual and group coordinated tasks. Our approach has been implemented by prototyping a web-based, multiplatform, multiuser, and versatile clinical information system built upon multitier software architecture, using the Java programming language.
Abstract: STUDY OBJECTIVE: To compare the diagnostic performance of volumetric capnography (VCap), which is the plot of the expired CO(2) partial pressure against the expired volume during a single breath, with the PaCO(2) to end-tidal CO(2) (EtCO(2)) gradient, in the case of suspected pulmonary embolism (PE). DESIGN: Single-center, prospective study. SETTING: Emergency department of a teaching hospital. PATIENTS: A total of 45 outpatients with positive enzyme-linked immunosorbent assay d-dimer levels of > 500 ng/mL. The diagnosis of PE was confirmed in 18 outpatients according to a validated procedure based on the ventilation-perfusion lung scan and/or spiral CT scanning. INTERVENTIONS: Curves of VCap were obtained from a compact monitor connected to a computer. A sequence of four to six stable breaths allowed the calculation of the following several variables: alveolar dead space fraction; the ratio of alveolar dead space (VDalv) to airway dead space (VDaw); the VDalv to physiologic dead space (VDphys) fraction; the slope of phase 3; and the late dead space fraction (Fdlate) corresponding to the extrapolation of the capnographic curve to a volume of 15% of the predicted total lung capacity. RESULTS: The mean (+/- SD) PaCO(2)-EtCO(2) gradient was 5.3 +/- 0.7 mm Hg in the PE-positive group and 2.8 +/- 0.7 mm Hg in the PE-negative group (p = 0.019). Four variables of the VCap exhibited a statistical difference between both groups, as follows: the VDalv/VDaw fraction(;) the slope of phase 3; the VDalv/VDphys fraction; and the Fdlate, which was 8.2 +/- 3.3% vs -7.7 +/- 2.8%, respectively (p = 0.000011). The diagnostic performance expressed as the mean area under a receiver operating characteristic curve comparison was 75.9 +/- 7.4% for the PaCO(2)-EtCO(2) gradient and 87.6 +/- 4.9% for the Fdlate (p = 0.02). CONCLUSION: Fdlate, a variable of VCap, had a statistically better diagnostic performance in suspected PE than the PaCO(2)-EtCO(2) gradient. VCap is a promising computer-assisted bedside application of pulmonary pathophysiology. Future research should define the place of this technique in the diagnostic workup of PE, especially in the presence of positive d-dimers.
Abstract: OBJECTIVE: To describe the use of volumetric capnography, a plot of expired CO(2) concentration against expired volume, in monitoring fibrinolytic treatment of major pulmonary embolism. DESIGN AND SETTING: Two case reports in the emergency department of a teaching hospital. PATIENTS: Two conscious and spontaneously breathing patients (69- and 31-year-old women) with major pulmonary embolism requiring thrombolysis. Decision for thrombolysis was based on the association of right ventricular afterload on echocardiography, with respiratory failure and hypotension in the first patient, and dyspnea and hemodynamically stable parameters in the second one. INTERVENTIONS: Successive capnographic measurements were performed before, during, and after thrombolysis. Curves of volumetric capnography were obtained from a sidestream gas monitor with flow sensor and an arterial blood gas analysis for CO(2) partial pressure. MEASUREMENTS AND RESULTS: We calculated late deadspace fraction, previously suggested as the most effective capnographic parameter in the diagnosis of pulmonary embolism. Late deadspace fraction decreased in the two patients, respectively, from 64.4% to 1.1% and from 25.6% to 5.7% after thrombolysis, with a concomitant disappearance of right heart dysfunction signs on echocardiography. CONCLUSIONS: Volumetric capnography can monitor thrombolysis in major pulmonary embolism. Differences between volumetric capnography technology and the more traditional arterial to end-tidal CO(2) gradient are important to take into account for clinical application.
Abstract: INTRODUCTION: At present, most emergency services handle the multitude of various demands in the same unity of place and by the same team of nurses aides, with direct consequences on the waiting time and in the handling of problems of varying degrees of importance. Our service examines other administrative models based on a triage of time and of orientation. METHODS AND RESULTS: In a prospective study on 679 patients, we have validated a triage tool inspired from the ICEM model (International Cooperation of Emergency Medicine) allowing patients to receive, while they wait, information and training, based on the resources provided, in order to deal with their particular medical problem. CONCLUSION: The validation of this tool was carried out in terms of its utilization as well as its reliability. It appears that, with the type of triage offered, there is a theoretical reserve of waiting time for the patients in which the urgency is relative, and which could be better used in the handling of more vital cases.
Abstract: A 36-year-old woman presented to the Emergency Room because of abdominal pain associated with hematuria and red blood blending to stool. On admission, the physical examination revealed abdominal tenderness and diffuse cutaneous hematoma. The laboratory findings showed abnormal clotting tests with high International Normalised Ratio (INR) and prolonged activated partial thromboplastin time. Hemoperitoneum and ureteral hematoma were noted on the abdomen computed tomography. The patient confessed she had ingested difenacoum for several weeks. All the symptoms resolved with fresh frozen plasma perfusion and vitamin K.
Abstract: The aim of the present study was to clarify whether the known effects of noninvasive positive-pressure ventilation (NPPV) in patients with respiratory failure are real or due to placebo effects and whether early application of NPPV in the emergency department leads to rapid improvement of the patients condition and outcome. A prospective randomised placebo-controlled study was conducted in 20 patients with severe acute respiratory failure (ARF) secondary to an acute exacerbation of chronic obstructive pulmonary disease (COPD) or acute pulmonary oedema, not improving under conventional medical therapy and on the edge of intubation. Patients received either conventional medical therapy plus two-level NPPV (hi-level NPPV) or conventional medical therapy plus "placebo" NPPV. The main outcome measures involved the need for endotracheal intubation in the bi-level NPPV arm and in the placebo arm after crossing over to active NPPV. Morbidity, length of stay, mortality and the effect of the ventilatory mode on clinical, arterial-blood gas parameters, and the sternocleidomastoid muscles electromyogram (EMG) activity were also measured. The 10 patients in the active NPPV group rapidly improved and none needed intubation. Placebo NPPV resulted in no change in the clinical condition of patients that continued to worsen and the 10 patients were crossed over to active NPPV. Three patients were intubated. No differences in terms of morbidity, length of stay or mortality between the two groups were observed. Active NPPV (but not placebo NPPV) led to a rapid and significant improvement in the clinical parameters, pH and the carbon dioxide tension in arterial blood and to a decrease in respiratory frequency and sternocleidomastoid EMG activity. Early application of bi-level noninvasive positive-pressure ventilation in patients with severe acute respiratory failure, due to chronic obstructive pulmonary disease and acute pulmonary oedema, leads to a rapid improvement in clinical status and blood gases. Noninvasive positive-pressure ventilation had no placebo effect.
Abstract: Severe poisoning with effervescent paracetamol tablets has never been described in the literature. Indeed, the effervescent formulation contains high amounts of sodium and bicarbonate, both responsible for important emetic properties in the case of massive ingestion. Moreover, dissolving more than 6-8 tablets in the same glass appears to be difficult. We report a well-documented case of a patient with potentially hepatotoxic serum levels after the ingestion of 16 g effervescent paracetamol, apparently without vomiting. We show that the difficulties of a massive oral intake may be overcome by a slow intake. Nevertheless, this case report does not modify the important assertion that effervescent paracetamol use could limit the risk of life-threatening intoxication by a single massive acute overdose.
Abstract: A study was undertaken to assess the availability and use of non-invasive ventilation (NIV) for the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) in emergency departments in Belgium. A questionnaire was sent to the head physicians of 145 emergency departments (EDs) found in the list of the Belgian College of Emergency Physicians (BeCEP). Ninety eight questionnaires were analysed (representing 68% of the questionnaires sent). NIV was used in 49% of the EDs. In the hospitals where NIV was not used, the most important reasons given were no available equipment in 71%, lack of experience with this form of treatment in 32.7%, and more time consuming for physicians and nursing staff in 22.8%. Only 3.8% of the physicians doubted the benefit of NIV treatment. In the hospitals where NIV was used, the patient was watched during the first hour by one nurse only in 19.6%, by one physician in 8.6% and by a nurse and a physician in 54.5%. NIV was used for more than 4 h in 33% of EDs. Pressure-controlled ventilation (with home respirators) was used more often than volume-controlled ventilation.
Abstract: To maintain arterial oxygen saturation (Sa,O2) above 90% in patients with acute respiratory failure, oxygen (O2) is often added to the circuit of two-level noninvasive positive pressure ventilation (NPPV). However, the final inspiratory oxygen fraction (Fi,O2) is not known. To clarify this issue, the effect of different inspiratory positive airway pressures (IPAP) of the oxygen tubing connection site and the flow rate of O2, on Fi,O2 was assessed. The effects of the tidal volume (VT) and the respiratory rate on the Fi,O2 were then clarified in a model study. The Fi,O2 varied depending on the point where O2 was added to the circuit. When all other variables were constant, the connection closest to the exhaust port (ventilator side) gave the highest Fi,O2. Increases in IPAP led to decreases in Fi,O2. Finally, Fi,O2 increased with O2 flow, although it was difficult to obtain an Fi,O2 >0.30 unless very high O2 flows were used. Paradoxically, NPPV with low IPAP values and without O2 supplementation led to a Fi,O2 <0.21 at the circuit-patient interface. VT and respiratory rate did not appear to influence Fi,O2. To conclude, when using noninvasive positive pressure ventilation with two-level respirators, oxygen should be added close to the exhaust port (ventilator side) of the circuit. If inspiratory airway pressure levels are >12 cmH2O, oxygen flows should be at least 4 L x min(-1).
Abstract: End tidal CO(2) measurement may be helpful in detecting the efficacy of thrombolysis after a massive pulmonary embolism. We report the case of a 76-year-old man with a massive pulmonary embolism, who required early intubation and mechanical ventilation. Thrombolysis with rtpA (total dosage: 60 mg) was initiated. During this procedure, clinical data, arterial blood gases and end-tidal CO(2) with a capnograph were recorded. Before thrombolysis the P(a-ET)CO(2) gradient was raised to 25 mmHg. During thrombolysis, the clinical data improved and the P(a-ET) gradient fell to 14 mmHg. We postulate that the P(a-ET)CO(2) gradient seems to be a reasonable indicator of efficacy of thrombolysis in this setting. However, the gradient did not return to normal values (4-5 mmHg). The possible reasons for this may be that during mechanical ventilation there was a large ventilation-perfusion ratio and the cardiac output may have still reduced. With these limitations, we conclude that the P(a-ET)CO(2) gradient should be evaluated as an indicator of pulmonary reperfusion in massive pulmonary embolism.
Abstract: The aim of this study was to analyze the color Doppler sonographic findings in primary epiploic appendagitis. Color Doppler sonographic findings of ten patients with primary epiploic appendagitis were reviewed. The following sonographic features were analyzed: identification of a mass adjacent to the colonic wall; identification of spotty color areas with arterial flow in this mass and detection of abnormalities of the colonic wall adjacent to the infiltrated fatty tissue. A well-delineated hyperechoic mass adjacent to the colonic wall was detected in each patient with sonography. No colonic wall abnormalities were observed nor color Doppler signal in and around the hyperechoic area. Absence of flow at color Doppler sonography is an additional feature of epiploic appendagitis.
Abstract: OBJECTIVE. The objective of this study was to compare the value of color Doppler sonography with early clinical and laboratory findings in determining the prognosis of patients with ischemic colitis. SUBJECTS AND METHODS. We reviewed the early clinical, laboratory, and color Doppler sonographic data of 24 patients with ischemic colitis. The patients were divided into two groups on the basis of their outcome. The first group comprised the patients with transient ischemia who recovered uneventfully, and the second group included the patients who needed surgery because of symptomatic transmural colic gangrene or colic stricture. Clinical data and laboratory values were compared with color Doppler sonographic findings including colic wall thickness, presence of stratification, and arterial flow in the bowel wall. RESULTS. At univariate analysis, increased age (p = 0.007), leukocyte count (p = 0.030), lactate dehydrogenase level (p = 0.030), blood lactate level (p = 0.041), and absence of vascular flow in the colic wall (p<0.001) were significantly related to complicated ischemic colitis. At multivariate analysis, absence of arterial flow was the only significant predictor of complicated ischemic colitis (p = 0.002), with a sensitivity of 82%, a specificity of 92%, a positive predictive value of 90%, and a negative predictive value of 86%. CONCLUSION. Absence of arterial flow in the wall of the ischemic colon on initial color Doppler sonography is suggestive of an unfavorable outcome and is more closely associated with outcome than early clinical and laboratory findings.
Abstract: There are few data on the use of two-level non-invasive positive pressure ventilation (two-level nIPPV) in the initial treatment of severe acute respiratory failure in emergency departments (ED). In a prospective, non-randomized, pilot study, we assessed (1) the feasability of this method in an ED, (2) its effect on clinical and laboratory data, and (3) its effect on the need of intubation and the final outcome of patients. During a 1-year period all eligible patients admitted for acute respiratory failure, with absence of improvement after periods of specific classic treatments, were included in the study. Each patient received a specific classic treatment and two-level nIPPV with a two-level positive pressure ventilator through a face mask. We recorded parameters on admission, after 15 and 45 minutes of nIPPV and at the end of nIPPV. Sixty-two patients were included: 29 with acute pulmonary oedema (APO), 16 with acute exacerbation of chronic obstructive pulmonary disease (COPD), four with asthma, and 13 with various diseases. In the APO-group, we observed a statistically significant improvement of respiratory and pulse rates, diastolic blood pressure, pH, PaCO2 and SaO2. In acute exacerbation of COPD, we observed only a statistical improvement of respiratory and pulse rates without any significant change of PaCO2 and pH. In the two other groups, there was a clinical, gasometric and haemodynamic improvement in all patients. Four patients were intubated and 10 died, but none in the ED or in the first 24 hours after hospital admission. We were able to institute two-level nIPPV for severe acute respiratory failure in an ED without complications. Its addition to the rest of classic specific treatment seems to bring about a rapid improvement of various clinical and laboratory parameters in most patients. We found no deleterious effect of nIPPV when implemented for short periods of time in the emergency department setting.
Abstract: Emergency medicine has emerged as a specific medical specialty for 30 years. To be efficient, the emergency clinician frequently needs the contribution of radiological examinations. This is the reason why emergency radiology has emerged as a new radiologic subspecialty. The aim of this paper is to review the recent history of emergency medicine and to summarize the present state of the radiological organisation for emergency care in the Western countries.
Abstract: The congenital complete heart block (CCHB) is a rare affection. In our two centers, in a period of 10 years, 1405 pacemakers were placed and only 10 (0.71%) for CCHB. We review the clinical history, the EKG's, echocardiography and Holter monitoring of these 10 patients. All of them were symptomatic. After pacemaker implantation, symptoms were improved in 90%. No death or other morbidity were observed during the long-term follow-up. So, the clinical outcome of patients with CCHB who underwent prophylactic pacemaker implantation seems to be associated with an excellent prognosis.
Abstract: Chemotherapy has become a very important part of the therapy for several cancers. Complete remission, and sometime cure, can be achieved with this treatment modality. However, when relapse occur, a second remission is seldom obtained. This failure is believed to be linked, at least in part, to the development of drug resistant tumor cells. Our understanding of the mechanisms underlying this resistance, especially regarding the multidrug resistance (MDR) phenomenon, has improved over the recent years. New strategies are being developed to circumvent drug resistance and come now to clinical trials.
