Denis Baron

Comparative study of methods of measuring acute pain intensity in an ED

The best one-dimensional method for routine self-assessment of acute pain intensity in a hospital emergency department is unknown. In this study, an 11-point numerical rating scale (NRS), a simple verbal rating scale describing five pain states (VRS), and a visual analogue scale (VAS) were presented successively on admission to 290 patients with acute pain (200 with and 90 without trauma). VAS and NRS were closely correlated for both traumatic (r = .795) and nontraumatic pain (r = .911). The VAS could not be used with 19.5% of patients with trauma and the VRS with 11% of patients without trauma, whereas the NRS could be used with 96% of all patients. The NRS proved more reliable for patients with trauma, giving equivalent results to those with the VAS for patients without trauma. These two scales showed better discriminant power for all patients. Thus, the NRS would appear to be the means for self-evaluation of acute pain intensity in an emergency department.

Prognostic factors in acute cardiogenic pulmonary edema

The purpose of this study was to determine the clinical and biological findings at admission in the Department of Emergency Medicine associated with a poor prognosis, and to evaluate early response to treatment as a prognostic factor. It was a prospective cohort study with a 5-month follow-up. One hundred eighty-six patients admitted for acute cardiogenic pulmonary edema were included. Features were analyzed at the admission and on response to initial treatment. The main outcome measure was survival at 2 end-points: hospital discharge, and 5 months of follow-up. Multivariate analysis showed that in-hospital mortality was associated with marbleization (mottling) odd-ratio (OR) = 9.0), low diuresis (OR = 4.0), high breath rate 6 hours after admission (OR = 4.0), and chronic digoxin use (OR = 3.39). Five-month mortality was associated with a bedridden state (OR = 9.0), marbleization (mottling) (OR = 5.5), myocardial infarction (OR = 3), and poor early response to initial treatment (OR = 3.2). In addition to well-known factors, the response to initial treatment evaluated 6 hours after admission was a major determinant of outcome.

Efficacy of alteplase thrombolysis for ED treatment of pulmonary embolism with shock

Our objective was to assess efficacy and tolerance of thrombolysis using 0.6 mg/kg of Alteplase in patients with massive pulmonary embolism defined as the association of a pulmonary embolism with shock. We retrospectively included 21 patients presenting with a massive pulmonary embolism confirmed by either scintigraphy or spiral computed tomography. Patients were treated on the basis of a standard rationale followed by thrombolysis with 0.6 mg/kg Alteplase over a period of 15 minutes. Hospital mortality, vital signs before and 2 hours after thrombolysis, and incidence of hemorrhagic events were recorded. Five patients (23.8%) died, 4 of these deaths occurred during the first 4 hours after hospital admission. Systolic and diastolic blood pressure (Sp02) were significantly improved 2 hours after the beginning of thrombolysis. Five minor hemorrhagic events occurred. This study demonstrates that for patients with pulmonary embolism and shock, a bolus treatment with Alteplase is potentially effective and well tolerated.

Score predicting imminent delivery in pregnant women calling the emergency medical service.

Objective To develop a telephone score predicting imminent delivery. Methods Prospective multicenter (n=38) study including pregnancies of 33 weeks or more amenorrhea (n=3.499). Values in points were assigned to risk factors (Coxs model) and the score tested on a validation cohort and receiver operating characteristic curves. Results Risk was increased if the caller was panicking or declared delivery to be imminent (+3 points), if the pregnant woman could not be spoken to herself (+3), was aged 26–35 (+3) years, was having frequent contractions (from +4 to +8), had the urge to push (+2 to +6 depending on starting time), had a history of rapid or home delivery (+2), or had not been followed up during pregnancy (+8). Nulliparous women (−7) or those on tocolytic treatment (−3) were less at risk. The score is reproducible and relevant. Conclusion Score predicting imminent delivery scoring during calls is a valid means of assessing risk of delivery.

Méningites à examen bactériologique direct négatif: Évaluation prospective d’un arbre décisionnel

Resume Objectif Elaborer un arbre decisionnel pour la prise en charge, en urgence, des meningites a examen bacteriologique direct negatif. Methode Etude prospective d’un an, dans un service d’urgences pour adultes. Comparaison avec la periode precedant immediatement la mise en application de l’arbre decisionnel. Resultats 56 patients ont ete inclus. Pas d’erreur diagnostique en ce qui concerne les meningites bacteriennes, mais petit nombre (n = 4). Pour les meningites virales (n = 40), la sensibilite de l’arbre decisionnel est de 86 % et la specificite de 83 %. Le taux de patients hospitalises plus de 24 heures a diminue de 62,5 % a 41 % (p = 0,05) et celui des prescriptions d’antibiotiques de 55 % a 16 % (p Conclusion L’arbre elabore permet, avec securite, de differencier les etiologies bacteriennes des etiologies virales, lorsque l’examen bacteriologique direct est negatif, avec pour consequence une diminution des hospitalisations et des antibiotherapies inutiles. Cette methode peut etre particulierement utile en periode d’epidemie de meningites virales.

The use of tombramycin in the management of severe infections. Clinical and pharmacological data

Tobramycin was used in the treatment of 35 severe infections. Its clinical effectiveness was confirmed in broncho-pulmonary infections without septicemia and in septicemia without lung involvement. Poor results were obtained in septicemia where the initial site 9 infection was in the lungs. This antibiotic appeared as a very good antistaphylococcal agent. In vitro superiority over gentamicin againstPseudomonas was not be confirmed clinically. Tobramycin deserves to be administered initially in serious infections because of the possibility that the causative organism might be a gentamicin-resistant, tobramycin susceptible strain. Three such cases were observed in our 35 patients. This susceptibility dissociation in favor of tobramycin was demonstrated in two strains ofKlebsiella and one strain ofEnterobacter. A dosage regimen in patients with impaired renal function is proposed. It requires confirmation.