Y.-E. Claessens

Do ED staffs have a role to play in the prevention of repeat falls in elderly patients

BACKGROUND Fall-related morbidity is a serious public health issue in older adults referred to emergency departments (EDs). Emergency physicians mostly focus on immediate injuries, whereas the specific assessment of functional consequences and opportunities for prevention remain scarce. The aim of this study was to determine the factors influencing 6-month independence. METHODS We used a prospective observational study at the ED of a tertiary teaching hospital over a 6-month period. Uni- and multivariate assessments of factors related to loss of independence were examined. RESULTS A total of 367 patients survived to 6 months, mean age was 86 years, and 79% were women. The population was initially healthy and independent. Because this independence reassured the medical staff, more than 42% percent were directly discharged home without any improvement of home facilities; only 63% had recovered their independence at the end of the follow-up. There were 111 patients were hospitalized for 30 days or more. Older patients, initial Katz score, and absence of immediate trauma consequences were associated with an increased risk for loss of independence. CONCLUSIONS Because prevention is an emerging role of ED, a multidisciplinary team should evaluate fallers and propose medical and environmental changes as required for those discharged after their ED visit.

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

IntroductionFebrile 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).MethodsThis 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.Results198 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).ConclusionsIn 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.

Paracetamol vs piroxicam to relieve pain in renal colic. Results of a randomized controlled trial.

PURPOSE We tested whether paracetamol could improve pain relief in patients visiting the emergency department with acute renal colic as compared to piroxicam, a nonsteroidal anti-inflammatory drug (NSAID). MATERIALS AND METHODS Patients with a diagnosis of acute renal colic were prospectively randomized to receive either intravenous paracetamol (1 g) or intramuscular piroxicam (20 mg). We monitored patients for visual analog scale (VAS), heart rate, arterial blood pressure, need for rescue therapy, and adverse events at different time points for 90 minutes. We recorded admission requirement and new visit for renal colic at 72 hours. The primary end point was pain relief at 90 minutes, defined as a decrease of 50% or more as compared to the initial VAS. The secondary objectives were comparison of the 2 groups for VAS at any time points and the occurrence of adverse events. RESULTS Of the 226 eligible patients, 100 entered the study. Fifty patients received paracetamol and 50 received NSAID. Pain relief at 90 minutes was obtained in 40 patients receiving paracetamol (80%) and 24 (48%) receiving NSAID (P = .002). Visual analog scale was lower in the paracetamol group since 45 minutes. Only 2 adverse events were observed. CONCLUSION A single therapy with intravenous paracetamol more efficiently relieved pain in acute renal colic than did intramuscular piroxicam.

Anxiety after a fall in elderly subjects and subsequent risk of developing post traumatic stress disorder at two months. A pilot study.

BackgroundThe psychological burden suffered by elderly subjects after a fall adds to rehabilitation difficulties. We hypothesised that Post Traumatic Stress Disorder (PTSD) may be at the root of these psychological post-fall problems. The immediate psychological state was examined after 2 months post-fall in order to determine the prevalence of anxiety and PTSD and their possible correlates.MethodA single centre prospective survey including elderly subjects referred to an emergency department (ED) after a fall with a 2-month follow-up.Results30.5% of patients showed a significant level of anxiety after their fall and (26%) showed evidence supporting the presence of PTSD at 2-months. Immediate anxiety, ability to re-establish upright posture and a history of repeated falls were significant predictors of PTSD at 2-months.Conclusionpersistent psychological problems post fall may be related to PTSD which is significantly correlated to immediate anxiety. This study can be seen as a first step in patient characterisation, and predicts who may benefit from which of the various approaches of rehabilitation.

Phloroglucinol as an adjuvant analgesic to treat renal colic

PURPOSE We tested whether the addition of phloroglucinol to piroxicam could improve pain relief in patients with acute renal colic visiting the emergency department. MATERIALS AND METHODS Patients with a diagnosis of acute renal colic were prospectively randomized to receive intravenous phloroglucinol (200 mg) or placebo combined with intramuscular piroxicam (20 mg). We monitored the visual analogic scale (VAS), heart rate, arterial blood pressure, need for rescue therapy, and adverse events at different time points for 1 hour. We recorded admission requirement and new visit at 72 hours for renal colic. The primary end point was to assess pain relief at 1 hour, defined as a decrease of 50% or more as compared with the initial VAS. The secondary objectives were to compare the 2 groups for VAS at any time points, the need for rescue therapy, and the occurrence of adverse events. RESULTS Of the 309 eligible patients, 253 entered the study. A total of 126 patients received phloroglucinol and 127 patients received placebo. Pain relief at 1 hour was obtained in 89 patients (71%) receiving phloroglucinol and 89 patients (70%) receiving placebo (P = .89). There were no differences in VAS between the 2 groups at any time points. Rescue therapy was required in 37 patients (29%) receiving phloroglucinol and 38 patients (30%) receiving placebo (P = .51). Number of adverse events was similar with phloroglucinol and placebo: 20 (16%) and 16 (13%), respectively (P = .44). CONCLUSIONS There was no evidence that the addition of phloroglucinol improved the efficiency of piroxicam to relieve pain in acute renal colic.

Accuracy of D-Dimers to Rule Out Venous Thromboembolism Events across Age Categories

Background. Strategies combining pretest clinical assessment and D-dimers measurement efficiently and safely rule out venous thromboembolism events (VTE) in low- and intermediate-risk patients. Objectives. As process of ageing is associated with altered concentrations of coagulation markers including an increase in D-dimers levels, we investigated whether D-dimers could reliably rule out VTE across age categories. Method. We prospectively assessed the test performance in 1,004 patients visiting the emergency department during the 6-month period with low or intermediate risk of VTE who also received additional diagnostic procedures. Results. 67 patients had VTE with D-dimers levels above the threshold, and 3 patients displayed D-dimers levels below the threshold. We observed that specificity of D-dimers test decreased in an age-dependent manner. However, sensitivity and negative predictive value remained at very high level in each age category including older patients. Conclusion. We conclude that, even though D-dimers level could provide numerous false positive results in elderly patients, its high sensitivity could reliably help physicians to exclude the diagnosis of VTE in every low- and intermediate-risk patient.

Offline exhaled nitric oxide in emergency department and subsequent acute asthma control.

Background. Few studies have evaluated exhaled NO measurement during acute asthma. Objectives. To evaluate exhaled NO fraction (FENO) and peak expiratory flow (PEF) time-courses during acute asthma treatment (β 2-agonist plus systemic steroid) and to assess whether FENO time-course predicts subsequent asthma control. Methods. Sixty-five asthmatic patients (mean ± SD, 34 ± 10 years) were prospectively enrolled in three Emergency Departments. Results. Sixteen patients were excluded (failure of offline FENO measurement at 100 mL/s [FENO 0.1], n = 4, and early discharge). The 49 remaining patients performed FENO 0.1 and PEF on admission, at the 2nd (H2) and 6th hour (H6). Follow-up using an Asthma Control Diary was obtained in 27 of 49 patients, whether they were hospitalized (n = 9) or discharged (n = 18). All but 2 patients had elevated FENO on admission (median [interquartile], 49 [26–78] ppb). Unlike PEF, mean FENO 0.1 of our sample was not significantly modified by treatment. No significant relationship was evidenced between exhaled NO and PEF variations. The variation of FENO 0.1 [H0 minus H6] was different in patients who were hospitalized (decrease of 8 ± 20 ppb) versus discharged (increase of 5 ± 20 ppb, p = 0.04). This variation of FENO 0.1 was correlated with the Diary score (control of subsequent week), an initial increase in FENO 0.1 being associated with better asthma control. Nevertheless, neither exhaled NO nor PEFR were good predictors of asthma control. Conclusions. An increase in FENO is observed in almost all patients with acute asthma, and its subsequent increase within 6 hours is associated with a better degree of asthma control in the subsequent week.

Chilaiditi’s sign or Chilaiditi’s syndrome in the emergency department

A 40-year-old woman presented to our emergency department with an acute 4-hour history of central abdominal pain associated with nausea and vomiting. She had no past medical or surgical history but had undergone a second uncomplicated delivery 15 days previously. Her body mass index was in the normal …

Computer-assisted prescription improves the delay of morphine infusion after nurse triage in patients admitted in the emergency department with intense pain: a randomized trial

Summary Objectives First analgesic administration is usually delayed in the Emergency Department (ED). According to recommendations, intravenous morphine should be used for intense pain. To improve delay before morphine infusion, we evaluated the feasibility and efficacy of morphine administration by nurses before medical examination using a computer-assisted algorithm. Methods We designed a randomized trial in the ED of a teaching hospital (March 2003 - May 2003). Patients were adults with pain above 7/10 using the numerical rating scale (NRS). Exclusion criteria were systolic blood pressure below 100 mmHg or impaired consciousness. Patients were assigned to receive morphine either after prescription by a physician (medical arm) or using a computer-assisted algorithm before physical examination (nurse arm). Two milligrams of intravenous morphine were infused every five minutes until NRS was below 3/10. Monitoring consisted in pain assessment and recording of adverse events. Main end point was delay between triage and first morphine infusion. Secondary end points were delay before analgesia, morphine dose regimen, use of other painkillers, hospitalization rate and occurrence of side effects. Results Ninety-one patients were enrolled. Delay before morphine infusion was 41.4+22.5 minutes in the medical arm and 30+19.5 minutes in the nurse arm (P=0.01). Delay of analgesia was 50+23,6 minutes in the nurse arm and 73.4+35,58 minutes in the medical arm (Pl0.01). Two minor side effects occurred in each group. Conclusion Intravenous morphine can be safely administered by nurses for intense pain in the ED patients before physical examination using a computer-assisted algorithm and improves the delay before analgesia.

TO32 Étude de la prévalence des douleurs neuropathiques aux urgences

Introduction 80 % des patients se presentant aux urgences sont douloureux. Ces douleurs sont le plus souvent des douleurs aigues et supposees nociceptives. Objectif Le but de cette etude est d’etudier la prevalence des douleurs neuropathiques (DN) aux urgences en utilisant le questionnaire DN4. Materiel et methode Durant 15 jours, 24 heures sur 24 et 7 jours sur 7, des auditeurs ont interroge les patients se presentant aux urgences de Cochin et ont pose le questionnaire DN4. Pour chaque patient ont ete releves les antecedents, traitements, eventuelles intoxications associees. Resultats Sur 1 942 passages, 882 patients ont ete interroges (45 %). 684 questionnaires ont ete exploitables (67 refus et 131 exclus). Sur 565 patients se declarant douloureux, (82,6 % des passages), 107 patients (soit 19,1 %) ont eu un score DN4 superieur ou egal 4 donc evocateur de douleur neuropathique. Les principaux facteurs associes aux douleurs neuropathiques etaient : des douleurs aigues (98 %), post-traumatiques (52 %), une prise chronique de medicaments (33 %), des plaies (22,6 %), la presence d’une douleur radiculaire ou d’une tendinite (21 %), une infection chronique (HIV ou hepatite dans 14,1 %). La presence de toxiques, l’antecedent de cancer ou de diabete ne sont que peu presents (respectivement 2 %, 5,6 % et 2,8 %). Conclusion Cette etude a donc permis de mettre en evidence une prevalence insoupconnee de douleurs neuropathiques repondant aux criteres du DN4. Il parait necessaire qu’un depistage plus systematique des DN soit effectue aux urgences afin d’optimiser le traitement de la douleur aux urgences.