0043: Prognosis of patients admitted with chest pain in emergency department and discharged with low risk of acute coronary syndrome

IntroductionChest pain is a frequent cause of admission to the emergency department (ED). The diagnosis and medical care of acute coronary syndrome (ACS) with ST-segment elevation (ST+ ACS) are more standardized than non ST-segment elevation ACS (NST ACS). There is very few series on patients classified as low ACS-diagnosis probability. We aimed to assess the 1-year outcome of patients admitted for chest pain in ED and discharged with low risk of ACS.MethodsThis restrospective study included all patients admitted in the ED of University Hospital Center of Limoges between January and March 2013 for chest pain, without ST-segment elevation and normal troponin level. Patients’ characteristics and initial diagnosis were collected in ED records. Final diagnosis was obtained by phone one year later, from general practitioners or alternatively directly from the patients themselves.ResultsAmong the 244 patients studied, 38 (15.6%) were lost during follow-up. Mean age was 50±17 years, 58% being males. Among the 41% of cases in whom the initial diagnosis (i.e. ED discharge) was modified during follow-up, 9% (n=8) were diagnosed with coronary disease, and 38% (n=32) with panic attack. Major adverse cardiac events rate was 2.4% (n=5) in the whole population, and 60% of them were directly discharged to home. In the ED, the detection of a cardiovascular etiology of chest pain was accurate with good specificity (96%) but lower sensibility (61%). Of note, the rate of false negative patients was 8.5%.ConclusionLow probability NST SCA diagnosis is complex in the ED and may frequently lead to erroneous diagnosis associated with therapeutic delay. Nevertheless, cardiac disorders are uncommonly misdiagnosed. A systematic, individualized and close monitoring after ED discharge is mandatory

Intérêt de la ventilation non invasive dans la bronchiolote aiguë du nourrisson en réanimation pédiatrqiue (étude rétrospective au CHU de Limoges de 2009 à 2012)

LIMOGES-BU Médecine pharmacie (870852108) / SudocSudocFranceF

Utilisation du défibrilateur semi-automatique par les sapeurs-pompiers de Haute-Vienne (étude sur les interventions médicalisées de juillet 2000 à juin 2005)

LIMOGES-BU Médecine pharmacie (870852108) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Prise en charge du traumatisé crânien grave en pré-hospitalier (étude rétrospective sur l'année 2005 au Samu 87)

Les traumatismes crâniens graves (TCG) , définit par un score de Glasgow (GCS) <=8, sont une cause majeure de décès et de handicaps pour la population des adultes jeunes. Les particularités de la régulation du débit sanguin cérébral et du liquide céphalorachidien, permettent de comprendre l'importance des agressions cérébrales secondaires d'origine systèmique (ACSOS) dans l'aggravation d'une lésion cérébrale primitive traumatique. La prise en charge pré-hospitalière des TCG doit donc s'organiser comme une véritable chaîne de lutte contre les ACSOS. Patients et Méthodes- Tous les traumatisés crâniens graves(TCG) pris en charge par le SMUR de Limoges de plus de 18 ans et hospitalisés en réanimation au CHRU, ont été étudiés rétrospectivement. Le GCS, la pression artérielle, la Saturation artérielle en O2 (SAO2), la prise en charge circulatoire, respiratoire, anesthésique; l évaluation thermique et glycémique, ainsi que les délais de transport sont relevés initialement, pendant le transport et à l arrivée aux urgences. Les premiers examens au déchoquage sont aussi relevés. Chaque paramètre a été statistiquement comparé au score de pronostique à 1 mois et 6 mois (GOS). Résultats- 30 patients ont été inclus. La mortalité à 6 mois était de 40 % et 30% des patients n ont présenté aucune séquelles ou des séquelles modérées. Un pic d incidence, lié aux AVP est confirmé chez les hommes jeunes. L intérêt d une médicalisation pré hospitalière est mis en évidence d autant que le délai moyen d admission, 1h29 +- 35 min, est faible. L intérêt du GCS initial (p<0.008) et de sa réévaluation sont confirmés en terme de pronostique. La pression artérielle chute significativement pendant le transport alors que la SAO2 s améliore. Malgré un remplissage correct, l utilisation des catécholamines semble insuffisante, ainsi que la transfusion. L osmothérapie reste sous utilisée. La mise en place de la capnographie et d un monitorage multi-modale reste peu fréquente. Conclusion-La prise en charge du TCG permet une correction des hypoxémies mais l ensemble des ACSOS n est pas corrigé de manière suffisante. Le respect des recommandations reste essentiel pour améliorer cette prise en charge.LIMOGES-BU Médecine pharmacie (870852108) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

MORT SUBITE DU NOURRISSON (ETUDE RETROSPECTIVE AU CHRU DE LIMOGES DE 1990 A 1999)

LIMOGES-BU Médecine pharmacie (870852108) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Traitement de l'oedème aigu du poumon cardiogénique par boli de dérivés nitrés intra veineux

LIMOGES-BU Médecine pharmacie (870852108) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Is prehospital endobronchial intubation a risk factor for subsequent ventilator associated pneumonia? A retrospective analysis

International audienceMore than half of patients under mechanical ventilation in the intensive care unit (ICU) are field-intubated, which is a known risk factor for ventilator associated pneumonia (VAP). We assessed whether field endobronchial intubation (EBI) is associated with the development of subsequent VAP during the ICU stay. This retrospective, nested case-control study was conducted in a cohort of field-intubated patients admitted to an ICU of a teaching hospital during a three-year period. Cases were defined as field-intubated patients with EBI and controls corresponded to field-intubated patients with proper position of the tracheal tube on admission chest X-ray. Primary endpoint was the development of early VAP. Secondary endpoints included the development of early ventilator associated tracheo-bronchitis, late VAP, duration of mechanical ventilation, length of stay and mortality in the ICU. A total of 145 patients were studied (mean age: 54 ± 19 years; men: 74%). Reasons for field intubation were predominantly multiple trauma (49%) and cardiorespiratory arrest (38%). EBI was identified in 33 patients (23%). Fifty-three patients (37%) developed early or late VAP. EBI after field intubation was associated with a nearly two-fold increase of early VAP, though not statistically significant (30% vs. 17%: p = 0.09). No statistically significant difference was found regarding secondary outcomes. The present study suggests that inadvertent prehospital EBI could be associated with a higher incidence of early-onset VAP. Larger studies are required to confirm this hypothesis. Whether strategies aimed at decreasing the incidence and duration of EBI could reduce the incidence of subsequent VAP remains to be determined

The mortality rates in registries of patients with STEMI are highly affected by inclusion criteria and population characteristics

International audienceBackground: Different mortality rates are reported in registries of patients with ST-segment elevation myocardial infarction (STEMI), but comparisons between registries are challenging. Aims: To determine whether the higher mortality rate in our regional French registry (SCALIM) is related to different inclusion criteria and demographic characteristics. Methods: The SCALIM registry included all patients with STEMI within the first 24 h in the region of Limousin, France (06/2011-01/2015). To compare mortality rates with other contemporary registries in France and European neighbouring countries, the others' inclusion criteria were applied to the SCALIM registry. Results: Among 1501 patients included, in-hospital and 1-month mortality were 8.2% and 8.8% respectively, significantly higher than many other registries. The use of inclusion criteria from EMUST (France), MINAP (UK) or LOMBARDIMA (Italy) markedly decreased the number of enrolled patients by 64%, 36%, and 21%, respectively. When those inclusion criteria were applied to the SCALIM registry, difference in in-hospital and 1-month mortality rates between other registries and ours remained significant. In the multivariate analysis, age, initial acute pulmonary oedema (Killip class ≥2), complication occurring before percutaneous coronary intervention, absence of transfer to an interventional cardiology centre for primary angioplasty and lack of reperfusion therapy within 12 h were associated with higher risk of 1-month mortality (all p < 0.05). Age (65 versus 63.3 years, p < 0.001) was higher and reperfusion rate (84.2 versus 74.7%, p < 0.001) was significantly lower in SCALIM than FAST-MI, the national French registry on STEMI patients. Interestingly, the 3% of patients included in SCALIM who would be excluded from FAST-MI registry had 91% mortality at one month. Conclusion: Higher mortality rate in our regional SCALIM registry is in part due to differences in inclusion criteria and demographic data. Consensus should be made to harmonise inclusion criteria in STEMI registries for the sake of comparability

Direct transfer to angiosuite for patients with severe acute stroke treated with thrombectomy: the multicentre randomised controlled DIRECT ANGIO trial protocol

International audienceIntroduction Mechanical thrombectomy (MT) increases functional independence in patients with acute ischaemic stroke with anterior circulation large vessel occlusion (LVO), and the probability to achieve functional independence decreases by 20% for each 1-hour delay to reperfusion. Therefore, we aim to investigate whether direct angiosuite transfer (DAT) is superior to standard imaging/emergency department-based management in achieving 90-day functional independence in patients presenting with an acute severe neurological deficit likely due to LVO and requiring emergent treatment with MT. Methods and analysis DIRECT ANGIO (Effect of DIRECT transfer to ANGIOsuite on functional outcome in patient with severe acute stroke treated with thrombectomy: the randomised DIRECT ANGIO Trial) trial is an investigator-initiated, multicentre, prospective, randomised, open-label, blinded endpoint (PROBE) study. Eligibility requires a patient ≤75 years, pre-stroke modified Rankin Scale (mRS) 0–2, presenting an acute severe neurological deficit and admitted within 5 hours of symptoms onset in an endovascular-capable centre. A total of 208 patients are randomly allocated in a 1:1 ratio to DAT or standard management. The primary outcome is the rate of patients achieving a functional independence, assessed as mRS 0–2 at 90 days. Secondary endpoints include patients presenting confirmed LVO, patients eligible to intravenous thrombolysis alone, patients with intracerebral haemorrhage and stroke-mimics, intrahospital time metrics, early neurological improvement (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0–1 at 24 hours) and mRS overall distribution at 90 days and 12 months. Safety outcomes are death and intracerebral haemorrhage transformation. Medico-economics analyses include health-related quality of life and cost utility assessment. Ethics and dissemination The DIRECT ANGIO trial was approved by the ethics committee of Ile de France 1. Study began in April 2020. Results will be published in an international peer-reviewed medical journal. Trial registration number NCT03969511

Direct transfer to angiosuite for patients with severe acute stroke treated with thrombectomy: the multicentre randomised controlled DIRECT ANGIO trial protocol

Introduction Mechanical thrombectomy (MT) increases functional independence in patients with acute ischaemic stroke with anterior circulation large vessel occlusion (LVO), and the probability to achieve functional independence decreases by 20% for each 1-hour delay to reperfusion. Therefore, we aim to investigate whether direct angiosuite transfer (DAT) is superior to standard imaging/emergency department-based management in achieving 90-day functional independence in patients presenting with an acute severe neurological deficit likely due to LVO and requiring emergent treatment with MT.Methods and analysis DIRECT ANGIO (Effect of DIRECT transfer to ANGIOsuite on functional outcome in patient with severe acute stroke treated with thrombectomy: the randomised DIRECT ANGIO Trial) trial is an investigator-initiated, multicentre, prospective, randomised, open-label, blinded endpoint (PROBE) study. Eligibility requires a patient ≤75 years, pre-stroke modified Rankin Scale (mRS) 0–2, presenting an acute severe neurological deficit and admitted within 5 hours of symptoms onset in an endovascular-capable centre. A total of 208 patients are randomly allocated in a 1:1 ratio to DAT or standard management. The primary outcome is the rate of patients achieving a functional independence, assessed as mRS 0–2 at 90 days. Secondary endpoints include patients presenting confirmed LVO, patients eligible to intravenous thrombolysis alone, patients with intracerebral haemorrhage and stroke-mimics, intrahospital time metrics, early neurological improvement (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0–1 at 24 hours) and mRS overall distribution at 90 days and 12 months. Safety outcomes are death and intracerebral haemorrhage transformation. Medico-economics analyses include health-related quality of life and cost utility assessment.Ethics and dissemination The DIRECT ANGIO trial was approved by the ethics committee of Ile de France 1. Study began in April 2020. Results will be published in an international peer-reviewed medical journal.Trial registration number NCT03969511