Evaluation de la prise en charge des traumatisés crâniens légers

Le traumatisme crânien léger (TCL) est un motif fréquent de consultation dans les services d urgence (SU). La difficulté de leur prise en charge repose sur l identification des patients à risque de lésion post traumatique. La Société Française de Médecine d Urgence (SFMU) a publié des recommandations en Juin 2011, définissant les critères de recours à l'imagerie et à l'hospitalisation. Elles insistent particulièrement sur le risque accru de complication immédiate et secondaire sous traitements antithrombotiques. Une évaluation des pratiques professionnelles a été menée dans le SU du CHU d'Angers. L objectif était d analyser la conformité des prises en charge des TCL par rapport aux recommandations de la SFMU. Une analyse spécifique des TCL sous antithrombotique était également menée (impact sur le devenir fonctionnel et la prescritpion des antithrombotiques) 253 TCL ont été inclus dans notre étude avec des caractéristiques épidémiologiques comparables à la littérature. Notre étude objective un respect partiel du recours à l'imagerie (63%) et à l'hospitalisation (61%) en présence d'un facteur de risque identifié. Seul 38% des patients sous antiagrégant plaquettaire et 71% sous anti-vitamine K ont bénéficié de la prise en charge recommandée. Un défaut d'information concernant la surveillance post traumatique a été également pointé pour deux tiers des TCL retournant à domicile. Par ailleurs, au décours du traumatisme, la majorité des médecins traitants ont procédé à une remise en question de leurs prescriptions d antithrombotique, conscient du risque encouru par leur patient; débouchant sur une part non négligeable (18,5%) d arrêt de prescription.Minor head trauma (MHT) is a common presentation in emergency rooms. These patients can be difficult to assess and their management depends on the identification of post traumatic lesion. SFMU's recommendations published in June 2011 define criteria for computed tomographic scanning and hospitalisation decisions. The serious risk of early and secondary complications is highlighted for patient with antithrombotic therapies. This study has been conducted by the CHU d'Angers in the emergency service. The goal of the evaluation of professional practice in minor head trauma management is to analyse the conformity with the published guidelines. A specific analyse of patients with antithrombotic therapies has also been carried out to demonstrate the impact of these practice on the physical complication and on the antithrombotic's prescription. 253 patients with MHT and epidemiologic characteristic similar to the medical literature were including. It result a partial compliance regarding imaging performance (63%) and hospitalisation (61%) when a risk factor was identified. Only 38% patient taking antiplatelet medication and 71% patient receiving oral anticoagulant received a recommended management. A lake of information about the post traumatic survey has also been pointed out for two-third of the patient leaving. In addition, following the trauma, a majority of the referring physician put into question their antithrombotic's prescription, aware of the potential risk; generating a significant part of them to stop the treatment (18.5%).ANGERS-BU Médecine-Pharmacie (490072105) / SudocSudocFranceF

Outpatient Management of Patients With COVID-19: Multicenter Prospective Validation of the Hospitalization or Outpatient Management of Patients With SARS-CoV-2 Infection Rule to Discharge Patients Safely

International audienceBACKGROUND: The Hospitalization or Outpatient Management of Patients With SARS-CoV-2 Infection (HOME-CoV) rule is a checklist of eligibility criteria for home treatment of patients with COVID-19, defined using a Delphi method. RESEARCH QUESTION: Is the HOME-CoV rule reliable for identifying a subgroup of COVID-19 patients with a low risk of adverse outcomes who can be treated at home safely? STUDY DESIGN AND METHODS: We aimed to validate the HOME-CoV rule in a prospective, multicenter study before and after trial of patients with probable or confirmed COVID-19 who sought treatment at the ED of 34 hospitals. The main outcome was an adverse evolution, that is, invasive ventilation or death, occurring within the 7 days after patient admission. The performance of the rule was assessed by the false-negative rate. The impact of the rule implementation was assessed by the absolute differences in the rate of patients who required invasive ventilation or who died and in the rate of patients treated at home, between an observational and an interventional period after implementation of the HOME-CoV rule, with propensity score adjustment. RESULTS: Among 3,000 prospectively enrolled patients, 1,239 (41.3%) demonstrated a negative HOME-CoV rule finding. The false-negative rate of the HOME-CoV rule was 4 in 1,239 (0.32%; 95% CI, 0.13%-0.84%), and its area under the receiver operating characteristic curve was 80.9 (95% CI, 76.5-85.2). On the adjusted populations, 25 of 1,274 patients (1.95%) experienced an adverse evolution during the observational period vs 12 of 1,274 patients (0.95%) during the interventional period: -1.00 (95% CI, -1.86 to -0.15). During the observational period, 858 patients (67.35%) were treated at home vs 871 patients (68.37%) during the interventional period: -1.02 (95% CI, -4.46 to 2.26). INTERPRETATION: A large proportion of patients treated in the ED with probable or confirmed COVID-19 have a negative HOME-CoV rule finding and can be treated safely at home with a very low risk of complications. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04338841; URL: www.clinicaltrials.gov

Age-Adjusted D-Dimer Cut-off Levels to Rule out Pulmonary Embolism:A Prospective Outcome Study

Thrombosis and Hemostasi