Improving tetanus prophylaxis in the emergency department: a prospective, double-blind cost-effectiveness study.

BACKGROUND: The choice of tetanus prophylaxis for patients with wounds depends on obtaining their vaccination history, which has been demonstrated to be unreliable. Use of a rapid immunoassay (Tétanos Quick Stick, the TQS), combined with knowledge of certain demographic characteristics, may improve the evaluation of tetanus immunity and thus help to avoid inadequate prophylactic measures and reduce costs. OBJECTIVES: To evaluate the contribution of the TQS in the choice of tetanus prophylaxis and to perform a cost-effectiveness analysis. The final aim was to define the place of the TQS in a modified algorithm for assessment of tetanus immunity in the emergency department. METHOD: In this Belgian prospective, double-blind, multicentre study, 611 adult patients with a wound were included; 498 (81.5%) records were valid. The TQS test was performed by a nurse before the vaccination history was taken and the choice of prophylaxis was made, using the official algorithm (Belgian Superior Health Council), by a doctor who was unaware of the TQS result. RESULTS: The prevalence of protective anti-tetanus immunity was 74.1%. Immunity was lower in older patients and in female patients. The TQS was a cost-effective tool for patients presenting with a tetanus-prone wound and considered from the vaccination history to be unprotected. Use of the TQS would have improved management in 56.9% (95% CI 47.7% to 65.7%) of patients by avoiding unnecessary treatments, leading to a reduction in the mean cost per patient (10.58 euros/patient with the TQS versus 11.34 euros/patient without). The benefits of the TQS use were significantly greater in patients <61 years old: unnecessary treatment would have been avoided in 76.9% (95% CI 65.8% to 85.4%) of cases and the mean cost per patient reduced to 8.31 euros. CONCLUSION: In selected patients, the TQS is a cost-effective tool to evaluate tetanus immunity. An algorithm is proposed for ED assessment of tetanus immunity integrating age and the TQS result

How to Improve Assessment of Tetanus Immunity in the Emergency Room: A Prospective Cost-Effectiveness, Double Blind Study

peer reviewe

Effect of Trans-Nasal Evaporative Intra-arrest Cooling on Functional Neurologic Outcome in Out-of-Hospital Cardiac Arrest : The PRINCESS Randomized Clinical Trial

© 2019 American Medical Association. All rights reserved.Importance: Therapeutic hypothermia may increase survival with good neurologic outcome after cardiac arrest. Trans-nasal evaporative cooling is a method used to induce cooling, primarily of the brain, during cardiopulmonary resuscitation (ie, intra-arrest). Objective: To determine whether prehospital trans-nasal evaporative intra-arrest cooling improves survival with good neurologic outcome compared with cooling initiated after hospital arrival. Design, Setting, and Participants: The PRINCESS trial was an investigator-initiated, randomized, clinical, international multicenter study with blinded assessment of the outcome, performed by emergency medical services in 7 European countries from July 2010 to January 2018, with final follow-up on April 29, 2018. In total, 677 patients with bystander-witnessed out-of-hospital cardiac arrest were enrolled. Interventions: Patients were randomly assigned to receive trans-nasal evaporative intra-arrest cooling (n = 343) or standard care (n = 334). Patients admitted to the hospital in both groups received systemic therapeutic hypothermia at 32°C to 34°C for 24 hours. Main Outcomes and Measures: The primary outcome was survival with good neurologic outcome, defined as Cerebral Performance Category (CPC) 1-2, at 90 days. Secondary outcomes were survival at 90 days and time to reach core body temperature less than 34°C. Results: Among the 677 randomized patients (median age, 65 years; 172 [25%] women), 671 completed the trial. Median time to core temperature less than 34°C was 105 minutes in the intervention group vs 182 minutes in the control group (P < .001). The number of patients with CPC 1-2 at 90 days was 56 of 337 (16.6%) in the intervention cooling group vs 45 of 334 (13.5%) in the control group (difference, 3.1% [95% CI, -2.3% to 8.5%]; relative risk [RR], 1.23 [95% CI, 0.86-1.72]; P = .25). In the intervention group, 60 of 337 patients (17.8%) were alive at 90 days vs 52 of 334 (15.6%) in the control group (difference, 2.2% [95% CI, -3.4% to 7.9%]; RR, 1.14 [95% CI, 0.81-1.57]; P = .44). Minor nosebleed was the most common device-related adverse event, reported in 45 of 337 patients (13%) in the intervention group. The adverse event rate within 7 days was similar between groups. Conclusions and Relevance: Among patients with out-of-hospital cardiac arrest, trans-nasal evaporative intra-arrest cooling compared with usual care did not result in a statistically significant improvement in survival with good neurologic outcome at 90 days. Trial Registration: ClinicalTrials.gov Identifier: NCT01400373.Peer reviewedFinal Accepted Versio

How accurate is a POC bloodgas analyser?

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Novel IT Application for Reverse Triage Selection: A Pilot Study

OBJECTIVE: The objective of this study was to develop and evaluate an evidence-based information technology (IT) application that guides clinical decision-making during the reverse-triage selection process in mass casualty incidents. METHODS: Based upon 28 validated critical interventions (CI) relevant for determining whether a patient qualifies for early discharge, we developed the Reverse Triage Tool of Leuven (RTTL). The RTTL is compatible with the health electronic record (HER) of UZ Leuven, a tertiary hospital in Belgium. During a 3-week period in March 2015, we registered data from 2 groups of patients: a random group (no RTTL usage) and a filtered group (RTTL usage). RESULTS: When applying the original 28 CIs, we were able to select almost twice as many patients in the filtered group who qualified for early discharge compared with patients in the random group. The predictive validity was highly satisfactory. CONCLUSIONS: The RTTL saves time in 2 ways. First, it reduces the patient population that needs to be evaluated for potential early discharge to one-third. Second, it doubles the probability of selecting an actual dischargeable patient. Each selected patient, however, still must undergo multidisciplinary reassessment in order to qualify for early discharge. Thus, further research is required to optimize the IT application.(Disaster Med Public Health Preparedness. 2018;12:599-605).status: publishe

Deliberate self-poisoning: characteristics of patients and impact on the emergency department of a large university hospital

STUDY OBJECTIVE: The epidemiology, management and cost of emergency department (ED) visits for deliberate self-poisoning (DSP) are described. METHODS: In a retrospective study, the medical records of all DSP patients older than 16 years, who presented to the ED from 1 January 2009 to 31 December 2009, were reviewed. RESULTS: 312 episodes of DSP were included, accounting for 0.6% of all ED visits. 190 patients were women, with a female to male ratio of 1.56:1. Mean patient age was 37 years. More than 60% (n=190) of DSP patients were <40 years of age. Most patients presented to the ED between 18:00 and 23:00. A single drug was ingested in 39% (n=121) of patients. Alcohol was co-ingested by 36% of patients who were mostly middle-aged men. Of the overdoses, 50.8% were due to benzodiazepines, 23.2% were due to antidepressants and 16.4% were due to antipsychotics. Two-thirds of patients were treated with oral activated charcoal and 89% were seen by a psychiatrist. Nearly 90% of patients were admitted to the ED observation ward, with a mean length of stay of 16.7 h. The estimated total cost was €;266 134.89, with an average of €;872.57 per patient. CONCLUSION: Self-poisoning cases in Belgium are grossly similar to those in other Western countries. Supportive treatment alone should be considered in the majority of patients presenting with oral drug overdose. Overall, DSP leads to a significant financial burden on the community.status: publishe

Using medical software in quality assessment in an ED

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Admission glycemia for patients with a hip fracture: a predictive parameter of outcome?

status: publishe

Use of tramadol drip in controlling renal colic pain

BACKGROUND AND PURPOSE: Although the continuous perfusion of antispasmodic drugs has been the traditional mainstay in the treatment of renal colic, the results more often than not are unsatisfactory. Our hypothesis was that a continuous intravenous (IV) drip of tramadol would be an effective and safe alternative. PATIENTS AND METHODS: In this prospective study, 300 patients with renal colic were randomized into four treatment groups, single blind for the patients. At the start, all received an anti-inflammatory drug intramuscularly and an antiemetic and antispasmodic IV. Group A was given the classical IV antispasmodic perfusion combined with a sham drip. Group B received the classical antispasmodic perfusion in combination with a tramadol drip. Group C had a sham perfusion and drip. Group D received a sham perfusion and tramadol drip. There was no significant difference in the degree of pain between the groups on a visual analog scale (VAS) at the start. The pain was scored again on the VAS at 30 minutes, 1 hour, and 4 hours after the start of the treatment and at IV urography. Side effects, as well as the need for rescue medication, were registered. RESULTS: Both tramadol groups scored significantly better after 60 and 240 minutes and during IV urography (P < 0.005). There was a significant decrease in VAS in group B after 30 minutes. The tramadol groups needed significantly less rescue medication (P = 0.001). There was no significant difference in the reported side effects. The combination spasmolytic-tramadol drip scored the best, although the difference was not statistically significant. CONCLUSION: We consider our hypothesis proved that a continuous tramadol drip is a safe and valuable analgesic regimen in renal colic.status: publishe

Emergency department visits due to alcohol intoxications: characteristics of patients and impact on the emergency room

AIMS: The aim of the study was to describe the epidemiology, management and cost of emergency department (ED) visits due to alcohol intoxication. METHODS: A retrospective review of medical records of all episodes of alcohol intoxication was made, excepting those where another diagnosis such as trauma or psychiatric illness was primary, in patients older than 16 years, who presented to the ED of a large university hospital in Belgium over a 12-month period from 1 January 2009. RESULTS: A total of 635 such patients accounted for 1.2% of all ED visits; 429 were males and 48.3% were aged between 41 and 60 years; 63.8% of the patients had a history of alcohol use disorder and 60.3% had a history of psychiatric disorder; 74.3% of the patients received some form of medical treatment and 62% were seen by a psychiatrist. Of the total, 57.5% of the patients were admitted to the ED observation ward, with a mean length of stay of 8.4 h. The estimated total cost was €318 838.25, with an average of €541.32 per patient. CONCLUSION: Alcohol intoxication leads to a financial burden on the community. In addition to imposing physical, social and psychological stress on the community, the often agitated or aggressive patient imposes stress on ED staff. Close surveillance of trends in alcohol abuse is warranted, and the ED should consider implementing a questionnaire method of screening for alcohol abuse.status: publishe