Efficacy and safety of two protocols of intravenous insulin therapy in the management of diabetic ketoacidosis.

INTRODUCTION: The correction of insulin deficiency in ketoacidosis DKA is recommended by intravenous (IV) route. Despite abundant literature, the place of the initial bolus of insulin has remained controversial. AIMS: This study was designed to compare the safety and the efficacy of two protocols of intravenous (IV) insulin therapy in the management of DKA admitted in the emergency department. Protocol (A): IV bolus of regular insulin 0.10 UI/Kg followed by a continuous IV infusion of insulin 0.10 UI/kg/H. Protocol (B): No bolus, a continuous IV infusion of regular insulin 0.14 UI/kg/H. METHODS: This was a prospective, not blinded, randomized study including patients aged more than 16 years with moderate to severe DKA. Fluid therapy and potassium replacement were standardized. Patients were randomized into two groups: Bolus-maintenance 0.10 group received protocol (A) and Maintenance 0.14 group received protocol (B). The Primary outcome data was the time to recovery defined by the time to acidosis resolution. The safety was tested by the occurrence of complications: hypoglycemia and hypokalemia. RESULTS: We enrolled 129 consecutive DKA patients. There were no differences between the two groups in clinical and biochemical data on admission, Bolus-maintenance 0.10 group versus Maintenance 0.14 group: mean age (37±18 vs. 38±17 years; p=0.810), Type 1 diabetes n (%): 34(55.7) vs. 34(50); p=0.911, pH (7.14±0.13 vs. 7.15±0.12; p=0.43). There were no differences between the two groups in the outcomes data: Bolus-maintenance 0.10 group versus Maintenance 0.14 group: Time to recovery (17 vs. 16 hours; p=0.76), complication n (%): Hypoglycemia (7(11.5) vs. 10(15.9); p=0.57) and hypokalemia (32(56.1) vs. 30(46.9); p=0.30). CONCLUSION: In the treatment of diabetic ketoacidosis, the two protocols of IV insulin were safe and had a comparable efficiency.

Predictive value of shock index ≥ 1 in severe trauma patients in emergency department.

BACKGROUND: the shock index (SI) defined by the ratio of systolic blood pressure to heart rate was demonstrated as a simple tool in the triage and orientation of severe trauma patients to trauma centers. AIM: To assess the prognostic value of the SI ≥ 1 in terms of mortality in severe trauma patients admitted to the emergency room. METHODS: We performed a prospective, observational and descriptive study with the inclusion of severe trauma patients over the age of 18 years admitted to the Vital Emergency Room over a 21-month period. SI was calculated at admission: SI = heart rate / systolic blood pressure, a SI threshold value ≥1 was fixed to define two groups: SI<1 and SI≥1. RESULTS: A total of 290 trauma patients were included, 231 (79%) had a SI<1, whereas 59 (21%) had an SI≥1. Mean age was 43.5 ± 18 years, 82% were male. There was a significant difference in hospital mortality at 7 days and at 30 days between the two groups respectively (group SI<1 vs group SI≥1): [12% vs 40%; p <0.001 and 15% vs 47%; p <0.001]. In multivariate analysis, SI≥1 appears as an independent factor of hospital mortality at 7 days [OR = 2.03; 95% CI = 1.3-3.3; p =0.001] and at 30 days [OR = 2.69; 95% CI = 1.4- 5; p =0.002]. CONCLUSION: In severe trauma patients admitted to the emergency department; a SI ≥1 represents a predictive factor of hospital mortality at 7 days and one month.

Drug related adverse events due to cardiotropic agents : Epidemiology and prognosis in the emergency department.

INTRODUCTION: The severity of cardiotropic agents overuse is related to the risk of cardiac and hemodynamic life-threatening situations. Toxicity is attributed to their narrow therapeutic spectrum and pharmacodynamic properties. The clinical presentation, however, remains polymorphic and represents a challenge for the emergency physician to relate accountability to the exact agent. AIM: To evaluate epidemiological, clinical and prognostic profile of patients visiting emergency department in whom iatrogeny secondary to cardiotropic use was diagnosed. METHODS: This was a single-center prospective study over 12 months. We included successively all patients aged over 18 years in whom diagnosis of cardiotropic iatrogeny was made. Cardiotropic related drug-induced events were selected after collegial decision making processing. Prognosis was evaluated in terms of severity and mortality at day 30. Univariate analysis was conducted. P<0.05 was significant. RESULTS: We enrolled 51 patients. Median age was 72 years with IQR (25,75) of (62,78). Sex ratio was 0.64. Twenty cases of misuse were identified (39%) with 51% of cases being related to the physician. Accountability of the adverse drug event (ADE) was 51%. The ADE was considered severe in 45% of cases and the death rate on day 30 was 12%. Drug classes were dominated by beta-blockers in 20 patients (39%) and anti-arrhythmic agents (Amiodarone ®) in 18 patients (35%). Beta-blockers were significantly the most incriminated in the occurrence of severe ADE. A double iatrogeny was found in 13 patients (25%). Misuse and physician-related ADE were found to be predictive of the severity of ADE in univariate analysis with respectively: For misuse:(OR brut=22, CI95%=[5.2;93.5] ; p<0.001) and for related physician ADE (OR brut = 3,7 ; CI95%=[1.1;12] ; P= 0.015). Predictive factors of mortality at day 30 in the univariate analysis were: Past renal failure : OR brut 5,8; CI95%[1,3-26,5]; p=0,015 ; misuse with OR brut=16.7, 95% CI=[1.9-143.5], p=0.002 and severe ADE with OR brut=15, 95% CI=[1.75-129], p=0.032. CONCLUSION: This study showed that ADE related to Cardiotropic agents are frequent and remain a serious condition especially in elderly. Betablockers agents were the mostly incriminated therapeutic class in the severity of the clinical condition by its hemodynamic repercussions responsible of a high rate of hospitalizations and mortality. Misuse and physician-related ADE were found to be predictive of the severity. Whereas, occurrence of severe ADE, misuse and past renal failure were predictive of mortality. Moreover, in 51% patients, ADE was preventable and related to the prescription of physician showing the main role of the preventability and the role of the prescriber in the genesis of this severe condition.

[Epidemiological and prognostic profile of acute heart failure: experience in the emergency department at the Charles Nicole Hospital of Tunis from 2013 to 2014]. / Profil épidémiologique et pronostic de l'insuffisance cardiaque aiguë: expérience du service d'accueil des urgences de l'hôpital Charles Nicole de Tunis de 2013 à 2014.

INTRODUCTION: Acute Heart Failure (AHF) is a specific syndromic disorder grouping several heterogeneous clinical conditions frequently seen in the emergency department. This study aimed to describe the epidemiological, clinical, therapeutic and prognostic features of patients with AHF admitted to the emergency department. METHODS: We conducted a prospective, descriptive study in the emergency department. It included all patients admitted with AHF. We studied the epidemiological, clinical, therapeutic and prognostic features of these patients. RESULTS: The study enrolled 180 patients with AHF admitted to the emergency department. Sex ratio was 1.27. The average age of patients was 66±12 years. Eighty-two percent of patients were hypertensive and 69% were known diabetic patients. The causes of decompensation included primarily hypertensive crisis (61.7% of patients), acute coronary syndrome (24% of patients). Respiratory support was mainly provided by CPAP (Continuous Positive Airway Pressure) in 73.3% of cases. Pharmacological treatment was based on nitrate derivatives (70% of cases) and diuretic (40.5% of cases). Acute heart failure incidence at one month was 21.7% (n=39 patients) and mortality rate at 3 months was 13.3%. CONCLUSION: Patients with AHF treated in the emergency department mainly had hypertensive crisis. Treatment is primarily based on CPAP, vasodilators and diuretics. Recurrence rate and mortality rate were high.

[Epidemiological profiles of diabetic ketoacidosis in the Emergency Department]. / Profils épidémiologiques des acidocétoses diabétiques aux urgences.

INTRODUCTION: Diabetic ketoacidosis (DKA) is a severe metabolic complication of diabetes. Recent years have seen a marked increase in prevalence of diabetic ketoacidosis, but mortality is low. This study aimed to describe the epidemiological, clinical, therapeutic and prognostic features of patients with severe or moderate DKA admitted to the Emergency Department. METHODS: He conducted a prospective, descriptive study including patients with moderate or severe DKA. Standardized care protocol. We studied the epidemiological, clinical, therapeutic and prognostic features of these patients. RESULTS: The study involved 185 patients with moderate or severe DKA. The average age of patients was 38+/-18 years, with a sex ratio of 0.94. Known diabetes was reported in 159 patients (85%) of whom 116 had type 1 diabetes. The most common factors of decompensation were treatment discontinuation in 42% and infection in 32%. Average blood glucose was 32.7+/-12 mmol/L, pH =7.14+/-0.13, HCO3- =7.2+/-3.56 mmol/L. The mean duration of intravenous insulin was 17.3 +/- 16 hours. Hypoglycaemia was reported in 26 patients (14%), hypokalemia in 80 (43%) patients and hyperchloraemic mineral acidosis in 43 patients (23%). Intrahospital mortality was 2.1%. CONCLUSION: Diabetic ketoacidosis occurs in young subjects treated with insulin therapy. Treatment is based on intravenous insulin associated with correction of fluid deficit. Complications mainly include hypokalemia and hypoglycemia and mortality is low.

Base Excess usefulness for prediction of immediate mortality in severe trauma patients admitted to the Emergency department.

BACKGROUND: Trauma is a leading cause of death in young people and hemorrhagic shock is a leading mechanism of this mortality. Hypoperfusion can be difficult to diagnose clinically, especially in younger patients. Arterial Base Excess (BE) has been used as an early indicator of hypoperfusion. AIM: To evaluate the prognostic value of admission BE in severe trauma patients admitted to the emergency department (ED). METHODS: In this prospective study, severe trauma patients meeting high velocity criteria admitted to the ED during the study period were included. BE was calculated from arterial blood gas samples. Multivariate analysis was performed for Day-1 and Day-7 post trauma mortality. ROC characteristics and survival curves were used. RESULTS: We included 479 patients. Median age was 37 (18-90). Eighty-one per cent were male. Clinical characteristics n(%): GCS<13: 170(35); SBP<90 mmHg: 64(13) and SpO2 <90%: 82(17). Mean ISS was 22 ± 13. Mortality was at days 1 and 7: 2.2% and 27.3%, respectively. Median BE was -3.2 mmol/l (-25; 28). Forty-five per cent had a BE ≤ -3.5 mmol/l. In multivariate analysis, initial BE ≤ -6.5 mmol/l was predictive of first day mortality with an Odds Ratio; [CI95%] = 3.17; [1.4-7.1]; p=0.005. Similar results were found at Day 7: Odds Ratio; [CI95%] = 1.5; [1.14-1.96]; p=0.003. BE showed high prognostic value for both mortality rates. Survival curve was significant for BE> -6.5mmol/l. CONCLUSION: in this study, a high BE above 6.5mmol/L showed a significant prognostic value in immediate and early mortality and is proposed as a marker of injury severity in trauma patients admitted to the ED. Prediction was better for the immediate mortality and thus could be proposed as a triage tool in the ED.

Profils épidémiologiques des acidocétoses diabètiques aux urgences

Introduction: l'acidocétose diabétique (ACD) est une complication métabolique grave du diabète. Son incidence est en augmentation ces dernières années, cependant sa mortalité reste faible. L'objectif de cette étude a été de décrire les caractéristiques épidémiologiques, cliniques, thérapeutiques et pronostiques des patients admis aux urgences pour ACD sévère ou modérée. Méthodes: il s'agissait d'une étude prospective, descriptive qui a inclus les ACD modérée ou sévère. Standardisation du protocole de prise en charge thérapeutique. Nous avons étudié les caractéristiques épidémiologiques, cliniques, thérapeutiques et pronostiques chez ces patients. Résultats: nous avons inclus 185 patients avec ACD sévère ou modérée. L'âge moyen a été de 38±18 ans; le sexe ratio=0,94. Diabète connue= 159 patients (85%) dont 116 étaient des diabétiques type 1. Les facteurs de décompensation les plus fréquents étaient l'arrêt du traitement chez 42% et l'infection chez 32%. La glycémie moyenne a été de 32,7±12mmol/L, pH =7,14±0,13, HCO-3 =7,2±3,56 mmol /L. La durée moyenne de l'insuline intraveineuse était de 17,3±16 heures. L'hypoglycémie a été observée chez 26 patients (14%), l'hypokaliémie chez 80 (43%). La mortalité au cours de l'hospitalisation a été de 2,1%. Conclusion: l'acidocétose diabétique survient chez les sujets jeunes traités par insulinothérapie. Le traitement est à base d'insuline par voie intraveineuse en plus de la correction du déficit hydrique. Les complications sont essentiellement l'hypokaliémie et l'hypoglycémie; et la mortalité reste faible