Post-traumatic fracture-dislocation of the humeral head with intrathoracic migration: A case report.

INTRODUCTION: Severe trauma is a frequent condition encountered in Emergency department (ED) in which vital prognosis can easily be engaged. This condition could be responsible for unusual injuries occurrence. Emergency physician must be aware of these situations where adequate management is urgently required. We report a case of e 45-year-old patient who was admitted to the ED after a high velocity road traffic accident resulting in multiple injuries and fracture dislocation and migrating humeral head into intra thoracic position. OBSERVATION: We report the clinical case of a patient aged 45 years without medical history admitted to the ED after being involved in a high-velocity road traffic accident. On clinical presentation, the patient was dyspneic and desaturated on ambient air room, he presented moreover clinical signs of blunt right shoulder trauma and deformation of the 2 thighs. Final screening of injuries by radiological and a tomographic exams retained a polytrauma status with fracture dislocation and migration of humeral head, homolateral hemothorax and double femur fracture. Patient was managed by multidisciplinary surgical approaches. Discusssion et conclusion: We illustrated by this case a very rare post trauma condition represented by a fracture dislocation of the humeral head resulting in an intrathoracic migration and a homolateral hemothorax. This diagnosis was reported only a few times by the literature within last decades and management suffers from lack of treatment guidelines, which remain team-dependent. At the very early stage of management and before surgical step, emergency physician must be aware of the possibility of this clinical condition with evolution into some threatening clinical presentations with specific management.

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.

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.

Prognostic value of scoring tools in severe trauma patients admitted to the emergency department.

BACKGROUND: Severe Trauma is a misleading cause of death in young people. Early assessment of prognosis is the cornerstone in the management of such patients. Several prognostic scores have been proposed during the last decade. AIM: To evaluate the prognostic performance of trauma scores in terms of mortality in severe trauma patients admitted to the emergency department. METHODS: This was a prospective, observational and prognostic study with inclusion of severe trauma patients admitted to the emergency department over a 20 months period. We focused on the predictive value of 4 trauma scores in terms of mortality in severe trauma admitted to the resuscitation room. Four scores were included: ISS, NISS, EMTRAS and GAP score. Univariate and multivariate analysis of mortality at the 30th post-traumatic day were conducted with comparison of ROC curves of the scores. Moreover, Correlation between the several scores was studied. RESULTS: We included 298 patients. The median age was 40 (15-90) years. The sex ratio was 4,5. Clinical characteristics were n (%): GCS ≤ 8: 62 (21); PAS <90 mm Hg: 32 (11) and pulse oximetry <90%: 44 (15). The median ISS was 17 (1-75) and 176 (59%) trauma patients had a score ISS ≥ 16. The median NISS was 22 (1-75). The median EMTRAS was 3 (0-9). The median GAP was 21 (3-26). The global mortality was 21.5%. Independent predictors of mortality were: EMTRAS score ≥ 3 (adjusted OR 1.80, 95% CI [1.05-3.08], p = 0.0033), ISS ≥ 16 (adjusted OR 2.05; 95% CI [1.26-3.46], p = 0.002), GAP <20 (adjusted OR 1.92, 95% CI [1.268-2.92], p = 0.002) 1.74, 95% CI [1.17-2.592], p = 0.005). The GAP score had the best AUC= 0.811 followed by the EMTRAS with an AUC of 0.789. Finally, all the scores were strongly correlated. CONCLUSION: Severe trauma is a dynamic process with a heavy morbidity and mortality. In our study, physiological scores and combined score were correlated with prognosis as well as anatomical scores and could be proposed for early gravity assessment in severe trauma enhancing triage, management and prognosis of polytrauma patients.

Drug-adverse related events in emergency department : Epidemiological,clinical profile and prognosis.

INTRODUCTION: Adverse-drug events (ADe) are frequent in emergency medicine and remain misdiagnosed depending on the clinical polymorphism and the underlying comorbidities. Older patients with multiple comorbidities and polypharmacy are more frequently affected and makes poor prognosis. AIM OF THE STUDY: The aim of this study was to evaluate the epidemiology of ADe in the emergency department (ED) visits and to identify the prognostic value mortality within 30 days. METHODS: Prospective, monocentric study. Patients were included if they met criteria of aADe. We evaluated severity and mortality at 30 days. Moreover, misuse and preventabilty were studied. RESULTS: We included 159 cases within 113,272 ED visits. Mean age = 64 ± 19 years, sex ratio =0.6.The average number of drugs was 4.5 ± 3. Polymedication was found in 54%. In 10 cases, the prescription contained twice the same molecule. A double ADe was found in 11 patients. We identified 55 cases of misuse, 94% of them were due to physician. An interaction was found in 23 patients. Improper prescription with age, renal function or presence of contra-indications was found in 46 patients. In 41% cases, ADR events were preventable. An ADR event was considered severe in 44% of cases and 30-Days mortality's rate was 9.4%. Drugs n (%): Anticoagulants 53(34,6); Antihypertensive 29(19); Antiarrhythmic 15(10). Multivariate analysis of mortality at day 30: Misuse and polyapthology were independent predictors; Respective Odds ratios: (OR: 2.6; 95% CI [1.25-5.38]; p=0,001) and (OR 2.31; 95% CI [1,16 - 4,61]; p=0,017). CONCLUSION: Drug-related ED visits are common in elderly. ADe is severe in 44% cases and preventable in 41%. Mortality rate was 9,4%. Misuse, polypharmacy and comorbidities were independent predictors of severity and mortality.