Score predicting imminent delivery in pregnant women calling the emergency medical service.

OBJECTIVE: To develop a telephone score predicting imminent delivery. METHODS: Prospective multicenter (n=38) study including pregnancies of 33 weeks or more amenorrhea (n=3.499). Values in points were assigned to risk factors (Cox's model) and the score tested on a validation cohort and receiver operating characteristic curves. RESULTS: Risk was increased if the caller was panicking or declared delivery to be imminent (+3 points), if the pregnant woman could not be spoken to herself (+3), was aged 26-35 (+3) years, was having frequent contractions (from +4 to +8), had the urge to push (+2 to +6 depending on starting time), had a history of rapid or home delivery (+2), or had not been followed up during pregnancy (+8). Nulliparous women (-7) or those on tocolytic treatment (-3) were less at risk. The score is reproducible and relevant. CONCLUSION: Score predicting imminent delivery scoring during calls is a valid means of assessing risk of delivery.

Withholding and withdrawing life-support therapy in an Emergency Department: prospective survey.

OBJECTIVES: Few studies have focused on decisions to withdraw or withhold life-support therapies in the emergency department. Our objectives were to identify clinical situations where life-support was withheld or withdrawn, the criteria used by physicians to justify their decisions, the modalities necessary to implement these decisions, patient disposition, and outcome. DESIGN AND SETTING: Prospective unicenter survey in an Emergency Department of a tertiary care teaching hospital. PATIENTS: All non-trauma patients (n=119) for whom a decision to withhold or withdraw life-sustaining treatments was taken between January and September 1998. MAIN OUTCOME MEASURES: Choice of criteria justifying the decision to withhold or withdraw life-sustaining treatments, time interval from ED admission to the decision; type of decision implemented, outcome. RESULTS: Fourteen thousand eight hundred and seventy-five non-trauma patients were admitted during the study period, 119 were included, mean age 75+/-13 years. Resuscitation procedures were instituted for 96 (80%) patients before a subsequent decision was taken. Physicians chose on average 6+/-2 items to justify their decision; the principal acute medical disorder and futility of care were the two criteria most often used. Median time interval to reach the decision was 187 min. Withdrawal involved 37% of patients and withholding 63% of patients. The family was involved in the decision-making process in 72% of patients. The median time interval from the decision to death was 16 h (5 min to 140 days). CONCLUSION: Withdrawing and withholding life-support therapy involved elderly patients with underlying chronic cardiopulmonary disease or metastatic cancer or patients with acute non-treatable illness.

[Development of a tool for the identification of socially vulnerable hospital patients]. / Elaboration d'un outil de repérage des usagers en situation de vulnérabilité sociale consultant à l'hôpital.

OBJECTIVE: To develop and assess the metrological properties of a simple to use tool to identify socially vulnerable outpatients. METHODS: A multidisciplinary group of professionals selected five characteristics identifying social vulnerability, integrated in a self-reported questionnaire, from which 5 criteria identify the socially vulnerable outpatients consulting the hospital. The metrological performance of the tool was assessed on a sample of randomly selected outpatients admitted to the emergency department and the results referred to the independent assessment of two social workers. The sensitivity and specificity of the tool were determined and ROC curves drawn. RESULTS: 222 patients were included, aged from 15 to 93 Years (mean: 53 Years), 59% of whom were men. 78% filled out the questionnaire on their own, while 22% required help, usually for physical or material reasons and 87% answered the five questions without any difficulty. The kappa coefficient of agreement between the two social workers was estimated at 0.94 (CI: 0.89-0.98). The sensitivity of the self reported questionnaire was of 70% (CI: 64-76) and its specificity of 77% (CI: 71-82). The ROC curves showed that the modified tool had a sensitivity of 80% (Sp: 67%). With only 2 characteristics, this sensitivity was of 76% (Sp: 73%). CONCLUSION: This tool, which is based on the advice of various experts, is valid and presents acceptable metrological properties. Once some simplifications have been made, the questionnaire could be used in routine in any patient consulting the hospital because it is acceptable, simple to use and can be rapidly filled-in.

[Meningitis with direct negative bacteriological examination. Prospective assessment of a decision making tree]. / Méningites à examen bactériologique direct négatif. Evaluation prospective d'un arbre décisionnel.

OBJECTIVE: Elaboration of a decision-making tree for differential diagnosis of bacterial and viral meningitis, when initial Gram's staining is negative. Method One-Year prospective study in an adult emergency department. Comparison with the immediately-preceding period. RESULTS: 56 patients were included. Only 4 bacterial meningitis, but none misdiagnosed. 86% sensitivity and 83% specificity for viral meningitis (n=40). Rate of patients hospitalised more than 24 hours decreasing from 62.5 to 41% (p=0.05). Antibiotic chemotherapy decreasing from 55 to 16% (p<0.001). CONCLUSION: This decision-making tree safely allows emergency differentiation between bacterial and viral meningitis, when initial Gram's staining is negative. It consequently leads to decreased rates of useless hospitalisations and antibiotic treatments. We believe that this method can be helpful during outbreaks of viral meningitis.

Efficacy of alteplase thrombolysis for ED treatment of pulmonary embolism with shock.

Our objective was to assess efficacy and tolerance of thrombolysis using 0.6 mg/kg of Alteplase in patients with massive pulmonary embolism defined as the association of a pulmonary embolism with shock. We retrospectively included 21 patients presenting with a massive pulmonary embolism confirmed by either scintigraphy or spiral computed tomography. Patients were treated on the basis of a standard rationale followed by thrombolysis with 0.6 mg/kg Alteplase over a period of 15 minutes. Hospital mortality, vital signs before and 2 hours after thrombolysis, and incidence of hemorrhagic events were recorded. Five patients (23.8%) died, 4 of these deaths occurred during the first 4 hours after hospital admission. Systolic and diastolic blood pressure (Sp02) were significantly improved 2 hours after the beginning of thrombolysis. Five minor hemorrhagic events occurred. This study demonstrates that for patients with pulmonary embolism and shock, a bolus treatment with Alteplase is potentially effective and well tolerated.