RESUMO
Emergency medicine is facing many challenges, particularly related to the consequences of the pandemic on the pressure of patient flows and the lack of human resources. More than ever, our discipline seeks to offer our patients quality care based on several recent studies, of which the following is a section: a) Gender effect in the administration of tranexamic acid; b) External validation of the Canadian Syncope Risk Score; c) Role of neuro-imaging in psychiatric decompensation; d) Choice of analgesia in renal colic; e) Use of carotid ultrasound for pulse control in cardiac arrest and f) The safetyness of performing simple sutures in non-sterile conditions.
La médecine d'urgence est confrontée à de nombreux défis, notamment liés aux conséquences de la pandémie sur la pression des flux patients et du manque de ressources médico-soignantes. Plus que jamais, notre discipline cherche à offrir à nos patients des soins de qualité en s'appuyant sur plusieurs études récentes dont voici une sélection : a) effet de genre dans l'administration d'acide tranexamique ; b) validation externe du Canadian Syncope Risk Score ; c) rôle de l'imagerie cérébrale dans les décompensations psychiatriques ; d) choix de l'antalgie dans la colique néphrétique ; e) utilisation de l'US carotidien dans le contrôle du pouls lors d'ACR et f) possibilité de réaliser des sutures simples sans conditions stériles.
Assuntos
Analgesia , Medicina de Emergência , Cólica Renal , Humanos , Canadá , Fatores de Risco , Analgesia/métodosRESUMO
OBJECTIVES: The occurrence of mediastinitis after cardiac surgery remains a rare and severe complication associated with poor outcomes. Whereas bacterial mediastinitis have been largely described, little is known about their fungal etiologies. We report incidence, characteristics and outcome of post-cardiac surgery fungal mediastinitis. METHODS: Multicenter retrospective study among 10 intensive care units (ICU) in France and Belgium of proven cases of fungal mediastinitis after cardiac surgery (2009-2019). RESULTS: Among 73,688 cardiac surgery procedures, 40 patients developed fungal mediastinitis. Five were supported with left ventricular assist device and five with veno-arterial extracorporeal membrane oxygenation before initial surgery. Twelve patients received prior heart transplantation. Interval between initial surgery and mediastinitis was 38 [17-61] days. Only half of the patients showed local signs of infection. Septic shock was uncommon at diagnosis (12.5%). Forty-three fungal strains were identified: Candida spp. (34 patients), Trichosporon spp. (5 patients) and Aspergillus spp. (4 patients). Hospital mortality was 58%. Survivors were younger (59 [43-65] vs. 65 [61-73] yo; p = 0.013), had lower body mass index (24 [20-26] vs. 30 [24-32] kg/m2; p = 0.028) and lower Simplified Acute Physiology Score II score at ICU admission (37 [28-40] vs. 54 [34-61]; p = 0.012). CONCLUSION: Fungal mediastinitis is a very rare complication after cardiac surgery, associated with a high mortality rate. This entity should be suspected in patients with a smoldering infectious postoperative course, especially those supported with short- or long-term invasive cardiac support devices, or following heart transplantation.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Mediastinite , Humanos , Estudos Retrospectivos , Mediastinite/epidemiologia , Mediastinite/microbiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Candida , BélgicaRESUMO
Nonobstetric emergencies are frequent during pregnancy. The emergency physician must be knowledgeable regarding the physiological changes related to pregnancy, and must evaluate the benefit/risk ratio of any medication given to the mother. Though maternal side-effects are easy to predict, the fetal risk remains difficult to evaluate as medications are numerous and clinical evidence scarce. For analgesia as for sedation, the choice will depend on both the clinical context of the patient, the desired objective, and the assumed fetal risk.
Les urgences non obstétricales de la femme enceinte sont fréquentes. La prise en charge de ces patientes implique de la part de l'urgentiste une connaissance des modifications physio-lo-giques liées à la grossesse et du rapport risques/bénéfices de toute médication administrée à la mère. Alors que les risques maternels peuvent être anticipés, le risque fÅtal reste difficile à cerner tant les molécules sont nombreuses et les données cliniques rares. Pour l'analgo-sédation, le choix des molécules dépend à la fois du contexte clinique de la patiente, de l'objectif souhaité, et du risque fÅtal présumé.
Assuntos
Analgesia , Anestesia , Manejo da Dor , Complicações na Gravidez , Sedação Consciente , Feminino , Humanos , Dor , Manejo da Dor/métodos , GravidezRESUMO
Several articles have been published during 2016 suggesting amendments in certain established practices of emergency medicine. Amongst such practices now in question are : 1) the use in mechanical cardiopulmonary resuscitation of amiodarone and lidocaine which appear not to improve survival or neurological outcome ; 2) apneic oxygenation being associated with a significant increase in first pass success intubation ; 3) an updating of the definition of sepsis and septic shock which facilitate earlier identification of susceptible patients ; 4) the use of the high sensitivity troponin 0-hour / 1-hour algorithm which differentiates earlier patients with or without acute myocardial infarction ; 5) that intramuscular non-steroidal anti-inflammatory drugs offer effective sustained analgesia for renal colic, and finally 6) that irrigation of an abscess cavity after incision and drainage is not beneficial.
Plusieurs articles publiés en 2016 ont fait évoluer les connaissances dans divers domaines de la médecine d'urgence : 1) lors de réanimations cardiopulmonaires, le recours à des dispositifs de compression mécanique, comme l'utilisation de l'amiodarone ou de la lidocaïne, n'améliore ni la survie ni le pronostic neurologique ; 2) la préoxygénation apnéique diminue le risque de désaturation lors d'intubation en séquence rapide ; 3) les nouvelles définitions du sepsis et du choc septique ont évolué et permettent l'identification rapide des patients avec un sepsis ; 4) l'utilisation d'un algorithme avec le dosage précoce des troponines ultrasensibles à 0 et +1 heure permet de trier efficacement les patients avec ou sans infarctus du myocarde ; 5) le traitement des coliques néphrétiques avec des AINS par voie intramusculaire est efficace et 6) enfin, irriguer un abcès cutané après son incision et drainage n'offre pas de bénéfice.
