Improving management of intravenous maintenance fluids in the emergency department of a university hospital.

OBJECTIVE: Intravenous (IV) fluid therapy is a known source of iatrogenic complications. Guideline implementation can be used to educate and guide physicians on adequate fluid management. In the emergency department (ED), a complex and interruption-driven environment, workload is high and active documentation is required to facilitate audits of fluid management quality. PATIENTS AND METHODS: Fluid management was evaluated in the ED records of adult non-critically ill patients admitted to a tertiary care center before (PRE: 1/12/2016-31/3/2017) and after (POST: 1/12/2018-31/3/2019) implementation of an educational intervention aiming to optimize IV fluid therapy in November 2018. First, the appropriateness of the 24-hour IV maintenance fluid prescription was evaluated, as prescribed by the emergency physician. Second, factors associated with appropriate prescribing were assessed, as well as the quality of fluid management documentation practice. Prescription appropriateness and documentation quality were evaluated retrospectively using a structured audit instrument and additional review by experts. RESULTS: A total of 237 patients (2.3%) were included in the PRE-intervention group and 253 patients (2.4%) in the POST-intervention group. The expert panel evaluated 214 prescriptions in 82.3% of patients (PRE: 99, POST: 115), and appropriateness increased significantly (19.2% vs. 61.2%, p=0.002). A higher odds of an appropriate IV maintenance fluid prescription was determined, attributed to the intervention (adjOR=2.580; 95% CI 1.363-4.884) and in patients having a prehospital intervention (adjOR=1.914, 95% CI 1.022-3.586). Appropriateness of fluid management documentation did not significantly improve after the implementation of the intervention (15.6% vs. 16.2%, p=0.858). CONCLUSIONS: The IV fluid prescriptions' appropriateness was significantly higher after guideline implementation. However, documentation quality of fluid management was poor in the studied ED records. Active stewardship programs are warranted to further monitor fluid management quality in the ED.

Provision of trauma care in asymmetric warfare: a conceptual framework to support the decision to implement frontline care services.

INTRODUCTION: The emerging trends of asymmetric and urban warfare call for a revision of the needs and the way in which frontline trauma care is provided to affected population. However, there is no consensus on the process to decide when and how to provide such lifesaving interventions in form of Trauma Stabilization Point (TSP). METHODS: A three-step Delphi method was used to establish consensus. A focus group discussion was convened to propose a framework and develop the list of twenty-one (21) statements for validation of a group of experts. RESULTS: A panel of twenty-eight (28) experts reviewed the statements and participated to both first and second rounds. Comments and recommendations provided by the FGD and during round 1 were used to analyze the findings of the study. The proposed framework includes five main categories identified as interconnected components that facilitate the decision to implement or not the TSP. A total of sixteen (16) elements distributed across the five categories have been considered as being able to guide the decision to utilize such capability in high-risk security and resource constrained settings. CONCLUSION: The TSP has the potential to prevent death and disability. The proposed framework and categories add a structure to the decision-making process and represents an important step to support emergency and trauma care planning and implementation efforts.

Characteristics and outcome of Emergency Department intubation in geriatric patients.

INTRODUCTION: The number of elderly patients admitted to the Emergency Department (ED) continues to grow due to the natural aging of the population. Consequently, tracheal intubation will be increasingly used in the oldest old. The objective of this retrospective study is to evaluate the characteristics and outcome of patients of 75 years and older undergoing an endotracheal intubation in the ED. METHODS: In a single center, retrospective study we reviewed digital medical files of patients of 75 years and older in the period from 1/01/2008 to 31/12/2010, who were admitted to the ED of the Universitair Ziekenhuis Brussel in Brussels, Belgium and underwent endotracheal intubation. Survival served as primary outcome and survival without sequelae as secondary endpoint. RESULTS: In the study period, 88 patients of 75 years and older were intubated in the ED. Sixty three (72%) patients died after intubation and 25 (28%) survived until discharge. All 23 patients (26%), who were intubated during cardiopulmonary resuscitation died. A survival rate of 48% was observed in patients, who were intubated for respiratory failure (28%), intracerebral hemorrhage or ischemic stroke (17%), cardiac failure (8%) or other reasons. Non-survivors were significant older, of male sex, had higher APACHE scores and more frequently used cholesterol lowering drugs. CONCLUSION: Senior adults, aged 75 years or older and undergoing endotracheal intubation at the ED, have a high mortality rate. Younger age and female sex at admission were positively correlated with survival. Of those who left the hospital, one-third were able to return home without major sequelae.

[Psychiatric applications at the emergency department of the Brussels University Hospital between 2003 and 2012]. / Psychiatrische aanmeldingen op de spoedgevallendienst van het uz Brussel, 2003-2012.

BACKGROUND: Although the emergency department in Belgian hospital is an important gateway to mental health care, there is lack of information about the way in which this population has evolved. Various studies have reported on the increasing numbers of patients with psychiatric problems, particularly in the younger age group. AIM: To focus on the psychiatric applications at the emergency department of the Brussels University Hospital over a period of 10 years. METHOD: All patients who arrived with a psychiatric problem were studied with regard to the following variables: age, gender, diagnosis, time of arrival, referral, destination and application for compulsory admission. The 10-year study involved a total of 6,519 patients. RESULTS: The largest group of patients were aged between 26 and 45. We noted that there were more depressive disorders in women than in men, but men had more psychotic and substance-related disorders. 60% of the applicants came on their own initiative. The number of patients who returned home after an emergency consultation declined over the period of time under study. About 25% of the patients arrived at the hospital after 8 p.m. and before 8 a.m. There was an increase in the number of persons requesting compulsory admission; about 60% of these actually resulted in a compulsory admission. CONCLUSION: The results demonstrate the importance of psychiatric care in an emergency department of a general hospital and are remarkably similar to the results of other studies. However, some of the comments on the Brussels situation are influenced specifically by the metropolitan area in which the hospital is situated.

Enteroaggregative Shiga toxin-producing Escherichia coli of serotype O104:H4 in Belgium and Luxembourg.

In 2011, a large outbreak of infections caused by Shiga toxin-producing Escherichia coli (STEC) O104:H4 occurred in Germany. This exceptionally virulent strain combined virulence factors of enteroaggregative E. coli (EAggEC) and STEC. After the outbreak only a few sporadic cases of infection with this rare serotype were reported, most of which were related to travel to the Middle East or North Africa. Here we describe two cases of enteroaggregative STEC (Agg-STEC) O104:H4 infection that occurred in Belgium in 2012 and 2013 respectively. In both cases travel in a Mediterranean country preceded the infection. The first strain was isolated from the stool of a 42-year-old woman presenting bloody diarrhoea, who had travelled to Tunisia the week before. The second case involves a 14-year-old girl who, upon her return from Turkey to Belgium, suffered from an episode of bloody diarrhoea and haemolytic uraemic syndrome. Extended typing of the isolates with pulsed field gel electrophoresis revealed that the strains were closely related, though not exactly the same as the 2011 outbreak strain. This report supports the previously made hypothesis that Agg-STEC has a human reservoir and might be imported by travellers coming from an area where the pathogen is endemic. Furthermore, it emphasizes the concern that these bacteria may cause future outbreaks as evenly virulent O104:H4 isolates seem to be widespread.

Adjunctive steroid treatment in acute bacterial meningitis. "To do or not to do: that is the question".

In experimental bacterial meningitis, adjunctive steroid treatment reduces the inflammatory response in the cerebrospinal fluid and subarachnoidal space, thereby improving neurological outcome. The clinical application of this concept was sustained by the European Dexamethasone Study which showed a beneficial effect of dexamethasone on neurological outcome and mortality in adult patients with bacterial--in particular S. pneumoniae-- meningitis. A thorough analysis of the data of this landmark trial as well as results from more recent trials in children and adults with bacterial meningitis worldwide do not support the use of adjunctive dexamethasone in meningitis. Moreover, dexamethasone may have detrimental effects with regard to antibiotic efficacy and late severe neurological complications. Until further data about steroid use in bacterial meningitis becomes available, we propose that dexamethasone therapy in this setting should be abandoned.

Spontaneous intrahepatic gas gangrene and fatal septic shock.

Gas gangrene of the liver is a rare clinical syndrome associated with a high rate of mortality. It is mostly associated with malignancy and immunosuppression. We report on a male patient who presented at the department of emergency medicine with high fever but no localised complaints. CT scan revealed a cavitary lesion filled with air in the liver. Clostridium perfringens was proved to be present in the hepatic lesion and the blood, and clostridium perfringens sepsis with gas gangrene of the liver was diagnosed. Despite early diagnosis and treatment the patient died. The importance of "an aggressive treatment policy" in this kind of life-threatening disease is emphasised.

Endogenous endothelins and nitric oxide in hypoxic pulmonary vasoconstriction.

The effects of endothelin receptor blockade on the pulmonary circulation have been reported variably, possibly in relation to a more or less important associated release of endogenous nitric oxide (NO). The aim of this study was to test whether endothelin antagonism would inhibit hypoxic pulmonary vasoconstriction, and if it would not, then would it do so after NO synthase inhibition. Hypoxic pulmonary vasoconstriction (HPV) was evaluated in anesthetised dogs by the increase in the mean pulmonary artery pressure (Ppa) minus occluded Ppa (Ppao) gradient in response to hypoxia (inspiratory oxygen fraction of 0.1) at constant pulmonary blood flow. Bosentan, an endothelin A and B receptor antagonist, did not affect baseline Ppa, Ppao or systemic arterial pressure (Psa) and did not alter HPV (n=8). The NO synthase inhibitor N(G)-nitro-L-arginine (L-NA) did not affect baseline Ppa and Ppao, but increased Psa and enhanced HPV (n=12). The addition of bosentan in these dogs did not affect baseline Ppa or Ppao, but decreased Psa and inhibited HPV. Exhaled NO was decreased by L-NA and by bosentan and abolished by L-NA+bosentan (n=9). The authors conclude that endogenous nitric oxide is released by, and opposes the vasoconstricting effects of, endothelins in vivo, reducing systemic blood pressure and limiting hypoxic pulmonary vasoconstriction.

A prospective, open, single blind, randomized study comparing four analgesics in the treatment of peripheral injury in the emergency department.

The efficacy of four analgesics, distinct concerning analgesic power and mechanism of action, was evaluated for pain relief in patients suffering from single peripheral injury. Patients were randomly allocated to receive either propacetamol (the pro-drug of paracetamol) 20 mg/kg i.v., piritramide 0.25 mg/kg i.m., tramadol 1 mg/kg i.v. or diclofenac 1 mg/kg i.v. Pain scores were measured by the patient using the visual analogue scale (VAS) and by an observer using a 4-point verbal rating scale (VRS). Cardiorespiratory variables and side effects were recorded. One hundred and sixty patients were included, 131 completed the study. Groups matched for demography and baseline pain levels. In general pain scores decreased with time. No significant differences were found between groups at any particular time point. VAS scores were significantly (p < 0.02) lower than baseline scores 30 minutes after injection in all treatment groups except for the piritramide group where significance (p < 0.01) was reached after 60 minutes. VRS score analysis showed a similar trend although significances differed. In the piritramide group significantly more side effects were noted than in the other groups (p < 0.05). We conclude that intravenous propacetamol, tramadol and diclofenac are equally efficacious for emergency analgesic treatment of single peripheral trauma.

Liver perfusion and hepatocellular inflammatory response in sepsis.

Sepsis is characterized by disturbances in liver perfusion and alterations in intrahepatic cellular functions and interactions. This provokes structural and functional liver damage as well as hepatocellular activation that is believed to perpetuate the immuno-inflammatory response. Changes in hepatic perfusion during sepsis are still poorly understood due to the heterogeneity of septic animal models and the difficult accessibility of the hepatic circulation in humans. Sinusoidal blood flow is severely compromised during sepsis due to a decline in perfused sinusoidal area in association with a decrease in sinusoidal flow velocity. Imbalances in the production of nitric oxide may account for these (micro) circulatory disorders. Interactions between liver macrophages, activated endothelial cells and hepatocytes determine the intensity of inflammation and contribute to initial liver damage. Hepatocellular injury is then enhanced by attracted and invading neutrophils. The management of hepatic dysfunction during sepsis is largely supportive and based on prevention and vigorous resuscitation including early nutritional support and adequate oxygenation. Interestingly, experimental studies suggest that pharmacological interventions with significant hemodynamic effects, such as dobutamine and nitric oxide synthase inhibitors, may adversely affect the liver during the septic process.

Assessing asthma management from interviews of patients and family physicians.

Directed self-care is recommended in asthma. Adequate patient education and follow-up are nevertheless necessary to optimize outcomes. We compared the agreement between detailed information on asthma history and management, collected from the patient and the family physician, to validate the files of physicians and to assess patients' knowledge, attitude, and behavior concerning asthma. A sample of 54 asthma patients were interviewed in detail about use of medications and self-care practice; 36 family physicians (FPs) were interviewed concerning asthma therapy, history, and attitudes of the same patients. Forty-eight percent of the patients expressed negative attitudes toward inhaled corticosteroids, for reasons of safety or lack of efficacy. Less than 20% of the patients made regular use of a peak flow meter. Eighty-three percent of the patients usually obtained prescriptions for asthma therapy from their FP, but on average, only 40% of these prescriptions were provided during visits specific to asthma. FPs were not optimally informed of actual treatments and outcomes and had poor perception of patients' attitudes toward treatment. Nonetheless, in about 30% of the patients, FPs identified risk factors for adverse outcome, such as depression and family conflicts. A majority of interviewed patients had a negative perception of anti-inflammatory therapy, specifically relating to issues of safety and efficacy. Peak flow meters were seldom used and therapy was commonly prescribed outside visits specific to asthma. Despite being centrally involved in the care of asthma patients, FP did not optimally assess therapy and outcomes. The findings suggest suboptimal education and health status in this asthma population.

Actual use of inhaled corticosteroids and risk of hospitalisation: a case-control study.

BACKGROUND: The relationship between therapy and adverse outcome in asthma is debated especially for naturally occurring situations. This is due in part to insufficient information regarding actual use of medications. OBJECTIVE: This study was conducted to clarify the relationship between actual intake of anti-asthma drugs and asthma hospitalisation, considered as an outcome. METHODS: A case-control study was performed. Patients hospitalised for an asthma exacerbation were matched to community controls identified in surrounding general practices. Patients were questioned to identify prior use of anti-asthma medications, level of use of inhaled corticosteroids and attitude towards therapy. RESULTS: Twenty-three cases and 31 matched controls were interviewed. Cases tended to have more severe asthma than controls, as judged by more frequent use of oral corticosteroids. Cases tended to make more frequent use of oral xanthines and inhaled anticholinergics, but the proportion of patients using inhaled beta 2-adrenoceptor agonists and inhaled corticosteroids was similar in both groups. Use of lower doses of inhaled corticosteroids was associated with an increased risk of hospitalisation, while higher dosage was associated with decreased risk. Cases and controls differed as to their answers to a questionnaire concerning attitudes: cases expressed less interest in optimal usage of inhaled corticosteroids than controls; they also expressed more confidence in inhaled beta 2-agonists. When both risks were combined, overconfidence in beta 2-agonists and suboptimal use of inhaled steroids, the relationship with hospitalisation was significant (OR 5.5, 95% CI 1.1; 26.1). CONCLUSION: The results suggest that patients' attitudes to inhaled corticosteroids and actual consumption of these medications are directly related to adverse outcome in asthma.

A rare case of diplopia: medial inferior pontine syndrome or Foville's syndrome.

A case of medial inferior pontine syndrome or Foville's syndrome is described. The patient presented to the emergency department with an acute history of slurred speech, vertigo and diplopia as major complaints. He also mentioned the appearance of weakness and numbness in his left leg. The physical examination revealed a crossed neurological deficit (ipsilateral cranial nerve deficit with contralateral motor weakness) which is typical for posterior circulation stroke in the brainstem territory. In our patient the lesion was located in the right medial inferior pontine region. All the symptoms and signs disappeared within 24 hours confirming the importance of a detailed physical and neurological examination of each patient presenting at the emergency department with a neurological deficit.

Early electrocardiographic signs in acute massive pulmonary embolism.

As a result of the increasing accuracy in diagnosing acute pulmonary embolism by isotopic ventilation-perfusion scintigraphy and pulmonary arterial angiography, the electrocardiographic changes associated with acute cor pulmonale are being abandoned as a diagnostic tool for this life-threatening disease. Nevertheless, certain electrocardiographic findings can raise the suspicion of pulmonary embolism. In our view the electrocardiogram does have some merits in the emergency work-up of a patient with a high suspicion of pulmonary embolism. In this case report we emphasize the importance of the electrocardiographic findings which forwarded the diagnosis of pulmonary embolism. Hence the necessary invasive diagnostic and therapeutic measures, i.e. pulmonary arterial angiography and thrombolytic therapy, can be taken immediately after admission to the emergency department.

Combined intoxication with a tricyclic antidepressive agent and a neuroleptic.

We report the case of a patient who co-ingested a tricyclic antidepressant (2500 mg of doxepin) and a neuroleptic drug (3500 mg of prothipendyl). Following overdose either agent can affect the central nervous and cardiovascular systems, inducing arrhythmias, conduction disturbances and hypotension. The presented case illustrates that a combined overdose of tricyclic antidepressants and neuroleptics enhances the possible toxic effects of each drug and especially the risk for adverse cardiac events. The clinical features and management of this combined intoxication are discussed. Treatment with sodium bicarbonate readily corrected a potentially life-threatening cardiac arrhythmia and is therefore suggested to be imperative in the treatment of these cases.

Reversible cardiac failure in an adolescent after prolonged exposure to carbon monoxide.

We describe the case of an adolescent who developed a severe but fully reversible cardiac dysfunction with low blood levels of carboxy haemoglobin (COHb = 10%) after a prolonged exposure to carbon monoxide. A 15-year-old male was admitted with a Glasgow Coma Scale of 8/15 with suspected postictal state and postanoxic encephalopathy. The cardiorespiratory failure which he developed soon after admission mandated mechanical ventilation, inotropic support and ultimately left ventricular support by intra-aortic balloon counterpulsation. The cardiac dysfunction was documented by radionuclide imaging and echocardiography. The patient fully recovered without neurological deficit. A low blood COHb concentration is a poor safety indicator since high tissue levels of accumulated carbon monoxide can be associated with coma and fulminant cardiorespiratory failure requiring advanced life support facilities.

Does age have an effect on the time of occurrence of cardiac arrest of presumed cardiac etiology? Belgian Cardiopulmonary-Cerebral Resuscitation Study Group.

To assess possible age-related differences in the time of occurrence (hour of the day, day of the week, month of the year) of cardiopulmonary collapses of presumed cardiac etiology, 3,305 out-of-hospital patients registered by the Belgian Cardiopulmonary-Cerebral Resuscitation Study Group between 1983 and 1990 were studied. Occurrence of call-time was separately tabulated for patients less than versus above 60 years of age and tested for differences with the Kolmogorov-Smirnov two-sample test. Only the circadian patterns of all out-of-hospital cardiac arrests of presumed cardiac etiology showed a significant difference between the two age-groups; the prominent morning peak (6 a.m.-10 a.m.) in incidence was less pronounced in the younger age-group. The overall incidence is lower in the summer and during mid-week. These trends are similar for both age-groups.

Adrenaline dosage during cardiopulmonary resuscitation: a critical review.

Since the end of the nineteenth century adrenaline has been used for the treatment of cardiac arrest. Since the 1960s a standard 1 mg dose administered intravenously every 5 min is common practice in cardiopulmonary resuscitation. Because of growing interest in the pharmacological aspects of cardiopulmonary resuscitation, experimental studies in animals conducted in the 1980s suggested the use of higher doses of adrenaline. Several case reports of successfully resuscitated patients who had been given high dose adrenaline were published, but large, prospective, randomized, controlled clinical trials in humans found no statistically significant improvement in survival rates between high dose and standard dose resuscitated patients. It seems that 1 mg adrenaline given intravenously every 3-5 min during resuscitation for cardiac arrest remains the standard.

Hepatic artery aneurysm. Case reports with review of the literature.

Two cases of hepatic artery aneurysm are reported. The first presented as obstructive jaundice, the second as an upper gastrointestinal bleeding. The diagnosis was made by performing ultrasound, CT-scan and angiography. In both cases surgery was the treatment. However, in some cases, interventional angiography with embolisation of the affected vessel offers an alternative treatment.