Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 12 de 12
Filtrar
1.
Soins ; 69(882): 37-40, 2024.
Artigo em Francês | MEDLINE | ID: mdl-38296419

RESUMO

The context of the emergency department particularly exposes professionals to situations where the question of restraint arises. This article describes the indications and modalities of physical restraint. Physical restraint should be considered as a last resort, and requires systematic ethical questioning.


Assuntos
Serviço Hospitalar de Emergência , Restrição Física , Humanos
3.
JAMA ; 326(21): 2141-2149, 2021 12 07.
Artigo em Inglês | MEDLINE | ID: mdl-34874418

RESUMO

Importance: Uncontrolled studies suggest that pulmonary embolism (PE) can be safely ruled out using the YEARS rule, a diagnostic strategy that uses varying D-dimer thresholds. Objective: To prospectively validate the safety of a strategy that combines the YEARS rule with the pulmonary embolism rule-out criteria (PERC) rule and an age-adjusted D-dimer threshold. Design, Settings, and Participants: A cluster-randomized, crossover, noninferiority trial in 18 emergency departments (EDs) in France and Spain. Patients (N = 1414) who had a low clinical risk of PE not excluded by the PERC rule or a subjective clinical intermediate risk of PE were included from October 2019 to June 2020, and followed up until October 2020. Interventions: Each center was randomized for the sequence of intervention periods. In the intervention period (726 patients), PE was excluded without chest imaging in patients with no YEARS criteria and a D-dimer level less than 1000 ng/mL and in patients with 1 or more YEARS criteria and a D-dimer level less than the age-adjusted threshold (500 ng/mL if age <50 years or age in years × 10 in patients ≥50 years). In the control period (688 patients), PE was excluded without chest imaging if the D-dimer level was less than the age-adjusted threshold. Main Outcomes and Measures: The primary end point was venous thromboembolism (VTE) at 3 months. The noninferiority margin was set at 1.35%. There were 8 secondary end points, including chest imaging, ED length of stay, hospital admission, nonindicated anticoagulation treatment, all-cause death, and all-cause readmission at 3 months. Results: Of the 1414 included patients (mean age, 55 years; 58% female), 1217 (86%) were analyzed in the per-protocol analysis. PE was diagnosed in the ED in 100 patients (7.1%). At 3 months, VTE was diagnosed in 1 patient in the intervention group (0.15% [95% CI, 0.0% to 0.86%]) vs 5 patients in the control group (0.80% [95% CI, 0.26% to 1.86%]) (adjusted difference, -0.64% [1-sided 97.5% CI, -∞ to 0.21%], within the noninferiority margin). Of the 6 analyzed secondary end points, only 2 showed a statistically significant difference in the intervention group compared with the control group: chest imaging (30.4% vs 40.0%; adjusted difference, -8.7% [95% CI, -13.8% to -3.5%]) and ED median length of stay (6 hours [IQR, 4 to 8 hours] vs 6 hours [IQR, 5 to 9 hours]; adjusted difference, -1.6 hours [95% CI, -2.3 to -0.9]). Conclusions and Relevance: Among ED patients with suspected PE, the use of the YEARS rule combined with the age-adjusted D-dimer threshold in PERC-positive patients, compared with a conventional diagnostic strategy, did not result in an inferior rate of thromboembolic events. Trial Registration: ClinicalTrials.gov Identifier: NCT04032769.


Assuntos
Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Embolia Pulmonar/diagnóstico , Tromboembolia Venosa/diagnóstico , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Causas de Morte , Intervalos de Confiança , Estudos Cross-Over , Serviço Hospitalar de Emergência , Feminino , França , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Estudos Prospectivos , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/mortalidade , Reprodutibilidade dos Testes , Espanha , Tromboembolia Venosa/sangue , Adulto Jovem
4.
BMJ Case Rep ; 14(6)2021 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-34088694

RESUMO

Patients with COVID-19 may be asymptomatic or present with extrarespiratory symptoms, such as liver injury. It has been reported that 22.5%-46.2% of patients have moderate elevation of liver enzymes. To our knowledge, acute hepatitis has never been described as an isolated symptom of COVID-19 in a previously healthy patient. We report the case of a 53-year-old patient with COVID-19 whose first clinical presentation was acute icteric hepatitis, several days before the development of others symptoms. During the pandemic, we suggest that patients with acute hepatitis be considered as COVID-19 suspects, tested and isolated.


Assuntos
COVID-19 , Hepatite , Icterícia , Doença Aguda , Hepatite/diagnóstico , Humanos , Pessoa de Meia-Idade , SARS-CoV-2
6.
Eur J Emerg Med ; 26(6): 458-461, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31609876

RESUMO

BACKGROUNDS: Paramount to guide the diagnostic strategy, the prevalence of pulmonary embolism in patients with syncope and no other symptoms is uncertain. We aimed to assess the pulmonary embolism prevalence in patients that present to the emergency department (ED) with syncope and no chest pain nor dyspnea. METHODS: Multicenter prospective cohort study in seven EDs in France. Adult patients who presented to the ED with syncope (transient loss of consciousness) were included. Patients with chest pain or dyspnea were excluded. Included patients underwent formal work-up for pulmonary embolism, including D-dimer testing and further imaging if positive. Cases of pulmonary embolism were adjudicated by two independent expert radiologists with the review of imaging studies. Secondary objectives included the pulmonary embolism prevalence in the subgroup of patients with cancer, in patients with negative Pulmonary Embolism Rule Out criteria (PERC) score, and according to the clinical probability assessed either by Wells or revised Geneva score. RESULTS: We analyzed 411 patients, in whom 128 (31%) underwent a computed tomographic pulmonary angiogram and 9 (2%) a ventilation-perfusion scan. A pulmonary embolism was confirmed in nine patients (prevalence of 2.2%, 95% confidence interval, 1.1-4.3%), including one subsegmental pulmonary embolism. This prevalence was of 18% (3-52%) in patients with cancer and 0.7% (0.1-4%) in PERC negative patients. CONCLUSION: In our sample of patients with isolated syncope, the prevalence of pulmonary embolism was 2.2%. This value is not sufficiently low to negate the requirement for a formal work up in the ED, even in the absence of chest pain or dyspnea. However, the large confidence interval precludes any strong conclusion.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Embolia Pulmonar/diagnóstico , Síncope/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia por Tomografia Computadorizada , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Pulmão/irrigação sanguínea , Pulmão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia
7.
Ann Emerg Med ; 74(4): 580-591, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30982631

RESUMO

STUDY OBJECTIVE: Efforts to reduce unnecessary and unnecessarily long antibiotic treatment for community-acquired pneumonia have been attempted through use of procalcitonin and through guidelines based on serial clinical assessment. Our aim is to compare guideline-based clinical assessment- and procalcitonin algorithm-guided antibiotic use among patients with community-acquired pneumonia. METHODS: We performed a pragmatic, randomized, multicenter trial from November 2012 to April 2015 at 12 French hospitals. We included emergency department (ED) patients older than 18 years with community-acquired pneumonia. Patients were randomly assigned to either the procalcitonin-guided or clinical assessment group. In accordance with past studies, we hypothesized that serial clinical assessment would be superior to procalcitonin-guided care. The primary outcome was antibiotic duration, and secondary outcomes included rates of antibiotic duration less than or equal to 5 days, and clinical success and combined serious adverse outcomes at 30 days in the intention-to-treat population. RESULTS: Of 370 eligible patients, 285 (77%) were randomly assigned to either clinical assessment- (n=143) or procalcitonin-guided care (n=142). Median age was 67 years (range 18 to 93 years) and 40% of patients were deemed to have Pneumonia Severity Index class IV or V. Procalcitonin algorithm adherence was 76%. Antibiotic duration was not significantly different between clinical assessment- and procalcitonin-guided groups (median 9 versus 10 days, respectively). Clinical success rate was 92% in each group and serious adverse outcome rates were similar (15% versus 20%, respectively). CONCLUSION: Guideline-based serial clinical assessment did not reduce antibiotic exposure compared with procalcitonin-guided care among ED patients with community-acquired pneumonia. The strategies were similar in terms of duration of antibiotic use and clinical outcomes.


Assuntos
Combinação Amoxicilina e Clavulanato de Potássio/administração & dosagem , Antibacterianos/administração & dosagem , Infecções Comunitárias Adquiridas/tratamento farmacológico , Pneumonia Bacteriana/tratamento farmacológico , Pró-Calcitonina/administração & dosagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Esquema de Medicação , Feminino , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Resultado do Tratamento , Procedimentos Desnecessários , Adulto Jovem
8.
JAMA ; 319(6): 559-566, 2018 02 13.
Artigo em Inglês | MEDLINE | ID: mdl-29450523

RESUMO

Importance: The safety of the pulmonary embolism rule-out criteria (PERC), an 8-item block of clinical criteria aimed at ruling out pulmonary embolism (PE), has not been assessed in a randomized clinical trial. Objective: To prospectively validate the safety of a PERC-based strategy to rule out PE. Design, Setting, and Patients: A crossover cluster-randomized clinical noninferiority trial in 14 emergency departments in France. Patients with a low gestalt clinical probability of PE were included from August 2015 to September 2016, and followed up until December 2016. Interventions: Each center was randomized for the sequence of intervention periods. In the PERC period, the diagnosis of PE was excluded with no further testing if all 8 items of the PERC rule were negative. Main Outcomes and Measures: The primary end point was the occurrence of a thromboembolic event during the 3-month follow-up period that was not initially diagnosed. The noninferiority margin was set at 1.5%. Secondary end points included the rate of computed tomographic pulmonary angiography (CTPA), median length of stay in the emergency department, and rate of hospital admission. Results: Among 1916 patients who were cluster-randomized (mean age 44 years, 980 [51%] women), 962 were assigned to the PERC group and 954 were assigned to the control group. A total of 1749 patients completed the trial. A PE was diagnosed at initial presentation in 26 patients in the control group (2.7%) vs 14 (1.5%) in the PERC group (difference, 1.3% [95% CI, -0.1% to 2.7%]; P = .052). One PE (0.1%) was diagnosed during follow-up in the PERC group vs none in the control group (difference, 0.1% [95% CI, -∞ to 0.8%]). The proportion of patients undergoing CTPA in the PERC group vs control group was 13% vs 23% (difference, -10% [95% CI, -13% to -6%]; P < .001). In the PERC group, rates were significantly reduced for the median length of emergency department stay (mean reduction, 36 minutes [95% CI, 4 to 68]) and hospital admission (difference, 3.3% [95% CI, 0.1% to 6.6%]). Conclusions and Relevance: Among very low-risk patients with suspected PE, randomization to a PERC strategy vs conventional strategy did not result in an inferior rate of thromboembolic events over 3 months. These findings support the safety of PERC for very low-risk patients presenting to the emergency department. Trial Registration: clinicaltrials.gov Identifier: NCT02375919.


Assuntos
Protocolos Clínicos , Técnicas de Apoio para a Decisão , Serviço Hospitalar de Emergência , Embolia Pulmonar/diagnóstico , Adulto , Estudos Cross-Over , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Risco , Tromboembolia/epidemiologia
9.
Scand J Trauma Resusc Emerg Med ; 25(1): 78, 2017 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-28807040

RESUMO

BACKGROUND: Upper gastrointestinal bleeding (UGB) is common in emergency departments (EDs) and can be caused by many eso-gastro-duodenal lesions. Most available epidemiological data and data on the management of UGB comes from specialized departments (intensive care units or gastroenterology departments), but little is known from the ED perspective. We aimed to determine the distribution of symptoms revealing UGB in EDs and the hemorrhagic lesions identified by endoscopy. We also describe the characteristics of patients consulting for UGB, UGB management in the ED and patients outcomes. METHOD: This was a prospective, observational, multicenter study covering 4 consecutive days in November 2013. Participating EDs were part of the Initiatives de Recherche aux Urgences network coordinated by the French Society of Emergency Medicine. All patients with suspected UGB in these EDs were included. RESULTS: In total, 110 EDs participated, including 194 patients with suspected UGB (median age 66 years [Q1-Q3: 51-81]). Overall, 104 patients (54%) had hematemesis and 75 (39%) melena. Endoscopy revealed lesions in 121 patients, mainly gastroduodenal ulcer or ulcerations (41%) or bleeding lesions due to portal hypertension (20%). The final diagnosis of UGB was reversed by endoscopy in only 3% of cases. Overall, 67 patients (35%) had at least one severity sign. Twenty-one patients died (11%); 40 (21%) were hospitalized in intensive care units and 126 (65%) in medicine departments; 28 (14%) were outpatients. Mortality was higher among patients with clinical and biological severity signs. CONCLUSION: Most of the UGB cases in EDs are revealed by hematemesis. The emergency physician diagnosis of UGB is rarely challenged by the endoscopic findings.


Assuntos
Serviço Hospitalar de Emergência , Endoscopia , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , França , Hemorragia Gastrointestinal/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Avaliação de Sintomas
10.
Am J Public Health ; 106(5): 893-8, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26985613

RESUMO

OBJECTIVES: To determine whether homeless patients experience suboptimal care in the emergency department (ED) by the provision of fewer health care resources. METHODS: We conducted a prospective multicenter cohort study in 30 EDs in France. During 72 hours in March 2015, all homeless patients that visited the participating EDs were included in the study. The primary health care service measure was the order by the physician of a diagnostic investigation or provision of a treatment in the ED. Secondary measures of health care services included ED waiting time, number and type of investigations per patient, treatment in the ED, and discharge disposition. RESULTS: A total of 254 homeless patients and 254 nonhomeless patients were included. After excluding homeless patients that attended the ED for the sole purpose of housing, we analyzed 214 homeless and 214 nonhomeless. We found no significant difference between the 2 groups in terms of health care resource consumption, and for our secondary endpoints. CONCLUSIONS: We did not find significant differences in the level of medical care delivered in French EDs to homeless patients compared with matched nonhomeless patients.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/normas , Pessoas Mal Alojadas/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Adulto , Idoso , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Estudos Prospectivos , Indicadores de Qualidade em Assistência à Saúde , Índice de Gravidade de Doença , Listas de Espera
11.
Eur J Emerg Med ; 23(1): 65-7, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25969346

RESUMO

To assess whether the quality of chest compressions (CC) differs before and after a night shift. We carried out a cluster randomized study in three Emergency Departments and three ICUs in Paris, France. Physicians were assessed on a control day and immediately following after a night shift. The primary endpoint was the proportion of CC with a depth greater than 50 mm. We analyzed 67 participants. The proportion of CC with a depth greater than 50 mm was similar on a control day and after a night shift [52% in both groups, mean difference of 0 (95% confidence interval: -17 to 17)]. Other indicators of CC quality were unchanged after a night shift, except for the mean depth of CC (51 vs. 48 mm, P=0.01). We report in our sample that the quality of CC after a night shift is not inferior to a control day.


Assuntos
Reanimação Cardiopulmonar/normas , Massagem Cardíaca/normas , Assistência Noturna , Pressão , Adulto , Reanimação Cardiopulmonar/tendências , Intervalos de Confiança , Estudos Cross-Over , Medicina de Emergência/métodos , Serviço Hospitalar de Emergência , Feminino , França , Massagem Cardíaca/tendências , Humanos , Unidades de Terapia Intensiva , Masculino , Manequins , Pessoa de Meia-Idade , Médicos/normas , Estudos Prospectivos , Valores de Referência , Análise e Desempenho de Tarefas
12.
Eur J Emerg Med ; 22(5): 366-9, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25564458

RESUMO

We aimed to evaluate the reliability of waiting times (WT) measures electronically retrieved. We prospectively collected true WT in four emergency departments during 20 predefined 2-h inclusion periods, and compared them with the electronically retrieved waiting time (ERWT). We assessed agreement with calculation of rate of outliers (difference exceeding 20 min), bias, and its 95% limits of agreements, and associated Bland and Altman plot. We analyzed 274 patients. The mean difference was -2 min (SD 13) between ERWT and true WT, with a 95% limits of agreements (-28 to 24 min). Bland and Altman plot showed a good agreement, and we report 7% of outliers. Using ERWT, 14 patients (5%) were misclassified as having their target WT exceeded or not. ERWT agree well with the true WT, although the significant rate of outlier and misclassification calls for caution in their interpretation.


Assuntos
Registros Eletrônicos de Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência , Listas de Espera , Adulto , Idoso , Distribuição de Qui-Quadrado , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Tempo , Serviços Urbanos de Saúde
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...