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Swiss Emergency Research collection

2010

  • Grossmann, F. F., Nickel, C. H., Christ, M., Schneider, K., Spirig, R., and Bingisser, R. “Transporting Clinical Tools To New Settings: Cultural Adaptation And Validation Of The Emergency Severity Index In German”. Ann Emerg Med 57, no. 3: 257-64. doi:10.1016/j.annemergmed.2010.07.021.
    Abstract: STUDY OBJECTIVE: To date, no German triage tool with proven reliability and validity exists. The goal of this project is to translate and culturally adapt the Emergency Severity Index (ESI) and to assess reliability and validity of the German version. METHODS: The ESI was translated following principles recommended for the translation and cultural adaptation of instruments. We performed a prospective, single-center cohort study. Reliability was assessed by calculating Cohen's weighted kappa for agreement of 2 experts who reviewed the triage nurses' notes. To assess validity, associations of the number of resources, hospitalization, admission to intensive care, length of stay, and mortality with the assigned ESI level were investigated. RESULTS: Only small cultural adaptations had to be made during the translation process. Interrater agreement was high (kappa(w) = 0.985) in a sample of 125 patients. For the assessment of validity, a sample of 2,114 patients was used. Spearman's rank correlation coefficient between ESI category and number of resources was rho = -0.567. The association (Kendall's tau) between ESI category and disposition, and hospitalization was tau = -0.429 and tau = -0.453, respectively. The areas under the curves for the predictive ability of the ESI for hospitalization in general and hospitalization to an ICU were 0.788 and 0.856, respectively. The association between emergency department length of stay and ESI category was also significant (Kruskal-Wallis chi(2) = 450.8; df = 4; P < .001). Furthermore, the association between ESI category and survival probability was significant (log-rank chi(2) = 36.06; df = 3; P < .001). CONCLUSION: Translation of the ESI following guidelines was feasible and resulted in a reliable and valid German version.
    Tags: *Translating, Adult, Aged, Chi-Square Distribution, Culture, Emergencies/*classification, Emergency Nursing/standards, Female, Germany, Humans, Male, Middle Aged, Observer Variation, Prospective Studies, Reproducibility of Results, ROC Curve, Severity of Illness Index, Statistics, Nonparametric, Triage/classification/*standards.
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  • Rudiger-Sturchler, M., Keller, D. I., and Bingisser, R. “Emergency Physician Intershift Handover - Can A Dinamo Checklist Speed It Up And Improve Quality?”. Swiss Med Wkly 140, no. SEPTEMBER: w13085. doi:10.4414/smw.2010.13085.
    Abstract: BACKGROUND: Physician intershift handover has been identified as an area of high risk for adverse events, representing a critical step in patient care transition. Due to frequent shift changes and high patient numbers, emergency departments offer an ideal study setting. AIM OF THE STUDY: At a tertiary care hospital emergency department we aimed to reduce the time needed for patient handover while maintaining or improving quality of information passed between shifts. METHODS: Between 31 March and 20 June 2008 we observed intershift handovers in all non-surgical patients at 8 a.m. between nightshift and dayshift. We collected data on handover characteristics and patient demographics. After the usual clinical rounds following each handover, we asked senior physicians about missing or wrong information and possible implications for patient management. From 31 March to 9 May pre-interventional observation took place. On 13 May the dINAMO checklist with five items and a standardised feedback following each handover was introduced. Post-interventional observation lasted until 20 June. RESULTS: 61 handovers totalling 23.4 hours of observation time covered 1011 patients. The intervention using the dINAMO checklist reduced mean handover time by 26% from 99 +/- 3.3 to 73 +/- 2.8 seconds per individual patient (p <0.0001). This resulted in a reduction of morning handover duration from 30 to 20 minutes. Senior physicians reported insignificant improvement of quality of handover. A significant decline in missing or wrong information from 194 incidents in 496 patients to 78 in 470 patients was recorded. CONCLUSIONS: An intervention consisting of a simple checklist of five items (dINAMO) and an immediate feedback on quality not only contributes to a significant shortening of time needed for physician intershift handover in a university hospital emergency department, but simultaneously helps to improve quality of information and therefore patient management.
    Tags: *Checklist, *Communication, Adult, Aged, Aged, 80 and over, Continuity of Patient Care/*standards, Cooperative Behavior, Efficiency, Organizational/*standards, Emergency Service, Hospital/*standards, Feedback, Female, Hospitals, University, Humans, Interdisciplinary Communication, Internship and Residency, Male, Medical Errors/prevention & control, Medical Records Systems, Computerized/standards, Middle Aged, Patient Care Team/*standards, Prospective Studies, Quality Assurance, Health Care/*standards, Switzerland, Time and Motion Studies.
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  • Lacroix, L. E., Vunda, A., Bajwa, N. M., Galetto-Lacour, A., and Gervaix, A. “Videos In Clinical Medicine. Catheterization Of The Urethra In Male Children”. N Engl J Med 363, no. 14: e19. doi:10.1056/NEJMvcm0808873.
    Tags: Catheterization/adverse effects/instrumentation/*methods, Child, Contraindications, Humans, Infant, Male, Urethra/anatomy & histology, Urinalysis/methods, Urinary Bladder, Neurogenic/therapy, Urinary Tract/anatomy & histology.
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  • Hasler, R. M., Berov, S., Benneker, L., Dubler, S., Spycher, J., Heim, D., Zimmermann, H., and Exadaktylos, A. K. “Are There Risk Factors For Snowboard Injuries? A Case-Control Multicentre Study Of 559 Snowboarders”. Br J Sports Med 44, no. 11: 816-21. doi:10.1136/bjsm.2010.071357.
    Abstract: OBJECTIVE: To analyse risk factors leading to injuries during snowboarding. DESIGN: A case-control multicentre survey of injured and non-injured snowboarders. SETTING: One tertiary and two secondary trauma centres in Bern, Switzerland. METHODS: All snowboard injuries admitted to our tertiary and two affiliated secondary trauma centres from 1 November 2007 to 15 April 2008 were analysed on the basis of a completed questionnaire incorporating 15 variables. The same questionnaire was applied in non-injured controls at valley stations after a snowboarding day during the same period. A multiple logistic regression was performed (dichotomous variables). Patterns of combined risk factors were calculated by inference trees. RESULTS: 306 patients and 253 controls were interviewed. The following variables were statistically significant for the injured PATIENTS: low readiness for speed (OR 0.20, 95% CI 0.06 to 0.64, p=0.0037), bad weather/visibility (OR 19.06, 95% CI 2.70 to 134.73, p=0.0031) and old snow (OR 0.11, 95% CI 0.02 to 0.68, p=0.0323). Not wearing a helmet and riding on icy slopes emerged as a combination of risk factors associated with injury. CONCLUSIONS: Several risk factors and combinations exist, and different risk profiles were identified. Future research should be aimed at more precise identification of groups at risk and developing specific recommendations for each group-for example, a snow-weather conditions index at valley stations.
    Tags: Adolescent, Adult, Aged, Athletic Injuries/epidemiology/etiology, Case-Control Studies, Child, Female, Humans, Male, Middle Aged, Risk Assessment, Risk Factors, Skiing/*injuries, Switzerland/epidemiology, Young Adult.
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  • Klopfstein, U., Kamber, J., and Zimmermann, H. “On The Way To Light The Dark: A Retrospective Inquiry Into The Registered Cases Of Domestic Violence Towards Women Over A Six Year Period With A Semi-Quantitative Analysis Of The Corresponding Forensic Documentation”. Swiss Med Wkly 140, no. JULY: w13047. doi:10.4414/smw.2010.13047.
    Abstract: AIMS: Domestic violence victims are increasingly identified at emergency departments (ED). Studies report a prevalence of 6-30%; women are more frequently affected and to a more serious extent than men. Studies have shown that without screening domestic violence victims are often not recognised. The primary aim of the study is to collect data descriptive of domestic violence victims and to show whether medical documentation meets the requirements of forensic medicine. METHODS: Retrospective analysis of medical records using the ED electronic patient database (Qualicare, Qualidoc Bern) at the ED of Bern University Hospital, Inselspital. Demographics, injuries, perpetrators and a semi-quantitative analysis of the medical records have been evaluated for each case. RESULTS: From 1 January 2000 to 31 December 2005, 40 914 women were admitted to the ED. During this time 160 women were identified as victims of domestic violence and met the inclusion criteria for our study. The age ranged from 15-68 years. 63.6% of these women are married or live in a steady relationship. 46% of all victims of domestic violence were treated from Fridays to Sundays. In 70.2% blunt trauma was documented, the head was affected in 49%, 53% showed injuries of only one body area. In 10 cases, strangulation was suspected. 75% of the assaults could be classified as simple assault on the basis of Swiss criminal law. The perpetrator was the husband or partner in 73.4%. 141 cases were included for a semi-quantitative evaluation of the forensic medical documentation. The type of injuries was described in every case, the localisation in 96%, the shape in 26% and the dimensions of the lesions in 36%. CONCLUSIONS: The present retrospective assessment of medical reports over a 6-year period shows that domestic violence against female patients was documented in 0.4%. This figure is far below the proportions to be expected from recent data. If these data are to be believed the majority of female victims of domestic violence must have been overlooked at the ED. The implementation of screening for domestic violence seems to be crucial. The types of injury are chiefly the result of superficial, blunt violence, meaning of mild degree from the viewpoint of criminal law. The quality of the forensic documentation is poor and usually insufficient for criminal prosecution. Clinicians require training in the forensic aspects of medical records.
    Tags: Adolescent, Adult, Aged, Causality, Craniocerebral Trauma/diagnosis/epidemiology, Cross-Sectional Studies, Disability Evaluation, Female, Hospitals, University/statistics & numerical data, Humans, Mass Screening/trends, Medical Records Systems, Computerized/statistics & numerical data, Middle Aged, Periodicity, Registries, Retrospective Studies, Spouse Abuse/diagnosis/*legislation & jurisprudence/*trends, Switzerland, Wounds and Injuries/diagnosis/*epidemiology, Wounds, Nonpenetrating/diagnosis/epidemiology, Young Adult.
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  • Deyle, S., Evangelopoulos, D. S., Brehmer, T., Zimmermann, H., and Exadaktylos, A. K. “Full Body Radiography (Lodox-Statscan) As A Screening Device For Maxillofacial Injuries, Where Ct Scanning Is Not Immediately Available”. Injury 42, no. 1: 112-3. doi:10.1016/j.injury.2010.07.322.
    Tags: Humans, Injury Severity Score, Maxillofacial Injuries/*diagnostic imaging, Tomography, X-Ray Computed, Whole Body Imaging/*instrumentation.
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  • Hartel, M. J., Jordi, N., Evangelopoulos, D. S., Hasler, R., Dopke, K., Zimmermann, H., and Exadaktylos, A. K. “Optimising Care In A Swiss University Emergency Department By Implementing A Multicentre Trauma Register (Tarn): Report On Evaluation, Costs And Benefits Of Trauma Registries”. Emerg Med J 28, no. 3: 221-4. doi:10.1136/emj.2009.083030.
    Abstract: BACKGROUND: Diagnostic and therapeutic approaches to trauma patients are, depending on experience, equipment and different therapeutic doctrines, subject to wide variations. The ability to compare trauma centres using a standardised trauma register helps to reveal unresolved systemic issues and simplifies the quality management in an Emergency Department (ED). METHODS: This study describes the selection, implementation and initial evaluation process of an international trauma register in a level 1 ED in a university hospital. Furthermore, first preliminary results and a literature review on the benefits are presented. RESULTS: The UK-based Trauma and Research Network (TARN) was found to be the most suitable register for a level 1 Swiss trauma centre. In contrast to the majority of the mortality-oriented registry systems, the database is capable of predicting the probability of survival for the referenced patients. Staff and technical adaptations were arranged and regular and reliable data acquisition and entry was ensured within 6 weeks. The University Hospital Bern has performed well from the very beginning and ranks within the top ten hospitals. CONCLUSIONS: With TARN, an appropriate trauma register has been chosen. First preliminary results have been obtained, and it was concluded that there was a good match between TARN's patient cohort and the Bernese. On the basis of the data entered into the register, the hospital authorities can now plan and perform improvements on the individual aspects of trauma care. Due to an objective comparability, weak points can be identified, lessons can be learned and further improvement can be achieved.
    Tags: *Quality Improvement, *Registries, Benchmarking/*statistics & numerical data, Cost-Benefit Analysis, Humans, Quality Control, Survival Analysis, Switzerland/epidemiology, Trauma Centers/*statistics & numerical data, Wounds and Injuries/*mortality/therapy.
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  • Carron, P. N., Cavassini, M., Maeder, P., and Hugli, O. W. “An Unusual Cerebral Computed Tomography Image”. Cjem 12, no. 3: 223, 227-8. doi:10.1017/s1481803500012288.
    Tags: *Tomography, X-Ray Computed, Adult, AIDS-Related Opportunistic Infections/complications/*diagnostic imaging/pathology, Brain Edema/*diagnostic imaging/etiology, Brain Neoplasms/diagnosis/diagnostic imaging, Consciousness Disorders/diagnosis/*diagnostic imaging/etiology, Diagnosis, Differential, Equatorial Guinea/ethnology, Glioblastoma/diagnosis/diagnostic imaging, Humans, Lymphoma/diagnosis/diagnostic imaging, Male, Neurosyphilis/diagnosis/diagnostic imaging, Prisoners, Switzerland, Toxoplasmosis, Cerebral/complications/diagnosis/*diagnostic imaging/pathology.
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  • Deyle, S., Brehmer, T., Evangelopoulos, D. S., Krause, F., Benneker, L. M., Zimmermann, H., and Exadaktylos, A. K. “Review Of Lodox Statscan In The Detection Of Peripheral Skeletal Fractures In Multiple Injury Patients”. Injury 41, no. 8: 818-22. doi:10.1016/j.injury.2010.03.021.
    Abstract: INTRODUCTION: As part of the primary survey, polytrauma patients in our emergency department are examined using the new 'Lodox Statscan' (LS) digital low-radiation imaging device. The LS provides full-body anterior and lateral views based on enhanced linear slot-scanning technology, in accordance with the recommended Advanced Trauma Life Support (ATLS) Guidelines. This study's objectives were to establish whether LS appropriately rules out peripheral bone injuries and to examine whether LS imaging provides adequate information for the preoperative planning of such lesions. METHODS: A total of 245 consecutive polytrauma patients aged 16 years or more undergoing LS imaging were included in this retrospective chart analysis. The results of the LS scans were reviewed and compared to additional plain radiographs or computed tomography scans, whenever further radiological imaging was required to determine consecutive therapy. RESULTS: The sensitivity and specificity of the LS scans were 73% and 100%, respectively, for peripheral skeletal injuries. Additional plain radiographs were performed in 50% of cases for (1) superior focussing and more precise resolution of the affected part of the body, (2) additional second or third plane, (3) additional information about fracture type and planning of the surgical approach and (4) for preoperative planning of implant size and positioning on calibrated digitised films, <1% because of the low quality of the LS scan and <1% because the fracture zone had not been fully captured. CONCLUSION: The study demonstrates that despite LS's high sensitivity and specificity in the detection of peripheral skeletal injuries, additional radiological imaging for diagnostic or preoperative reasons was required. Our results imply that LS, although efficient for patient screening in the emergency room, cannot always rule out peripheral skeletal injuries.
    Tags: Adolescent, Adult, Aged, Aged, 80 and over, Female, Fractures, Bone/*diagnostic imaging, Humans, Image Interpretation, Computer-Assisted/methods, Male, Middle Aged, Multiple Trauma/*diagnostic imaging, Practice Guidelines as Topic, Preoperative Care, Retrospective Studies, Sensitivity and Specificity, Technology, Radiologic/*instrumentation/methods, Tomography, X-Ray Computed/*instrumentation/methods, Young Adult.
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  • Grosgurina, O., Plojouxa, J., Kellerb, P. F., Niquillea, M., N'Kouloub, R., Machb, F., Sarasina, F. P., and Rutschmanna, O. T. “Prehospital Emergency Physician Activation Of Interventional Cardiology Team Reduces Door-To-Balloon Time In St-Elevation Myocardial Infarction”. Swiss Medical Weekly 140, no. 15-16: 228-232. https://www.scopus.com/inward/record.uri?eid=2-s2.0-77951630625&partnerID=40&md5=f980f4ecfcd22fd9980b41db149df610.
    Abstract: Question under study: To explore whether early activation of an interventional cardiology team, by prehospital emergency physicians, reduces doorto-balloon time (DTBT) in patients with ST-elevation myocardial infarction (STEMI) diagnosed with prehospital ECG. Methods: Design: before-after comparison. Setting: emergency department (ED) of an urban teaching hospital with a catheterisation laboratory open continuously. Study subjects: patients with STEMI diagnosed in the prehospital setting or in the ED within 12 hours of symptoms. Intervention: a paging system or "STEMI alarm", activated by prehospital physicians, which simultaneously notified both the catherisation laboratory and cardiology teams before the patient's arrival to the ED. Outcome measures: DTBT and the proportion of patients with DTBT <90 minutes. Results: A total of 196 patients were included; 77 before and 119 after implementation of the "STEMI alarm". Between the two periods, median DTBT decreased from 109 to 76 minutes (p <0.001) and the proportion of patients treated within 90 minutes increased from 36% to 66% (p <0.001). During intervention, the STEMI alarm was activated in 67 patients (56%). In these cases the median DTBT was 50 minutes, with 96% within 90 minutes. The alarm was inappropriately activated in 9 cases (11%). Conclusions: Catheterisation laboratory activation by a prehospital emergency physician markedly reduces DTBT in STEMI patients.
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  • Nemec, M., Koller, M. T., Nickel, C. H., Maile, S., Winterhalder, C., Karrer, C., Laifer, G., and Bingisser, R. “Patients Presenting To The Emergency Department With Non-Specific Complaints: The Basel Non-Specific Complaints (Banc) Study”. Acad Emerg Med 17, no. 3: 284-92. doi:10.1111/j.1553-2712.2009.00658.x.
    Abstract: OBJECTIVES: Patient management in emergency departments (EDs) is often based on management protocols developed for specific complaints like dyspnea, chest pain, or syncope. To the best of our knowledge, to date no protocols exist for patients with nonspecific complaints (NSCs) such as "weakness,""dizziness," or "feeling unwell." The objectives of this study were to provide a framework for research and a description of patients with NSCs presenting to EDs. METHODS: Nonspecific complaints were defined as the entity of complaints not part of the set of specific complaints for which evidence-based management protocols for emergency physicians (EPs) exist. "Serious conditions" were defined as potentially life-threatening or those requiring early intervention to prevent health status deterioration. During a 6-month period, all adult nontrauma patients with an Emergency Severity Index (ESI) of 2 or 3 were prospectively enrolled, and serious conditions were identified within a 30-day period. RESULTS: The authors screened 18,261 patients for inclusion. A total of 218 of 1,611 (13.5%) nontrauma ESI 2 and 3 patients presented with NSCs. Median age was 82 years (interquartile range [IQR]=72 to 87), and 24 of 218 (11%) were nursing home inhabitants. A median of 4 (IQR=3 to 5) comorbidities were recorded, most often chronic hypertension, coronary artery disease, and dementia. During the 30-day follow-up period a serious condition was diagnosed in 128 of 218 patients (59%). The 30-day mortality rate was 6%. CONCLUSIONS: Patients with NSC presenting to the ED are at high risk of suffering from serious conditions. Sensitive risk stratification tools are needed to identify patients with potentially adverse health outcomes.
    Tags: Accidental Falls/statistics & numerical data, Aged, Aged, 80 and over, Algorithms, Analysis of Variance, Clinical Protocols, Comorbidity, Cross-Sectional Studies, Diagnosis, Differential, Emergency Service, Hospital/statistics & numerical data, Emergency Treatment/*methods, Fatigue/*diagnosis/epidemiology/etiology, Female, Geriatric Assessment/*methods, Hospitals, University, Humans, Logistic Models, Male, Muscle Weakness/*diagnosis/epidemiology/etiology, Predictive Value of Tests, Prospective Studies, Risk Assessment/*methods, Severity of Illness Index, Switzerland/epidemiology, Triage/methods.
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  • Schaller, B., Evangelopoulos, D. S., Muller, C., Martinolli, L., Pouljadoff, M. P., Zimmermann, H., and Exadaktylos, A. K. “Do We Really Need 24-H Observation For Patients With Minimal Brain Injury And Small Intracranial Bleeding? The Bernese Trauma Unit Protocol”. Emerg Med J 27, no. 7: 537-9. doi:10.1136/emj.2009.073031.
    Abstract: BACKGROUND: Traumatic brain injury is one of the most common reasons for admission to hospital emergency departments. However, optimal diagnosis and treatment protocols remain controversial. The aim of this study is to assess whether a specific group of patients can be discharged from the hospital without 24-h neurological observation. METHODS: Retrospective analysis was performed for 1078 patients with a minor isolated head injury admitted to the authors' Emergency Department for 24-h observation. Exclusion criteria included intracranial bleeds with maximum diameter above 5 mm or multiple (>1) bleeds, a history of inherited coagulopathy or anticoagulant therapy, platelet aggregation inhibitor therapy, intoxication or multiple associated injuries. Furthermore, patients who had no-one to observe them at home or who lived more than 1 h away were excluded from the study. RESULTS: 110 patients presented with an isolated small intracranial bleed (<5 mm) with a Glasgow Coma Scale (GCS) of 13-15. Of these patients, 46% exhibited small intracerebral haematomas, 23% traumatic subarachnoid haematomas, 9% epidural haematomas and 7% subdural haematomas. Nine patients presented with a GCS of 13/15, 30 patients with a GCS 14/15 and 71 patients with a GCS 15/15. 85% of all patients regained GCS 15/15 within 1 h after admission and 15% within 2 h after admission. All patients maintained their GCS 15/15 over the 24-h period. CONCLUSIONS: Standard 24-h observation may not be required for adult patients with single intracranial bleeds with maximum diameter less than 5 mm, without a history of inherited coagulopathy or anticoagulant therapy, platelet aggregation inhibitor therapy, intoxication or multiple associated injuries. The decision for discharging patients may be made from the clinical picture. This might help to spare hospital resources and reduce unnecessary hospitalisations.
    Tags: Adult, Brain Injuries/*complications/*diagnosis, Emergency Service, Hospital, Female, Glasgow Coma Scale, Hematoma/classification/diagnosis/etiology, Humans, Intracranial Hemorrhages/classification/diagnosis/*etiology, Male, Observation, Retrospective Studies, Switzerland.
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  • Haberkern, M., Exadaktylos, A. K., and Marty, H. “Alcohol Intoxication At A University Hospital Acute Medicine Unit--With Special Consideration Of Young Adults: An 8-Year Observational Study From Switzerland”. Emerg Med J 27, no. 3: 199-202. doi:10.1136/emj.2008.065482.
    Abstract: BACKGROUND: Many media reports suggest an increase in alcohol intoxication, particularly among young people. Indeed, several surveys on young people have confirmed this fact. These were based on self-declaration of alcohol consumption. However, there are few clinical data that show an increase in alcohol intoxication in hospitals. The aim of this study was to evaluate the number of alcohol intoxications in relation to the total number of patients and to look for a statistical trend. METHODS: Using their electronic database, the authors identified all patients with alcohol intoxication who were treated in the acute medical wing of our ED in the years 2000-2007. In the group aged 16-25 years, the authors searched for combined intoxication. RESULTS: The authors found a significant increase in alcohol intoxication in all age groups and also in young people aged below 25 years. There were more intoxicated males than females (male to female ratio 1.5:1). The age distribution of our intoxicated patients showed a peak at 35-45 years of age and repeated admissions were frequent in this age class. Drugs consumed together with alcohol in the age group 16-25 were mostly cannabis and cocaine. CONCLUSION: Episodic drinking is not only a problem in the 16-25 age group, it also concerns men of 35-45 years. This is a major public health problem in industrialised countries. Intoxicated patients are at acute risk of injuries and violence following alcohol abuse. Preventive measures should not only be limited to younger adults.
    Tags: Adolescent, Adult, Age Distribution, Alcoholic Intoxication/*epidemiology/therapy, Female, Hospitals, University/*statistics & numerical data/trends, Humans, Incidence, Male, Patient Readmission, Retrospective Studies, Sex Distribution, Surveys and Questionnaires, Switzerland/epidemiology, Young Adult.
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  • Stephan, F. P., Nickel, C. H., Martin, J. S., Grether, D., Delport-Lehnen, K., and Bingisser, R. “Pain In The Emergency Department: Adherence To An Implemented Treatment Protocol”. Swiss Med Wkly 140, no. 23-24: 341-7. doi:10.4414/smw.2010.12975.
    Abstract: OBJECTIVES: Although pain is one of the most common presenting complaints in the Emergency Department (ED), pain management is often inadequate. Pain management protocols have been shown to be useful. The objective of this study was to assess the adherence to an already implemented pain management protocol in an urban ED. METHODS: Secondary analysis of a prospective single centre cohort study on patient preferences for analgesia in the ED. Patient charts were reviewed with a focus on selection, timing and dosage of analgesics according to a visual analogue scale (VAS) on arrival and during the ED stay. RESULTS: Three hundred and thirty-seven patient charts were reviewed. The adherence to the implemented pain management protocol was 42% at the time of initial evaluation and 43% during the course of therapy in all patients. Forty-two percent of the study population were discharged with at least moderate pain. However, 43% of the patients discharged with pain did not request analgesics. CONCLUSIONS: The benefits of pain management protocols are proven. However, adherence to these protocols needs to be monitored regularly in order to optimise pain management.
    Tags: *Clinical Protocols, Adolescent, Adult, Aged, Analgesics/*administration & dosage/therapeutic use, Emergency Service, Hospital/*statistics & numerical data, Female, Humans, Male, Middle Aged, Pain Management, Pain Measurement, Pain/*drug therapy, Prospective Studies, Time Factors, World Health Organization, Young Adult.
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  • Jeger, V., Zimmermann, H., and Exadaktylos, A. K. “Thrombelastography In Trauma, The Closer The Better”. J Trauma 68, no. 2: 508. doi:10.1097/TA.0b013e3181caa82e.
    Tags: *Point-of-Care Systems, Blood Coagulation Disorders/*diagnosis/etiology, Humans, Multiple Trauma/complications, Thrombelastography/*methods.
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  • Bernsmeier, C., Nickel, C., Bingisser, R., and Kim, M. J. “Urinary Tract Infection Presenting With Nonspecific Complaints And Normal Urinalysis In 84-Year-Old Woman”. American Journal Of Case Reports 11: 116-118. https://www.scopus.com/inward/record.uri?eid=2-s2.0-78649358338&partnerID=40&md5=c6d758826378fb0c1a2862fa3536c10d.
    Abstract: Background: Elderly patients with urinary tract infection have been well known to often present with nonspecific deterioration with confusion, but without urinary tract specific symptoms. In case of completely unremarkable results of the laboratory tests, the diagnosis can be a real challenge. Case Report: An 84-year old healthy woman presented with sudden onset of chest discomfort to a local hospital. Due to the development of speech disturbance and disorientation after the admission, she was referred to a tertiary care hospital for further evaluation. Laboratory tests including urinalysis, electrocardiogram, chest radiograph, computed tomography of the brain and lumbar puncture were normal. Alternating symptoms, such as chest discomfort and generalized weakness and cognitive impairment persisted. Six hours after admission, she developed fever and the third urinalysis taken 12 hours after the admission revealed a clear finding of urinary tract infection. Antimicrobial treatment led to resolution of symptoms within 24 hours. Conclusions: Our case demonstrates the diversity of symptoms preceding laboratory changes in elderly patients with urinary tract infection and the dynamic changes in urinalysis in the very early stage. Repetitive urinalysis can be the key diagnostic tool leading to a successful treatment in elderly patients with atypical presentation. © The American Journal of Case Reports, 2010.
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2009

  • Nickel, C. H., Stephan, F. P., Dangel, M., Blume, K., Gehrisch, R., Dumoulin, A., Tschudin, S., et al. “First Wave Of The Influenza A/H1N1V Pandemic In Switzerland”. Swiss Med Wkly 139, no. 51-52: 731-7. doi:10.4414/smw.2009.12952.
    Abstract: AIM: To describe the disease burden, clinical pattern and outcome of influenza-related cases presenting to a Swiss Emergency Department (ED), during the first wave of the 2009 pandemic. METHODS: Retrospective analysis of prospectively collected data at the University Hospital of Basel, Switzerland. All patients presenting to the ED with influenza-like symptoms from June 1 to October 23, 2009, were studied. Rate of hospitalisation, demographic characteristics, symptoms, microbiological diagnoses and complications of influenza infection were analysed. RESULTS: One tenth (808 of 8356 patients) of all non-trauma ED presentations, during the study period, were a result of suspected influenza-related illness. Influenza A/H1N1v infection accounted for 5% of these presentations. Patients aged 50 years or less accounted for 87% of these presentations and for 100% of A/H1N1v infection. The highest detection rate of A/H1N1v-infection occurred in July, and the highest rate of clinical presentations occurred in August 2009. Underlying medical disease was observed in 14% of all patients. The presence of fever, cough and myalgia was the prime clinical predictor for the presence of A/H1N1v infection. 16% of patients with this triad suffered from A/H1N1v. CONCLUSION: Suspected A/H1N1v infection contributed to a considerable health care burden in Switzerland. However, the rate of true positivity was low (5%), hospitalisations rare (5%), and mortality did not occur. Therefore, the first wave of the A/H1N1v pandemic in Switzerland was rather media "hype" than real threat.
    Tags: *Population Surveillance, Adult, Comorbidity, Disease Outbreaks, Female, Humans, Influenza A Virus, H1N1 Subtype/*genetics/isolation & purification, Influenza, Human/*epidemiology/virology, Male, Oseltamivir, Polymerase Chain Reaction, Prospective Studies, Retrospective Studies, Switzerland/epidemiology, Young Adult.
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  • Isenegger, J., Meier, N., Lammle, B., Alberio, L., Fischer, U., Nedeltchev, K., Gralla, J., Kohler, H. P., Mattle, H. P., and Arnold, M. “D-Dimers Predict Stroke Subtype When Assessed Early”. Cerebrovasc Dis 29, no. 1: 82-6. doi:10.1159/000256652.
    Abstract: BACKGROUND: Early classification of ischemic stroke subtype is important for secondary stroke prevention and may guide further investigations. METHODS: Levels of coagulation activation [fibrinopeptide A (FPA), prothrombin fragment 1+2 (F1+2), thrombin-antithrombin complex (TAT)] and fibrinolysis activation [plasmin-alpha(2)-antiplasmin complex (PAP), D-dimers] markers were measured in 98 consecutive patients with a first-ever acute ischemic stroke admitted within 12 h after symptom onset. RESULTS: Median age was 67 years and 44% were women. Median time from symptom onset to blood sampling was 4 h. Stroke subtype was classified as 'cardioembolic' (54%), 'large-artery atherosclerosis' (11%), 'small-vessel disease' (5%), 'other determined' (9%) or 'undetermined etiology' (20%). Patients with cardioembolic stroke suffered more often from coronary artery disease than patients with other stroke etiologies (40 vs. 22%, p = 0.019). There were no differences in age, sex, stroke severity, time to blood sampling, frequency of hypertension, diabetes mellitus or current smoking. D-dimers (medians) were higher in patients with cardioembolic strokes than in those with other etiologies (615 vs. 322 microg/l, p < 0.001). No differences in F1+2, FPA, TAT or PAP levels were found. After multivariate analysis, higher D-dimer levels remained independently associated with cardioembolic stroke (p = 0.022). When measured within 6 h, D-dimers below 300 microg/l excluded cardioembolic stroke with a sensitivity of 100% and a specificity of 52%. CONCLUSIONS: Low D-dimer levels in the first few hours make a cardioembolic stroke unlikely, and may be useful to guide further investigations. Other coagulation markers were not useful in differentiating between different stroke etiologies.
    Tags: *Blood Coagulation, *Fibrinolysis, Adolescent, Adult, Aged, Biomarkers/blood, Brain Ischemia/blood/*diagnosis/etiology, Diagnosis, Differential, Embolism/blood/complications, Female, Fibrin Fibrinogen Degradation Products/*analysis, Heart Diseases/blood/complications, Humans, Male, Middle Aged, Predictive Value of Tests, Risk Factors, ROC Curve, Sensitivity and Specificity, Stroke/blood/*diagnosis/etiology, Time Factors, Young Adult.
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  • Hasler, R. M., Dubler, S., Benneker, L. M., Berov, S., Spycher, J., Heim, D., Zimmermann, H., and Exadaktylos, A. K. “Are There Risk Factors In Alpine Skiing? A Controlled Multicentre Survey Of 1278 Skiers”. Br J Sports Med 43, no. 13: 1020-5. doi:10.1136/bjsm.2009.064741.
    Abstract: OBJECTIVE: To analyse risk factors in alpine skiing. DESIGN: A controlled multicentre survey of injured and non-injured alpine skiers. SETTING: One tertiary and two secondary trauma centres in Bern, Switzerland. PATIENTS AND METHODS: All injured skiers admitted from November 2007 to April 2008 were analysed using a completed questionnaire incorporating 15 parameters. The same questionnaire was distributed to non-injured controls. Multiple logistic regression was performed. Patterns of combined risk factors were calculated by inference trees. A total of 782 patients and 496 controls were interviewed. RESULTS: Parameters that were significant for the patients were: high readiness for risk (p = 0.0365, OR 1.84, 95% CI 1.04 to 3.27); low readiness for speed (p = 0.0008, OR 0.29, 95% CI 0.14 to 0.60); no aggressive behaviour on slopes (p<0.0001, OR 0.19, 95% CI 0.09 to 0.37); new skiing equipment (p = 0.0228, OR 59, 95% CI 0.37 to 0.93); warm-up performed (p = 0.0015, OR 1.79, 95% CI 1.25 to 2.57); old snow compared with fresh snow (p = 0.0155, OR 0.31, 95% CI 0.12 to 0.80); old snow compared with artificial snow (p = 0.0037, OR 0.21, 95% CI 0.07 to 0.60); powder snow compared with slushy snow (p = 0.0035, OR 0.25, 95% CI 0.10 to 0.63); drug consumption (p = 0.0044, OR 5.92, 95% CI 1.74 to 20.11); and alcohol abstinence (p<0.0001, OR 0.14, 95% CI 0.05 to 0.34). Three groups at risk were detected: (1) warm-up 3-12 min, visual analogue scale (VAS)(speed) >4 and bad weather/visibility; (2) VAS(speed) 4-7, icy slopes and not wearing a helmet; (3) warm-up >12 min and new skiing equipment. CONCLUSIONS: Low speed, high readiness for risk, new skiing equipment, old and powder snow, and drug consumption are significant risk factors when skiing. Future work should aim to identify more precisely specific groups at risk and develop recommendations--for example, a snow weather index at valley stations.
    Tags: Adult, Athletic Injuries/etiology, Case-Control Studies, Female, Humans, Male, Middle Aged, Protective Devices/statistics & numerical data, Risk Factors, Skiing/*injuries, Switzerland, Weather, Young Adult.
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  • Evangelopoulos, D. S., Deyle, S., Zimmermann, H., and Exadaktylos, A. K. “Personal Experience With Whole-Body, Low-Dosage, Digital X-Ray Scanning (Lodox-Statscan) In Trauma”. Scand J Trauma Resusc Emerg Med 17, no. 1: 41. doi:10.1186/1757-7241-17-41.
    Abstract: BACKGROUND: Lodox-Statscan is a whole-body, skeletal and soft-tissue, low-dose X-ray scanner Anterior-posterior and lateral thoraco-abdominal studies are obtained in 3-5 minutes with only about one-third of the radiation required for conventional radiography. Since its approval by the Food and Drug Administration (FDA) in the USA, several trauma centers have incorporated this technology into their Advanced Trauma Life Support protocols. This review provides a brief overview of the system, and describes the authors' own experience with the system. METHODS: We performed a PubMed search to retrieve all references with 'Lodox' and 'Stat-scan' used as search terms. We furthermore used the google search engine to identify existing alternatives. To the best of our knowledge, this is the only FDA-approved device of its kind currently used in trauma. RESULTS AND CONCLUSION: The intention of our review has been to sensitize the readership that such alternative devices exist. The key message is that low dosage full body radiography may be an alternative to conventional resuscitation room radiography which is usually a prelude to CT scanning (ATLS algorithm). The combination of both is radiation intensive and therefore we consider any reduction of radiation a success. But only the future will show whether LS will survive in the face of low-dose radiation CT scanners and magnetic resonance imaging devices that may eventually completely replace conventional radiography.
    Tags: *Radiation Dosage, Humans, Radiography, Review Literature as Topic, United States, Whole-Body Irradiation/*methods, Wounds and Injuries/*diagnostic imaging.
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  • Exadaktylos, A. K. “Full Life Support For Acute Care Surgery”. Ann Emerg Med 54, no. 3: 478; author reply 480-1. doi:10.1016/j.annemergmed.2008.06.475.
    Tags: *Interprofessional Relations, Critical Care/*organization & administration, Emergency Medicine/*organization & administration, Emergency Service, Hospital/organization & administration, Humans, Traumatology/*organization & administration, Workforce.
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  • Wagner, O. J., Vorburger, S. A., Exadaktylos, A. K., and Zimmermann, H. “Digital Rectal Examination And Its Value For Decision Making”. Am J Emerg Med 27, no. 2: 246. doi:10.1016/j.ajem.2008.12.008.
    Tags: *Rectum, Acute Disease, Adolescent, Appendicitis/*diagnosis/therapy, Child, Decision Making, Diagnosis, Differential, Female, Humans, Male, Physical Examination/*methods.
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  • Jeger, V., Zimmermann, H., and Exadaktylos, A. K. “Can Rapidteg Accelerate The Search For Coagulopathies In The Patient With Multiple Injuries?”. J Trauma 66, no. 4: 1253-7. doi:10.1097/TA.0b013e31819d3caf.
    Abstract: Early recognition of coagulopathy may improve the care of patients with multiple injuries. Rapid thrombelastography (RapidTEG) is a new variant of thrombelastography (TEG), in which coagulation is initiated by the addition of protein tissue factor. The kinetics of coagulation and the times of measurement were compared for two variants of TEG--RapidTEG and conventional TEG, in which coagulation was initiated with kaolin. The measurements were performed on blood samples from 20 patients with multiple injuries. The RapidTEG results were also compared with conventional measurements of blood coagulation. The mean time for the RapidTEG test was 19.2 +/- 3.1 minutes (mean +/- SD), in comparison with 29.9 +/- 4.3 minutes for kaolin TEG and 34.1 +/- 14.5 minutes for conventional coagulation tests. The mean time for the RapidTEG test was 30.8 +/- 5.72 minutes, in comparison with 41.5 +/- 5.66 minutes for kaolin TEG and 64.9 +/- 18.8 for conventional coagulation tests---measured from admission of the patients to the resuscitation bay until the results were available. There were significant correlations between the RapidTEG results and those from kaolin TEG and conventional coagulation tests. RapidTEG is the most rapid available test for providing reliable information on coagulopathy in patients with multiple injuries. This has implications for improving patient care.
    Tags: Adolescent, Adult, Aged, Aged, 80 and over, Blood Coagulation Disorders/*diagnosis/etiology, Blood Coagulation/drug effects, Emergency Service, Hospital, Female, Humans, Kaolin/pharmacology, Male, Middle Aged, Multiple Trauma/*complications/*physiopathology, Point-of-Care Systems, Thrombelastography/*methods, Thromboplastin, Young Adult.
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  • Quitt, J., Ryser, D., Dieterle, T., Luscher, U., Martina, B., and Tschudi, P. “Does Nonmedical Hospital Admission Staff Accurately Triage Emergency Department Patients?”. Eur J Emerg Med 16, no. 4: 172-6. doi:10.1097/MEJ.0b013e32830c2193.
    Abstract: OBJECTIVES: Utilization of hospital emergency departments (EDs) is continuously increasing. Though nurses and physicians are ultimately responsible for the definite triage decisions, initial ED patient triage is frequently performed by hospital admission staff. This study analyzes the quality of assessment of the severity of emergencies and the choice of treatment unit made by hospital admission staff. METHODS: One thousand fifty-nine consecutive surgical and medical patients entering the ED of the University Hospital Basel during an 11-day period were independently assessed by hospital admission staff without formal medical training, ED nursing staff, and ED physicians. Emergencies were classified by severity (intervention within minutes/hours/days) or by severity and resource utilization (immediate intervention with/without life-threatening condition, delayed intervention with high/low/no demand of resources). Emergency assessment and triage decision (surgical/medical, outpatient/inpatient treatment) were documented independently by all three ED staff groups. RESULTS: In 64% of the cases, initial assessment by admission staff corresponded with the final assessment by the ED physician. Concordance was, however, poor (kappa=0.23). Underestimation of the severity occurred in 7.5% of cases without severe or lethal consequences. Ninety-four percent of patients were treated in the unit to which they were originally triaged by the admission staff. CONCLUSION: Triage quality regarding the choice of treatment unit was found to be excellent, whereas the quality of the assessment of the severity of the emergency by nonmedical ED admission staff was acceptable. ED patients have to be assessed by medical staff early after admission to ensure adequate and timely interventions.
    Tags: *Emergency Service, Hospital, Adolescent, Adult, Aged, Aged, 80 and over, Child, Child, Preschool, Emergency Nursing, Female, Humans, Male, Medical Receptionists, Medical Staff, Hospital, Middle Aged, Observer Variation, Prospective Studies, Quality Assurance, Health Care, Switzerland, Triage/*standards, Young Adult.
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  • Deyle, S., Wagner, A., Benneker, L. M., Jeger, V., Eggli, S., Bonel, H. M., Zimmermann, H., and Exadaktylos, A. K. “Could Full-Body Digital X-Ray (Lodox-Statscan) Screening In Trauma Challenge Conventional Radiography?”. J Trauma 66, no. 2: 418-22. doi:10.1097/TA.0b013e31818a5d1a.
    Abstract: BACKGROUND: ATLS Guidelines recommend single plain radiography of the chest and pelvis as part of the primary survey. Such isolated radiographs, usually obtained by bedside machines, can result in limited, low-quality studies that can adversely affect management. A new digital, low-radiation imaging device, the "Lodox Statscan" (LS), provides full-body anterior and lateral views based on enhanced linear slot-scanning technology in just over 5 minutes. We have the first LS in Europe at our facility. The aim of this study was to compare LS with computed tomographic (CT) scanning, as the gold standard, to determine the sensitivity of LS investigation in detecting injuries to the chest, thoracolumbar spine, and pelvis from our own experience, and to compare our findings with those of conventional radiography in the literature. METHODS: We performed a retrospective chart analysis of 245 patients with multiple injuries examined by full-body LS imaging and CT scans between October 1, 2006 and October 1, 2007 at our facility. Patients under the age of 16 years were not included. LS and CT images of chest injuries, injuries to the thoracolumbar spine, and fractures of the pelvis were compared. At our facility, we no longer perform plain radiography for C-spine and head injury, but perform CT scans according to the Canadian rules. Findings with LS were also compared with those reported for conventional radiography in the literature. RESULTS: Compared with CT scanning, sensitivity and specificity of full-body digital X-ray of blunt chest trauma were 57% and 100%, respectively, thoracic spinal injury 43% and 100%, lumbar spine lesions 74% and 100%, and pelvic injury 72% and 99%. The positive and negative predictive value of LS imaging were 99% and 90% for blunt chest trauma, 100% and 93% for overall spinal injuries, and 90% and 97% for pelvic injuries. CONCLUSION: Full-body radiography with LS visualizes skeletal, chest, and pelvic pathologies "all-in-one." This low-radiation technology detected chest, thoracolumbar spine, and pelvic injuries with an overall sensitivity of 62% and a specificity of 99%. Compared with figures in the literature, LS was more accurate than conventional X-rays. A prospective randomized study is warranted to support these data.
    Tags: Adolescent, Adult, Aged, Aged, 80 and over, Confidence Intervals, Female, Humans, Injury Severity Score, Male, Middle Aged, Predictive Value of Tests, Retrospective Studies, Sensitivity and Specificity, Tomography, X-Ray Computed, Whole Body Imaging/*instrumentation, Wounds and Injuries/*diagnostic imaging.
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2008

  • Ecker, T. M., Kleinschmidt, M., Martinolli, L., Zimmermann, H., and Exadaktylos, A. K. “Clinical Presentation Of A Traumatic Cervical Spine Disc Rupture In Alpine Sports: A Case Report”. Scand J Trauma Resusc Emerg Med 16, no. 1: 14. doi:10.1186/1757-7241-16-14.
    Abstract: Isolated non-skeletal injuries of the cervical spine are rare and frequently missed. Different evaluation algorithms for C-spine injuries, such as the Canadian C-spine Rule have been proposed, however with strong emphasis on excluding osseous lesions. Discoligamentary injuries may be masked by unique clinical situations presenting to the emergency physician. We report on the case of a 28-year-old patient being admitted to our emergency department after a snowboarding accident, with an assumed hyperflexion injury of the cervical spine. During the initial clinical encounter the only clinical finding the patient demonstrated, was a burning sensation in the palms bilaterally. No neck pain could be elicited and the patient was not intoxicated and did not have distracting injuries. Since the patient described a fall prevention attempt with both arms, a peripheral nerve contusion was considered as a differential diagnosis. However, a high level of suspicion and the use of sophisticated imaging (MRI and CT) of the cervical spine, ultimately led to the diagnosis of a traumatic disc rupture at the C5/6 level. The patient was subsequently treated with a ventral microdiscectomy with cage interposition and ventral plate stabilization at the C5/C6 level and could be discharged home with clearly improving symptoms and without further complications. This case underlines how clinical presentation and extent of injury can differ and it furthermore points out, that injuries contracted during alpine snow sports need to be considered high velocity injuries, thus putting the patient at risk for cervical spine trauma. In these patients, especially when presenting with an unclear neurologic pattern, the emergency doctor needs to be alert and may have to interpret rigid guidelines according to the situation. The importance of correctly using CT and MRI according to both - standardized protocols and the patient's clinical presentation - is crucial for exclusion of C-spine trauma.
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  • Benneker, L. M., Leitner, C., Martinolli, L., Robert, K., Zimmermann, H., and Exadaktylos, A. K. “Isolated Vertebral Fractures Give Elevated Serum Protein S-100B Levels”. Scand J Trauma Resusc Emerg Med 16, no. 1: 13. doi:10.1186/1757-7241-16-13.
    Abstract: BACKGROUND: Serum protein S-100B determinations have been widely proposed in the past as markers of traumatic brain injury and used as a predictor of injury severity and outcome. The purpose of this prospective observational case series was therefore to determine S-100B serum levels in patients with isolated injuries to the back. METHODS: Between 1 February and 1 May 2008, serum samples for S-100B analysis were obtained within 1 hour of injury from 285 trauma patients. All patients with a head injury, polytrauma, and intoxicated patients were excluded to select isolated injuries to the spine. 19 patients with isolated injury of the back were included. Serum samples for S-100B analysis and CT spine were obtained within 1 hours of injury. RESULTS: CT scans showed vertebral fractures in 12 of the 19 patients (63%). All patients with fractures had elevated S-100B levels. Amongst the remaining 7 patients without a fracture, only one patient with a severe spinal contusion had an S-100B concentration above the reference limit. The mean S-100B value of the group with fractures was more than 4 times higher than in the group without fractures (0.385 vs 0.087 microg/L, p = 0.0097). CONCLUSION: Our data, although limited due to a very small sample size, suggest that S-100B serum levels might be useful for the diagnosis of acute vertebral body and spinal cord injury with a high negative predictive power. According to the literature, the highest levels of serum S-100B are found when large bones are fractured. If a large prospective study confirms our findings, determining the S-100B level may contribute to more selective use of CT and MRI in spinal trauma.
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  • Xafis, K., Thalmann, G., Benneker, L. M., Stoupis, C., Buggy, D. J., Zimmermann, H., and Exadaktylos, A. K. “Forget The Blood, Not The Stone! Microhaematuria In Acute Urolithiasis And The Role Of Early Ct Scanning”. Emerg Med J 25, no. 10: 640-4. doi:10.1136/emj.2006.043703.
    Abstract: BACKGROUND: Although urinalysis is simple and inexpensive to perform, the finding of microhaematuria on urinalysis may be unreliable for diagnosing urolithiasis. OBJECTIVE: To evaluate microhaematuria as a diagnostic marker for urolithiasis compared with low-dose unenhanced multidetector computed tomography (MDCT) as the "gold standard". SETTING: A level 1 emergency department in a tertiary referral university teaching hospital. DESIGN: Retrospective analysis. METHODS: A study was undertaken to assess whether the finding of microhaematuria was diagnostic for urolithiasis using a low-dose unenhanced MDCT-based diagnosis as the reference standard by reviewing the records of all patients who presented to the emergency department with colicky flank pain and underwent a CT scan between January 2003 and December 2005. RESULTS: Urolithiasis was present (as defined by low-dose unenhanced MDCT) in 507/638 patients (79%); 341/638 (53%) were true positive for urolithiasis, 76 (12%) were true negative, 55 (9%) were false positive and 166 (26%) were false negative. Microhaematuria as a test for urolithiasis in patients presenting to the emergency department therefore has a sensitivity, specificity, positive predictive value and negative predictive value of 67%, 58%, 86% and 31%, respectively. 58% of the urinalysis results were negative for haematuria in the subset of patients with significant alternative diagnoses. CONCLUSIONS: The sensitivity, specificity and negative predictive value of microhaematuria on urinalysis for urolithiasis using unenhanced MDCT as the reference standard were low. This suggests that, when urolithiasis is clinically suspected, unenhanced MDCT is indicated without urinalysis being a prerequisite.
    Tags: Adolescent, Adult, Aged, Aged, 80 and over, Early Diagnosis, Emergency Service, Hospital, False Negative Reactions, False Positive Reactions, Hematuria/*etiology, Humans, Middle Aged, Predictive Value of Tests, Retrospective Studies, Sensitivity and Specificity, Tomography, X-Ray Computed/*methods, Urinalysis/*standards, Urolithiasis/complications/*diagnosis, Young Adult.
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  • Exadaktylos, A. K., Sadowski-Cron, C., Mader, P., Weissmann, M., Dinkel, H. P., Negri, M., and Zimmermann, H. “Decision Making In Patients With Acute Abdominal Pain At A University And At A Rural Hospital: Does The Value Of Abdominal Sonography Differ?”. World J Emerg Surg 3, no. 1: 29. doi:10.1186/1749-7922-3-29.
    Abstract: INTRODUCTION AND OBJECTIVES: Abdominal sonography is regarded as a quick and effective diagnostic tool for acute abdominal pain in emergency medicine. However, final diagnosis is usually based on a combination of various clinical examinations and radiography. The role of sonography in the decision making process at a hospital with advanced imaging capabilities versus a hospital with limited imaging capabilities but more experienced clinicians is unclear.The aim of this pilot study was to assess the relative importance of sonography and its influence on the clinical management of acute abdominal pain, at two Swiss hospitals, a university hospital (UH) and a rural hospital (RH). METHODS: 161 patients were prospectively examined clinically. Blood tests and sonography were performed in all patients. Patients younger than 18 years and patients with trauma were excluded. In both hospitals, the diagnosis before and after ultrasonography was registered in a protocol. Certainty of the diagnosis was expressed on a scale from 0% to 100%.The decision processes used to manage patients before and after they underwent sonography were compared. The diagnosis at discharge was compared to the diagnosis 2 - 6 weeks thereafter. RESULTS: Sensitivity, specificity and accuracy of sonography were high: 94%, 88% and 91%, respectively.At the UH, management after sonography changed in only 14% of cases, compared to 27% at the RH. Additional tests were more frequently added at the UH (30%) than at the RH (18%), but had no influence on the decision making process-whether to operate or not. At the UH, the diagnosis was missed in one (1%) patient, but in three (5%) patients at the RH. No significant difference was found between the two hospitals in frequency of management changes due to sonography or in the correctness of the diagnosis. CONCLUSION: Knowing that sonography has high sensitivity, specificity and accuracy in the diagnosis of acute abdominal pain, one would assume it would be an important diagnostic tool, particularly at the RH, where tests/imaging studies are rare.However, our pilot study indicates that sonography provides important diagnostic information in only a minority of patients with acute abdominal pain.Sonography was more important at the rural hospital than at the university hospital. Further costly examinations are generally ordered for verification, but these additional tests change the final treatment plan in very few patients.
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  • Sztajzel, J. M., Picard-Kossovsky, M., Lerch, R., Vuille, C., and Sarasin, F. P. “Accuracy Of Cardiac Auscultation In The Era Of Doppler-Echocardiography: A Comparison Between Cardiologists And Internists”. Int J Cardiol 138, no. 3: 308-10. doi:10.1016/j.ijcard.2008.06.066.
    Abstract: To investigate the present accuracy of cardiac auscultation, we asked a group of senior cardiologists and internists to auscultate respectively 72 and 70 selected patients and to give a diagnosis of the type of lesions heard and their degree of severity, using transthoracic Doppler-echocardiography as the standard reference. The percentage of correctly identified auscultations by cardiologists and by internists, particularly for common valvular lesions, such as aortic stenosis and mitral regurgitation, was respectively 76.1 vs 64.9% (P=0.0787) for all types of lesions taken together, 57.1 vs 48%.0 (P=0.5057) for mild, 82.4 vs 76.0% (P= 0.3335) for moderate-severe and 81.8 vs 27.3% (P=0.0300) for lesions without degree of severity, which included cases of atrial septal defect (ASD) and of hypertrophic cardiomyopathiy (HCM). Our findings show that in the Doppler-echocardiographic era overall cardiac auscultatory proficiency for common valvular lesions is similar in cardiologists and internists. Cardiologists perform better than internists only when auscultating more rare cadiac lesions, such as cases of ASD or HCM.
    Tags: Aged, Aged, 80 and over, Cardiology/*standards, Echocardiography, Doppler, Female, Heart Auscultation/*standards, Heart Valve Diseases/*diagnosis/diagnostic imaging, Humans, Internal Medicine/*standards, Male, Middle Aged, Reproducibility of Results.
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  • Exadaktylos, A. K., and Velmahos, G. C. “Emergency Medicine And Acute Care Surgery: A Modern "Hansel And Gretel" Fairytale?”. Emerg Med J 25, no. 6: 321-2. doi:10.1136/emj.2008.058396.
    Tags: Emergencies, Emergency Medicine/*organization & administration, General Surgery/*organization & administration, Humans, Interprofessional Relations.
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  • Sedlak, M., Wagner, O. J., Wild, B., Papagrigoriades, S., Zimmermann, H., and Exadaktylos, A. K. “Is There Still A Role For Rectal Examination In Suspected Appendicitis In Adults?”. Am J Emerg Med 26, no. 3: 359-60. doi:10.1016/j.ajem.2007.06.006.
    Tags: *Rectum, Acute Disease, Adolescent, Appendicitis/*diagnosis/therapy, Child, Diagnosis, Differential, Female, Humans, Male, Physical Examination/*methods.
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  • Exadaktylos, A. K., Benneker, L. M., Jeger, V., Martinolli, L., Bonel, H. M., Eggli, S., Potgieter, H., and Zimmermann, H. “Total-Body Digital X-Ray In Trauma. An Experience Report On The First Operational Full Body Scanner In Europe And Its Possible Role In Atls”. Injury 39, no. 5: 525-9. doi:10.1016/j.injury.2007.10.019.
    Abstract: When patients enter our emergency room with suspected multiple injuries, Statscan provides a full body anterior and lateral image for initial diagnosis, and then zooms in on specific smaller areas for a more detailed evaluation. In order to examine the possible role of Statscan in the management of multiply injured patients we implemented a modified ATLS((R)) algorithm, where X-ray of C-spine, chest and pelvis have been replaced by single-total a.p./lat. body radiograph. Between 15 October 2006 and 1 February 2007 143 trauma patients (mean ISS 15+/-14 (3-75)) were included. We compared the time in resuscitation room to 650 patients (mean ISS 14+/-14 (3-75)) which were treated between 1 January 2002 and 1 January 2004 according to conventional ATLS protocol. The total-body scanning time was 3.5 min (3-6 min) compared to 25.7 (8-48 min) for conventional X-rays, The total ER time was unchanged 28.7 min (13-58 min) compared to 29.1 min (15-65 min) using conventional plain radiography. In 116/143 patients additional CT scans were necessary. In 98/116 full body trauma CT scans were performed. In 18/116 patients selective CT scans were ordered based on Statscan findings. In 43/143 additional conventional X-rays had to be performed, mainly due to inadequate a.p. views of fractured bones. All radiographs were transmitted over the hospital network (Picture Archiving and Communication System, PACS) for immediate simultaneous viewing at different places. The rapid availability of images for interpretation because of their digital nature and the reduced need for repeat exposures because of faulty radiography are also felt to be strengths.
    Tags: *Critical Care/methods/standards, *Emergency Service, Hospital/standards, *Whole Body Imaging/methods/standards, Humans, Multiple Trauma/*diagnostic imaging, Radiography, Switzerland, Time Factors.
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  • Hilty, M. P., Behrendt, I., Benneker, L. M., Martinolli, L., Stoupis, C., Buggy, D. J., Zimmermann, H., and Exadaktylos, A. K. “Pelvic Radiography In Atls Algorithms: A Diminishing Role?”. World J Emerg Surg 3, no. 1: 11. doi:10.1186/1749-7922-3-11.
    Abstract: BACKGROUND: Pelvic x-ray is a routine part of the primary survey of polytraumatized patients according to Advanced Trauma Life Support (ATLS) guidelines. However, pelvic CT is the gold standard imaging technique in the diagnosis of pelvic fractures. This study was conducted to confirm the safety of a modified ATLS algorithm omitting pelvic x-ray in hemodynamically stable polytraumatized patients with clinically stable pelvis in favour of later pelvic examination by CT scan. METHODS: We conducted a retrospective analysis of all polytraumatized patients in our emergency room between 01.07.2004 and 31.01.2006. Inclusion criteria were blunt abdominal trauma, initial hemodynamic stability and a stable pelvis on clinical examination. We excluded patients requiring immediate intervention because of hemodynamic instability. RESULTS: We reviewed the records of n = 452 polytraumatized patients, of which n = 91 fulfilled inclusion criteria (56% male, mean age = 45 years). The mechanism of trauma included 43% road traffic accidents, 47% falls. In 68/91 (75%) patients, both a pelvic x-ray and a CT examination were performed; the remainder had only pelvic CT. In 6/68 (9%) patients, pelvic fracture was diagnosed by pelvic x-ray. None of these 6 patients was found having a false positive pelvic x-ray, i.e. there was no fracture on pelvic CT scan. In 3/68 (4%) cases a fracture was missed in the pelvic x-ray, but confirmed on CT (false negative on x-ray). None of the diagnosed fractures needed an immediate therapeutic intervention. 5 (56%) were classified type A fractures, and another 4 (44%) B 2.1 in computed tomography (AO classification). One A 2.1 fracture was found in a clinically stable patient who only received CT scan (1/23). CONCLUSION: While pelvic x-ray is an integral part of ATLS assessment, this retrospective study suggests that in hemodynamically stable patients with clinically stable pevis, its sensitivity is only 67% and it may safely be omitted in favor of a pelvic CT examination if such is planned in adjunct assessment and available. The results support the safety and utility of our modified ATLS algorithm. A randomized controlled trial using the algorithm can safely be conducted to confirm the results.
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  • Ozgediz, D., Kijjambu, S., Galukande, M., Dubowitz, G., Mabweijano, J., Mijumbi, C., Cherian, M., Kaggwa, S., and Luboga, S. “Africa's Neglected Surgical Workforce Crisis”. Lancet 371, no. 9613: 627-628. doi:10.1016/S0140-6736(08)60279-2.
    Tags: *Health Priorities, Africa, General Surgery/*education, Health Services Accessibility, Health Services Needs and Demand, Humans, Uganda, Workforce.
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2007

  • Schneider, J., Staubli, G., Kubat, S., and Altermatt, S. “Treating Displaced Distal Forearm Fractures In Children”. Eur J Trauma Emerg Surg 33, no. 6: 619-25. doi:10.1007/s00068-007-6204-8.
    Abstract: PURPOSE: Distal forearm fractures are among the most common fractures in children. In the past few years the option of percutaneous pinning has gained more attention in the treatment of unstable fractures. However, it remains unclear in which cases a fracture or its reduction should be considered unstable. STUDY DESIGN: In order to evaluate which type of fractures profit most from additional pinning after closed reduction, we performed a retrospective analysis of 225 consecutive cases using the recently published AO pediatric classification of long bone fractures. RESULTS: After closed reduction, position in the cast was lost in 23% of the cases. The proportion of unstable reductions was much higher in completely displaced fractures. The amount of dislocation was more important than the type of fracture according to the AO classification proposal. CONCLUSIONS: Fully displaced fractures should always be reduced in a setting with pins immediately available. If anatomical reduction cannot be achieved, pinning is advocated. The AO proposal for pediatric long bone fracture classification could be a useful tool to render the diverse studies more comparable. However, the important feature of complete versus subtotal displacement is lacking.
    Tags: AO pediatric classification, Children, Distal forearm, Fracture.
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  • Gmel, G., Givel, J. C., Yersin, B., and Daeppen, J. B. “Injury And Repeated Injury - What Is The Link With Acute Consumption, Binge Drinking And Chronic Heavy Alcohol Use?”. Swiss Medical Weekly 137, no. 45-46: 642-648. https://www.scopus.com/inward/record.uri?eid=2-s2.0-36549053561&partnerID=40&md5=0b2558045c696199d34d528267943c3d.
    Abstract: Objectives: First, to test whether current injury is more closely related to acute intake than to usual consumption patterns, and second, to test whether repeated injury is more closely related to general consumption patterns than to acute intake. Methods: Screening of alcohol consumption of 7,872 patients enrolling between January 1, 2003 and June 30, 2004 in an emergency department (ED) in Lausanne, Switzerland. General consumption patterns were measured as usual volume (in drinks per week) and binge drinking (5+ drinks for men; 4+ drinks for women) at least once monthly. Acute intake was measured through number of drinks in the 24-hour period prior to attending the ED. Separate logistic regression models of current injury and repeated injury on alcohol consumption patterns were estimated. Results: Acute intake and binge drinking dominated the association with current injury, while general consumption patterns were predictive of repeated alcohol-related injury. Conclusions: Acute intake is associated with current injury in a dose-response relationship and with binge drinking. Because acute intake can be found among moderate volume drinkers as well as among chronic heavy drinkers, for current injury usual volume adds little predictive value over the effects of acute intake. Repeated injuries occur more often among chronic heavy drinkers, and thus general consumption patterns are more closely associated with injury "recidivism" than with acute intake. A screening question assessing prior injury may be a useful tool in the ED for distinguishing between chronic heavy drinkers and usually moderate drinkers with heavy drinking episodes, and thus prove helpful when creating preventive efforts tailored to different types of drinker.
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  • Lahzami, S., Eggenberger, P., and Lehmann, B. C. “Listen To Your Patient”. Eur J Emerg Med 14, no. 5: 274-5. doi:10.1097/MEJ.0b013e328200493e.
    Abstract: An 89-year-old patient was admitted to the emergency department (ED) because of sudden onset of chest pain. The chest radiograph appeared to show a detachment of the pleura on the right side. The diagnosis of a pneumothorax was made. Insertion of a chest tube was indicated, but the patient refused her consent. The next day, another chest radiograph was taken. It showed no more detachment of the pleura. The initial diagnosis of pneumothorax had to be abandoned as retrospectively the pneumothorax could be identified as an artefact. Different aspects of pseudopneumothorax are discussed.
    Tags: *Diagnostic Errors, Aged, Aged, 80 and over, Female, Humans, Pneumothorax/*diagnostic imaging, Radiography.
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  • Nobre, V., Sarasin, F. P., and Pugin, J. “Prompt Antibiotic Administration And Goal-Directed Hemodynamic Support In Patients With Severe Sepsis And Septic Shock”. Curr Opin Crit Care 13, no. 5: 586-91. doi:10.1097/MCC.0b013e3282e7d8e1.
    Abstract: PURPOSE OF REVIEW: Treatment protocols targeting the rapid administration of appropriate antibiotics and hemodynamic support are now recognized as a key measure in the initial care of patients presenting with severe sepsis and septic shock. Strong evidence exists showing that time parameters, particularly in the emergency department, are as important as the nature of the treatment administered. The concept of sepsis bundles integrates evidence-based and time-sensitive issues, derived from international sepsis guidelines, to ensure that all eligible patients receive the right treatment as early as possible. RECENT FINDINGS: Several studies have demonstrated that patients resuscitated according to sepsis bundles had a significantly lower mortality. SUMMARY: It seems logical that timely and protocolized treatment for patients presenting with severe sepsis and septic shock will impact on outcome. It remains to be shown, however, whether translating evidence into clinical practice will increase adherence to the bundles and positively impact on survival.
    Tags: *Hemodynamics, Anti-Bacterial Agents/administration & dosage/*therapeutic use, Cardiotonic Agents/therapeutic use, Clinical Protocols, Critical Care/*methods, Dopamine/therapeutic use, Drug Administration Schedule, Erythrocyte Transfusion, Fluid Therapy, Humans, Monitoring, Physiologic, Resuscitation, Sepsis/physiopathology/*therapy, Shock, Septic/physiopathology/therapy, Time Factors.
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  • Wiegand, J., Koller, M., and Bingisser, R. “Does A Negative D-Dimer Test Rule Out Aortic Dissection?”. Swiss Medical Weekly 137, no. 31-32: 462. https://www.scopus.com/inward/record.uri?eid=2-s2.0-34548147505&partnerID=40&md5=e69e34f9d0cb415dbabb320bc47951ab.
  • Fleischmann, T., and Fulde, G. “Emergency Medicine In Modern Europe”. Emerg Med Australas 19, no. 4: 300-2. doi:10.1111/j.1742-6723.2007.00991.x.
    Abstract: Emergency medicine in the highly advanced world is traditionally performed in two different ways. The first is the well-known Anglo-American system with skilled EDs, and a pre-hospital emergency medical service utilizing paramedics. The second is the so-called Franco-German system, with a highly developed pre-hospital emergency physician service, but only a basic organization of hospital-based emergency medicine. This gap is now closing fast because of the rapid advancement of hospital-based emergency medicine in Europe. Four criteria might be used to measure this: the recognition as a specialty, the specialist training programme, the professional organization of emergency physicians and the presence of academic centres in Europe. Eleven of the 27 European countries recognize hospital-based emergency medicine as a specialty already. These include Belgium, Czech Republic, Estonia, Hungary, Ireland, Italy, Malta, Poland, Romania, Slovenia and the United Kingdom. Other nations are striving to do so, for example Sweden, France, Germany and Greece. There is no doubt that emergency medicine is gaining momentum and other countries will follow. Training for the specialty of emergency medicine is advanced already. Several curricula presently exist in the respective European countries. A task force, governed by the European Society for Emergency Medicine has been working hard to create a model curriculum for all of Europe, which is expected to be published in 2007. This comprises a 5-year specialty training, with three of them spent in an ED. The curriculum follows a symptom-oriented approach to emergency medicine, and includes a skilled description of the key competencies of the future trained emergency physicians. Given the century-long history of the pre-hospital emergency physician service in some European countries, a number of professional bodies exist representing pre-hospital emergency doctors. Within the last few years, ED physicians followed suit forming organizations of their own. In some countries, the next step of amalgamation has occurred, with the merger of EMS and ED emergency physician organizations, although no country has abolished the pre-hospital emergency physician service. The last milestone, the development of academic emergency centres, has only just started. This process will take some time. The present paper describes the present and future of emergency medicine in some European countries using these criteria.
    Tags: Emergency Medical Services/*organization & administration/standards, Emergency Medicine/*organization & administration, Europe, Humans.
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  • Schaller, B. B., Exadaktylos, A. K., Andres, R. H., and Bonel, H. M. “A New Full Body Low-Dose X-Ray Technique Is An Alternative To Conventional "Shunt Series" In Patients With Ventriculoperitoneal Shunt Dysfunction”. Am J Emerg Med 25, no. 6: 702-3. doi:10.1016/j.ajem.2007.03.009.
    Tags: *Ventriculoperitoneal Shunt, Humans, Hydrocephalus/therapy, Radiation Dosage, Radiography/*methods.
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  • Daeppen, J. B., Gaume, J., Bady, P., Yersin, B., Calmes, J. M., Givel, J. C., and Gmel, G. “Brief Alcohol Intervention And Alcohol Assessment Do Not Influence Alcohol Use In Injured Patients Treated In The Emergency Department: A Randomized Controlled Clinical Trial”. Addiction 102, no. 8: 1224-33. doi:10.1111/j.1360-0443.2007.01869.x.
    Abstract: AIMS: To evaluate the effectiveness of brief alcohol intervention (BAI) in reducing alcohol use among hazardous drinkers treated in the emergency department (ED) after an injury; in addition it tests whether assessment of alcohol use without BAI is sufficient to reduce hazardous drinking. DESIGN: Randomized controlled clinical trial with 12-month follow-up conducted between January 2003 and June 2005. SETTING: Urban academic emergency department (ED) of the Lausanne University Hospital, Lausanne, Switzerland. PARTICIPANTS: A total of 5136 consecutive patients attending ED after an injury completed a seven-item general and a three-item alcohol screen and 1472 (28.7%) were positive for hazardous drinking according to the National Institute on Alcohol Abuse and Addiction definition; of these 987 (67.1%) were randomized into a BAI group (n = 310) or a control group with screening and assessment (n = 342) or a control group with screening only (n = 335) and then a total of 770 patients (78.0%) completed the 12-month follow-up procedures. INTERVENTION: A single 10-15-minute session of standardized BAI conducted by a trained research assistant. MEASUREMENTS: Percentage of participants who have changed to low-risk drinking at follow-up. FINDINGS: Data obtained at 12 months indicated that similar proportions were low-risk drinkers in BAI versus control groups with and without assessment (35.6%, 34.0%, 37.0%, respectively, P = 0.71). Data also indicated similar reductions in drinking frequency, quantity, binge drinking frequency and Alcohol Use Disorders Identification Test (AUDIT) scores across groups. All groups reported similar numbers of days hospitalized and numbers of medical consults in the last 12 months. A model including age groups, gender, AUDIT and injury severity scores indicated that BAI had no influence on the main alcohol use outcome. CONCLUSIONS: This study provides the evidence that a 10-15-minute BAI does not decrease alcohol use and health resource utilization in hazardous drinkers treated in the ED, and demonstrates that commonly found decreases in hazardous alcohol use in control groups cannot be attributed to the baseline alcohol assessment.
    Tags: Adolescent, Adult, Age Factors, Aged, Alcohol Drinking/adverse effects/epidemiology/*prevention & control, Emergency Service, Hospital, Female, Follow-Up Studies, Humans, Interviews as Topic/*methods, Male, Middle Aged, Switzerland/epidemiology, Wounds and Injuries/epidemiology/etiology/*prevention & control.
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  • Maile, S., and Slongo, T. “Atlantoaxial Rotatory Subluxation: Realignment And Discharge Within 48 H”. Eur J Emerg Med 14, no. 3: 167-9. doi:10.1097/MEJ.0b013e328014081c.
    Abstract: Atlantoaxial rotatory fixation is a rare disorder in which the atlas gets fixed in a position normally achieved during rotation. Patients present with painful torticollis and a typical 'cock robin' position of the head: rotation, slight flexion and head tilting contralateral to the direction of rotation. During childhood, laxity of the ligamentous apparatus and joint cups allows a wider range of motion and rotation within these joints. Traumatic effects contribute to subluxation at relevant degree (Fiedling type 2 and higher) for which skeletal traction is necessary. Duration of skeletal traction can be reduced to a minimum (24 h), as seen in this patient, when diagnosis is set as early as possible.
    Tags: Atlanto-Axial Joint/diagnostic imaging/*injuries, Child, Preschool, Humans, Joint Dislocations/*diagnostic imaging/therapy, Male, Spinal Injuries/*diagnostic imaging/therapy, Time Factors, Tomography, Spiral Computed, Torticollis/*diagnostic imaging/therapy, Traction.
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  • Henning, P., Brenner, B., Brunner, K., and Zimmermann, H. “Hemodynamic Instability Following An Avulsion Of The Corona Mortis Artery Secondary To A Benign Pubic Ramus Fracture”. J Trauma 62, no. 6: E14-7. doi:10.1097/01.ta.0000210355.44804.24.
    Tags: *Embolization, Therapeutic, Aged, 80 and over, Arteries/*injuries, Female, Fractures, Bone/*complications/physiopathology, Hemorrhage/etiology/physiopathology/*therapy, Humans, Pubic Bone/*injuries.
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  • Benneker, L. M., Bonel, H. M., Zumstein, M. A., and Exadaktylos, A. K. “A Novel Multiple-Trauma Ct-Scanning Protocol Using Patient Repositioning May Increase Risks Of Iatrogenic Injuries”. Emerg Radiol 13, no. 6: 349-51; author reply 353. doi:10.1007/s10140-007-0577-1.
    Tags: Accidental Falls, Adult, Brachial Plexus/*diagnostic imaging/*injuries, Diagnostic Errors, Emergency Medical Services, Female, Humans, Iatrogenic Disease, Multiple Trauma/*diagnostic imaging, Posture, Tomography, X-Ray Computed/*adverse effects.
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2006

  • Albrecht, Eric, Yersin, Bertrand, Spahn, Donat R., Fishman, Daniel, and Hugli, Olivier. “Success Rate Of Airway Management By Residents In A Pre-Hospital Emergency Setting: A Retrospective Study”. European Journal Of Trauma 32, no. 6: 516-522. doi:10.1007/s00068-006-6001-z.
    Abstract: Objective: The objective of this retrospective study over a 5-year period was to assess the success rate of airway management by residents. Criteria of successful airway management were both the adherence to a standardized protocol of pre-hospital airway management and successful endotracheal intubation (ETI) in rescue missions. Methods: The minimal level of training time required for residents rotating in the pre-hospital emergency team was either 1 year in our university department of anesthesiology, or 3 years of internal medicine including 20 ETIs under supervision in the operating room. According to a strict protocol detailing indications and drugs to be administered, residents performed rapid-sequence intubation (RSI) except in cases of cardiopulmonary arrests where ETI was performed without drugs. Adherence to the protocol of airway management was evaluated according to data provided by the residents. Successful endotracheal tube placement was confirmed only in transported patients with a combination of clinical signs, infrared capnography, and a chest X-ray on hospital admission. Results: A total of 13,537 rescue missions were reviewed.The protocol adherence was 96.1%. ETI was attempted in 753 patients, and successful placement was confirmed in 98.2%. Conclusion: Pre-hospital airway management (protocol adherence and proper endotracheal tube placement) was successful overall in 94.3% of rescue missions. Our results support the efficacy of a pre-hospital emergency rescue system reinforced by residents. © Urban & Vogel.
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  • Sadowski-Cron, C., Schneider, J., Senn, P., Radanov, B. P., Ballinari, P., and Zimmermann, H. “Patients With Mild Traumatic Brain Injury: Immediate And Long-Term Outcome Compared To Intra-Cranial Injuries On Ct Scan”. Brain Inj 20, no. 11: 1131-7. doi:10.1080/02699050600832569.
    Abstract: BACKGROUND: Mild traumatic brain injury (MTBI) defined as Glasgow Coma Scale (GCS) 14 or 15 has shown contradictory short- and long-term outcomes. The objective of this study was to correlate intra-cranial injuries (ICI) on CT scan to neurocognitive tests at admission and to complaints after 1 year. METHODS: Two hundred and five patients with MTBI underwent a CT scan and were examined with neurocognitive tests. After 1 year complaints were assessed by phone interviews. RESULTS: The neurocognitive tests in 51% of the patients showed significant deficits; there was no difference for patients with GCS 14-15, nor was there a difference between patients with ICI to patients without. After 1 year patients with ICI had significantly more complaints than patients without ICI, the most frequent complaint was headache and memory deficits. CONCLUSIONS: No correlation was found between GCS or ICI and the neurocognitive tests upon admission. After 1 year, patients with ICI have significantly more complaints than patients without ICI. No cost savings resulted by doing immediate CT scan on all.
    Tags: Adolescent, Adult, Aged, Aged, 80 and over, Brain Injuries/diagnostic imaging/economics/psychology/*rehabilitation, Employment, Female, Follow-Up Studies, Glasgow Coma Scale, Health Care Costs, Humans, Male, Middle Aged, Neuropsychological Tests, Prognosis, Prospective Studies, Skull Fractures/diagnostic imaging/rehabilitation, Tomography, X-Ray Computed/economics, Treatment Outcome.
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  • Tomaske, M., Gerber, A. C., Stocker, S., and Weiss, M. “Tracheobronchial Foreign Body Aspiration In Children - Diagnostic Value Of Symptoms And Signs”. Swiss Med Wkly 136, no. 33-34: 533-8. doi:10.4414/smw.2006.11459.
    Abstract: OBJECTIVE: Tracheobronchial foreign body (TFB) aspiration is a common cause of respiratory compromise in early childhood. Research indicates that a high number of children are missed with TFB aspiration. The aim of this study was to identify predictors of potential TFB aspiration. STUDY DESIGN: We analysed 370 endoscopic reports of children admitted to our emergency department who underwent explorative rigid bronchoscopy to exclude/remove a TFB (1989-2003). Patient characteristics, history, clinical, radiographic and bronchoscopic findings were noted. Sensitivities and specificities for TFB aspiration were calculated for patient history, clinical and radiographic findings. RESULTS: The median age was 1.8 years. In 59.7% of patients a TFB was found and removed. A group analysis was performed on children with symptoms less than 2 weeks (group A) and those more than 2 weeks (group B). The results showed that unilateral diminished breath sounds and unilateral overdistension on chest X-ray were the most sensitive (53-79%) and specific (68-88%) findings in both groups. The clinical triad of acute choking/coughing, wheezing and unilateral diminished breath sounds had a high specificity (96-98%) in both groups. In contrast, a positive history of acute choking/coughing in group A or a permanent cough in group B showed a low specificity (8-16%). CONCLUSION: In a paediatric respiratory compromise, the presence of unilateral diminished breath sounds, pathological chest X-ray or clinical triad is a powerful indicator for occurred TFB aspiration. Since no single or combined variables can predict TFB aspiration with full certainty, bronchoscopic exploration should be performed if TFB aspiration is suspected.
    Tags: Adolescent, Airway Obstruction/etiology, Bronchoscopy/methods, Child, Child, Preschool, Cough/etiology, Female, Foreign Bodies/*diagnosis, Humans, Infant, Male, Respiratory Aspiration/*diagnosis, Sensitivity and Specificity.
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  • Lehmann, B., Clemetson, I., Fantin, A. C., Henning, P., Kipfer, B., Muhlethaler, R., Vetsch, G., and Dinkel, H. P. “Arterioesophageal Fistula Secondary To Rupture Of An Aberrant Right Subclavian Artery Aneurysm: A Rare Differential Diagnosis In Upper Gastrointestinal Bleeding”. Endoscopy 38, no. 7: 762. doi:10.1055/s-2006-925172.
    Tags: *Subclavian Artery/abnormalities, Aged, Aneurysm, Ruptured/*complications/diagnosis, Diagnosis, Differential, Endoscopy, Gastrointestinal, Esophageal Fistula/diagnosis/*etiology, Gastrointestinal Hemorrhage/diagnosis/*etiology, Humans, Male, Vascular Fistula/diagnosis/*etiology.
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