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Swiss Emergency Research collection

2000

  • Kohler, H. P., and Grant, P. J. “Plasminogen-Activator Inhibitor Type 1 And Coronary Artery Disease”. N Engl J Med 342, no. 24: 1792-801. doi:10.1056/NEJM200006153422406.
    Tags: Coronary Disease/etiology/genetics/*physiopathology, Fibrin/*physiology, Fibrinolysis/genetics/*physiology, Humans, Insulin Resistance/physiology, Myocardial Infarction/etiology, Plasminogen Activator Inhibitor 1/genetics/*physiology, Polymorphism, Genetic, Risk Factors, Tissue Plasminogen Activator/physiology.
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  • Osterwalder, J. J., and Riederer, M. “[Quality Assessment Of Multiple Trauma Management Bu Iss, Triss Or Ascot?]”. Schweiz Med Wochenschr 130, no. 14: 499-504. https://www.ncbi.nlm.nih.gov/pubmed/10804601.
    Abstract: OBJECTIVES: Scores have been developed to assess the quality of trauma treatment. Our objective was to investigate prospectively whether there is a significant difference between the predicted survival and mortality rates with ISS, TRISS and ASCOT and observed rates in our patients. If the answer is affirmative, we also wished to evaluate whether the difference is significant enough to justify the greater data collection effort required for ASCOT as opposed to TRISS, and for TRISS as opposed to ISS. PATIENTS AND METHODS: Charts from 470 of 484 blunt multiple trauma patients with an ISS of 8 or more documented as part of a National Fund Study between June 1990 and June 1996 were reviewed. We compared the survival and mortality rates calculated by ISS, TRISS and ASCOT with the observed survival and death rates. RESULTS: Only the predicted survival and death rates calculated by ISS differed significantly from the observed rates. There were also significant differences between ISS and TRISS, and ISS and ASCOT, with regard to the predicted rates. CONCLUSIONS: In our unit ISS, which is simple to use, is not suitable for quality assessment. TRISS and ASCOT are of equal value. We prefer TRISS until a better, internationally recognised score is available, since it involves less effort and is less error-prone. General recommendations for Switzerland cannot be made until further results from other national accident and emergency units are available.
    Tags: *Severity of Illness Index, Adolescent, Adult, Aged, Aged, 80 and over, Child, Child, Preschool, Female, Humans, Male, Middle Aged, Multiple Trauma/*diagnosis/mortality/*therapy, Predictive Value of Tests, Reproducibility of Results, Retrospective Studies, Survival Analysis.
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  • Perrier, A., Miron, M. J., Desmarais, S., de Moerloose, P., Slosman, D., Didier, D., Unger, P. F., Junod, A., Patenaude, J. V., and Bounameaux, H. “Using Clinical Evaluation And Lung Scan To Rule Out Suspected Pulmonary Embolism: Is It A Valid Option In Patients With Normal Results Of Lower-Limb Venous Compression Ultrasonography?”. Arch Intern Med 160, no. 4: 512-6. doi:10.1001/archinte.160.4.512.
    Abstract: BACKGROUND: In patients with a low clinical probability of pulmonary embolism (PE) and a nondiagnostic lung scan, the prevalence of PE is theoretically very low. We assessed the safety and usefulness of this association for ruling out PE. METHODS: We analyzed data from 2 consecutive cohort management studies performed in 2 university hospitals (Geneva University Hospital, Geneva, Switzerland, and Hospital Saint-Luc, Montreal, Quebec), which enrolled 1034 consecutive patients who came to the emergency department with clinically suspected PE. All patients were submitted to a sequential diagnostic protocol of lung scan, D-dimer testing, lower-limb venous compression ultrasonography (US), and pulmonary angiography in case of inconclusive results of noninvasive workup. RESULTS: The prevalence of PE was 27.6%. Empirical assessment was accurate for identifying patients with a low likelihood of PE (8.2% prevalence of PE in the low clinical probability category). One hundred eighty patients had a low clinical probability of PE and a nondiagnostic lung scan. Among these patients, US showed deep vein thrombosis in 5. Hence, PE could be ruled out by a low clinical probability, a nondiagnostic lung scan, and a normal US in 175 patients (21.5%). The 3-month thromboembolic risk in these patients was low (1.7%; 95% confidence interval, 0.4%-4.9%). CONCLUSIONS: Anticoagulant treatment could be safely withheld in patients with a low clinical probability of PE and a nondiagnostic lung scan, provided that the US is normal. This combination of findings avoided pulmonary angiography in 21.5% of patients with suspected PE in this series.
    Tags: Adult, Aged, Angiography, Blood Gas Analysis, Cohort Studies, Diagnosis, Differential, Electrocardiography, Enzyme-Linked Immunosorbent Assay, Female, Humans, Male, Middle Aged, Physical Examination, Predictive Value of Tests, Pulmonary Embolism/blood/*diagnosis/diagnostic imaging, Risk, Risk Factors, Switzerland, Ultrasonography.
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  • Wagner, Patrick, Bucher, Heiner C., Bucheli, Bruno, Battegay, Edouard, and Martina, Benedict. “Predictors Of Hospitalization In Emergency Department Patients With Syncope”. European Journal Of Internal Medicine 11, no. 1: 39-44. doi:10.1016/s0953-6205(99)00070-9.
    Abstract: Background: Up to 67% of emergency department (ED) patients with syncope are hospitalized. Methods: To identify predictors of hospitalization in ED patients with syncope we studied all 95 patients admitted to our medical ED with syncope during a 3-month period. Complete records and triage decisions were analyzed. A 2-year follow-up was performed to evaluate the quality of the decision. Results: The mean age of 43 outpatients was 53±24 years compared to 73±16 years for 52 inpatients (P<0.002). All patients with cardiac syncope (n=7) had in-hospital care. In addition to cardiac etiology of syncope (OR 1.16, 95% confidence interval (CI) 1.04-1.29) and age (OR 1.05, 95% CI 1.02-1.08), predictors of hospitalization in age-adjusted analysis were unexplained etiology of syncope (OR 10.6, 95% CI 1.23-14.29, P=0.03) and the need for assistance with everyday activities (OR 3.48, 95% CI 0.95-107.7, P=0.05). Follow-up data were obtained in 84% of outpatients and in 98% of inpatients 27 months (range 24-34 months) after their ED stay. Conclusion: Predictors of in-hospital care include age, cardiac syncope, and factors unrelated to the prognosis, such as unexplained etiology of syncope and the need for assistance with everyday activities. © 2000 Elsevier Science B.V.
    Tags: adult, article, emergency ward, female, follow up, hospital care, hospitalization, human, major clinical study, male, prediction, prognosis, syncope, Syncope and predictors of hospitalization.
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  • Osterwalder, J. J., and Eymard, M. “Aggressive Oder Restriktive Volumen-Therapie Beim Mehrfachverletzten? - Entscheidungshilfe Bis Die Lang Erwarteten Prospektiv Kontrollierten Studien Vorliegen”. Der Notarzt 16, no. 2: 51-55. doi:10.1055/s-2000-159.
    Abstract: The value, timing, extent and target variables of fluid resuscitation in trauma patients are unclear and controversial. For this reason, we wanted to establish whether different amounts of infused fluids affected mortality in our blunt polytrauma patients with uncontrolled intraabdominal bleeding, or whether we ought to alter our approach to fluid resuscitation therapy in one way or another, or whether other conclusions could be drawn. Patients and Methods: We selected all blunt polytrauma patients with intraabdominal bleeding from our trauma register with an ISS of 8 or higher. 49 out of 458 patients (11%) fulfilled the inclusion criteria. We compared the pre-hospital and pre-operative amount of fluid infused in 13 patients who died and 36 survivors in a retrospective case-control study. Results: After allowing for confounding factors, no significant difference between the pre-hospital or the pre-operative amount of fluid or mortality was demonstrated. OR 1.5 (95% CI 0.7-3.0) for the total of pre-hospital infusions, and OR 1.1 (95% CI 0.7- 1.6) for the total volume. Conclusions: Even with small patient numbers, statistically relevant conclusions can be drawn using multiple logistic regression. Neither restrictive nor aggressive fluid resuscitation, but a moderate amount of administered fluid (median: 1000 ml) appears to be indicated in our emergency system, with its relatively long rescue period of 60 rain between alarm and admission to the emergency department, and also appears to support the hypothesis that the period after which surgery is still likely to be successful and life-saving is prolonged.
    Tags: adult, Amount of fluid infused, article, case control study, Case-control study, clinical article, Comparison, controlled study, Deaths and survivors, emergency health service, female, fluid therapy, human, male, mortality, multiple trauma, resuscitation, survival rate, treatment indication.
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  • Eberlin, J. L., and Hurtienne, Y. “Die Ersthelfer In Der Rettungskette”. Der Notarzt 16, no. 3: 99-100. doi:10.1055/s-2000-659.
    Abstract: The prognosis for a victim of an accident depend of the minimum fare's taking, which will be depending of the quality of the different links of rescue. The accent his here on the non medical links and their meaning.
    Tags: article, Chain of rescue, emergency health service, first aid, health care quality, Medical education, rescue personnel.
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1999

  • Yersin, B. “Cas No 3: Évaluation Du Patient Ayant Fait Un Épisode De Malaise Ou De Syncope”. Medecine Et Hygiene 57, no. 2276: 2173-2176. https://www.scopus.com/pages/publications/5744238608?origin=resultslist.
  • Schmid, P. “[Whiplash-Associated Disorders]”. Schweiz Med Wochenschr 129, no. 38: 1368-80. https://www.ncbi.nlm.nih.gov/pubmed/10536802.
    Abstract: Whiplash-associated disorders (WAD) represent a class of clinical complaints which commonly result from rear-end car accidents. An automobile collision can generate major forces which are transferred to the neck by an acceleration-deceleration mechanism (whiplash), resulting in bony or soft-tissue injuries (whiplash injury). Incidence of WAD is estimated to be 0.1 to 3.8/1000/year; WAD cost $29 billion a year in the USA. They can be classified clinically into 5 degrees of severity, namely WAD grades 0 to IV. Signs and symptoms typically crescendo during the first few days after an accident. Pathological findings (especially of musculo-skeletal or neurological types) must often be sought actively and should be documented at the earliest stage. Prevention of possible chronicity is the most important goal in clinical management of WAD. WAD grade IV patients are treated in the way their fracture or dislocation demands. Therapy of WAD grades I to III has three main aspects: non-narcotic analgesics, early active mobilisation (to the extent possible consistent with pain) and education of the patient. Soft collars should not be used (or only temporarily and sparingly). Most patients with WAD grades I-III feel well again relatively soon. Symptoms and signs that persist for longer than two months are important warning signs for imminent chronicity, which occurs at rates of 14-42%. In such cases, an interdisciplinary approach is recommended. Risk factors are accident severity, head position at the time of accident, age and pretraumatic existence of headache. Patients with chronic complaints can develop additional psychic and cognitive problems, which are caused by--and not the cause of--their chronic disorder. Therapy of chronic whiplash-associated disorders involves all the problems inherent in therapies of chronic pain. There are many therapeutic concepts, but little evidence that anything helps. Prevention of whiplash injuries is therefore very important in view of the lack of powerful treatment options. Although there is a substantial body of scientific literature about WAD, many unanswered questions remain. In particular the most important questions (how can patients with acute and chronic disorders be helped best) have no clear answer yet. Furthermore, there are many opinions and prejudices (especially concerning psycho-social factors of WAD) which have no scientific basis. Therefore, an intensive exchange of information between health care professionals, patients and the general public appears to be very important.
    Tags: *Accidents, Traffic, Cognition Disorders/etiology, Humans, Mental Disorders/etiology, Whiplash Injuries/classification/*complications/*physiopathology.
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  • Kehtari, R., and Holtz, J. “[Industrial Health Education In The Neuchatel Canton]”. Rev Med Suisse Romande 119, no. 7: 569-72. https://www.ncbi.nlm.nih.gov/pubmed/10467850.
    Tags: *Accidents, Occupational, Curriculum, Emergency Treatment/*methods, Humans, Job Description, Needs Assessment, Occupational Medicine/*education/legislation & jurisprudence, Switzerland, Wounds and Injuries/*therapy.
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  • Schlegel, M., Osterwalder, J. J., Galeazzi, R. L., and Vernazza, P. L. “Comparative Efficacy Of Three Mumps Vaccines During Disease Outbreak In Eastern Switzerland: Cohort Study”. Bmj 319, no. 7206: 352. doi:10.1136/bmj.319.7206.352.
    Tags: *Mumps Vaccine, Adolescent, Child, Child, Preschool, Cohort Studies, Disease Outbreaks/*prevention & control, Humans, Mumps/epidemiology/*prevention & control, Risk Factors, Switzerland/epidemiology, Treatment Outcome.
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  • Meier, F., and Unger, P. F. “Syncope”. Medecine Et Hygiene 57, no. 2257: 1154-1162. https://www.scopus.com/pages/publications/0042134303?origin=resultslist.
  • Vermeulen, B., Peter, R., Hoffmeyer, P., and Unger, P. F. “Prehospital Stabilization Of Pelvic Dislocations: A New Strap Belt To Provide Temporary Hemodynamic Stabilization”. Swiss Surg 5, no. 2: 43-6. doi:10.1024/1023-9332.5.2.43.
    Abstract: High energy pelvic fractures or dislocations are associated with a high rate of early complications, due to the associated intrapelvic organs. The high rate of early mortality is mostly due to the intrapelvic, retroperitoneal bleeding caused by the laceration of vascular structures located in the presacral area. External compression of the pelvic ring, using such devices as PASG or external fixators may prevent the intrapelvic collection of large hematomas by providing indirect tamponade. Unfortunately, these devices are either unavailable on the accident site, or the complexity of their handling is discouraging for the primary care-taker. A simple system of external pelvic compression which could be applied on the scene of trauma consisting of a pelvic strap-belt was therefore developed. The application of the device is easy, quick (30 seconds) and straightforward. Its use does not induce any known complications and requires minimal training. The cost and transportability of the system are further advantages. The system has already been used in 19 patients equipped on accident scene. Our first experiences using this device are reviewed.
    Tags: *Hemodynamics, Adult, Emergency Medical Services/*methods/*trends, Humans, Joint Dislocations/physiopathology/*therapy, Male, Orthopedic Fixation Devices/*trends, Pelvic Bones/*injuries.
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  • Vermeulen, B., Morabia, A., Unger, P. F., Goehring, C., Grangier, C., Skljarov, I., and Terrier, F. “Acute Appendicitis: Influence Of Early Pain Relief On The Accuracy Of Clinical And Us Findings In The Decision To Operate--A Randomized Trial”. Radiology 210, no. 3: 639-43. doi:10.1148/radiology.210.3.r99fe54639.
    Abstract: PURPOSE: To determine the influence of early pain relief on the diagnostic performance of ultrasonography (US) and on the appropriateness of the surgical decision. MATERIALS AND METHODS: A prospective randomized, double-blind placebo-controlled trial with morphine was conducted. A visual analog scale was used to evaluate pain in 340 patients aged 16 years or older. US was performed with a standardized protocol. Diagnosis was confirmed at histologic analysis or, in the patients released without surgery, at follow-up. RESULTS: One hundred seventy-five patients were injected with morphine, and 165 were injected with the placebo. Pain relief was stronger in the morphine group. In the morphine group, US had lower (71.1%) sensitivity (difference, -9.5%; 95% CI, -18.5%, -0.5%) and higher (65.2%) specificity (difference, 11.4%; 95% CI, 1.0%, 21.8%). This group had also a higher positive predictive value (64.6%) and a lower negative predictive value (71.4%), but the differences between this group and the placebo group were not statistically significant. Among female patients, the decision to operate was appropriate more often in the morphine group (75.8%), but the difference between this group and the placebo group was not statistically significant (5.1%; 95% CI, -7.4%, 17.6%). In male patients and overall, opiate analgesia did not influence the appropriateness of the decision. The appropriateness to discharge patients without surgery was 100% in all groups. CONCLUSION: Morphine does not improve US-based diagnosis of appendicitis.
    Tags: *Appendectomy, *Decision Making, Abdominal Pain/*drug therapy, Acute Disease, Adolescent, Adult, Analgesics, Opioid/administration & dosage/therapeutic use, Appendicitis/*diagnostic imaging/surgery, Confidence Intervals, Double-Blind Method, Female, Follow-Up Studies, Humans, Injections, Intravenous, Male, Morphine/administration & dosage/therapeutic use, Pain Measurement, Patient Discharge, Placebos, Predictive Value of Tests, Prospective Studies, Sensitivity and Specificity, Sex Factors, Ultrasonography.
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  • Perrier, A., Desmarais, S., Miron, M. J., de Moerloose, P., Lepage, R., Slosman, D., Didier, D., Unger, P. F., Patenaude, J. V., and Bounameaux, H. “Non-Invasive Diagnosis Of Venous Thromboembolism In Outpatients”. Lancet 353, no. 9148: 190-5. doi:10.1016/S0140-6736(98)05248-9.
    Abstract: BACKGROUND: We designed a simple and integrated diagnostic algorithm for acute venous thromboembolism based on clinical probability assessment of deep-vein thrombosis (DVT) or pulmonary embolism (PE), plasma D-dimer measurement, lower-limb venous compression ultrasonography, and lung scan to reduce the need for phlebography and pulmonary angiography. METHODS: 918 consecutive patients presenting at the emergency ward of the Geneva University Hospital, Geneva, Switzerland, and Hopital Saint-Luc, Montreal, Canada, with clinically suspected venous thromboembolism were entered into a sequential diagnostic protocol. Patients in whom venous thromboembolism was deemed absent were not given anticoagulants and were followed up for 3 months. FINDINGS: A normal D-dimer concentration (<500 microg/L by a rapid ELISA) ruled out venous thromboembolism in 286 (31%) members of the study cohort, whereas DVT by ultrasonography established the diagnosis in 157 (17%). Lung scan was diagnostic in 80 (9%) of the remaining patients. Venous thromboembolism was also deemed absent in patients with low to intermediate clinical probability of DVT and a normal venous ultrasonography (236 [26%] patients), and in patients with a low clinical probability of PE and a non-diagnostic result on lung scan (107 [12%] patients). Pulmonary angiography and phlebography were done in only 50 (5%) and 2 (<1%) of the patients, respectively. Hence, a non-invasive diagnosis was possible in 866 (94%) members of the entire cohort. The 3-month thromboembolic risk in patients not given anticoagulants, based on the results of the diagnostic protocol, was 1.8% (95% CI 0.9-3.1). INTERPRETATION: A diagnostic strategy combining clinical assessment, D-dimer, ultrasonography, and lung scan gave a non-invasive diagnosis in the vast majority of outpatients with suspected venous thromboembolism, and appeared to be safe.
    Tags: Acute Disease, Algorithms, Ambulatory Care, Enzyme-Linked Immunosorbent Assay, Fibrin Fibrinogen Degradation Products/analysis, Humans, Leg/*blood supply, Lung/diagnostic imaging, Prospective Studies, Pulmonary Embolism/*diagnosis/diagnostic imaging, Radionuclide Imaging, Risk Factors, Ultrasonography, Venous Thrombosis/*diagnosis/diagnostic imaging.
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  • Simon, J., Lemaitre, N., and Keumo, C. “Renal Colic In Adults: The Nurse's Role In Controlling Pain And Teaching Prevention; [Les Coliques Nephretiques De L'adulte. Prise En Charge Infirmiere: Gestion De La Douleur, Education Preventive]”. In, 8:598-602, Elsevier Masson SAS, 1999. doi:10.1016/S1164-6756(00)88313-9.
    Tags: adult, conference paper, human, kidney colic, nurse, pain assessment, patient care, prophylaxis.
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  • Cerruti, F., and Vermeulen, B. “Douleur Abdominale”. Medecine Et Hygiene 57, no. 2274: 2055-2065. https://www.scopus.com/pages/publications/0347536783?origin=resultslist.
    Tags: abdominal pain, antiemetic agent, antiinflammatory agent, appendicitis, cholecystitis, colic, diclofenac, diverticulitis, female, human, intestine obstruction, ketorolac, male, metoclopramide, morphine, narcotic analgesic agent, pancreatitis, pethidine, scopolamine butyl bromide, short survey, spasmolytic agent, thiethylperazine, thiethylperazine maleate, ulcer perforation.
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1998

  • Yersin, Bertrand, and Moeschler, O. “Acute Alcohol Intoxication In Emergency Services : Emergency And Alcohologic Aspects; [Intoxications Alcooliques Aiguës Au Service D'urgence : Aspects Urgentistes Et Alcoologiques]”. Medecine Et Hygiene 56, no. 2218: 1502-1504. https://www.scopus.com/pages/publications/2442451546?origin=resultslist.
    Abstract: Acute alcohol intoxication is frequently encountered in emergency services, as a reason for admission but also as a condition associated with other acute events such as accidents, various psychiatric or neurological syndromes, etc. like all other acute poisonings, acute alcohol intoxication should be identified precisely; it is also necessary to grade its severity, to evaluate its role in associated morbidities, to consider its signification as an alarm sign of a chronic alcohol problem and finally to strictly define its treatment and monitoring. This article is an attempt to answer these different questions and emphasizes the fact that an acute alcohol intoxication should never be considered by the emergency services as a pathology without interest and significance.
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  • Osterwalder, J. J. “Emergency Medicine In Switzerland”. Ann Emerg Med 32, no. 2: 243-7. doi:10.1016/s0196-0644(98)70144-1.
    Abstract: Situated in the heart of Europe, Switzerland's 7 million inhabitants, including 1 million foreigners, live in an area of 41,000 km2. German, French, Italian, and Rhaeto-Romanic are the official languages. The Swiss health service stands out because of the high quality and efficiency of its ambulatory and hospitalized health care management.
    Tags: *Emergency Medicine/education/organization & administration, Ambulatory Care, Education, Medical, Continuing, Efficiency, Organizational, Emergency Medical Services, Emergency Service, Hospital, Health Resources, Health Services Administration/economics, Health Services/economics, Hospital Administration, Humans, Language, Quality of Health Care, Switzerland.
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  • Perrier, A., Tamm, C., Unger, P. F., Lerch, R., and Sztajzel, J. “Diagnostic Accuracy Of Doppler-Echocardiography In Unselected Patients With Suspected Pulmonary Embolism”. Int J Cardiol 65, no. 1: 101-9. doi:10.1016/s0167-5273(98)00107-7.
    Abstract: This study investigates the diagnostic value of echocardiography in patients with suspected pulmonary embolism. Doppler-echocardiography was performed in fifty consecutive patients, predominantly presenting in the emergency ward, with clinically suspected pulmonary embolism. Patients were classified as having or not pulmonary embolism by a sequential non-invasive strategy including lung scan, D-dimer measurement and lower limb venous compression ultrasonography, pulmonary angiography being performed in case of an inconclusive non-invasive work-up. The prevalence of pulmonary embolism was 36% (18 of 50 patients). Right ventricular dilatation on 2-D echocardiography associated to a tricuspid regurgitation velocity > or =2.7 m/s, corresponding to a pulmonary systolic pressure > or =39 mmHg, were present in 12 of the 18 patients (67%) with and in two of the 32 patients (6.3%) without pulmonary embolism. They were, however, absent in five of the 18 patients (28%), in whom the definite diagnosis of pulmonary embolism was made. The combination of these both echocardiographic criteria yielded a sensitivity of 67% and a specificity of 94%, positive predictive value was 86% and negative predictive value was 83%. The diagnostic performance of these two combined echocardiographic criteria, when present, permitted to reach in patients with a high clinical pre-test probability of pulmonary embolism the post-test probability values above 90%. On the other hand, the absence of these two Doppler-echocardiographic criteria did not allow to exclude pulmonary embolism, except in presence of a low pre-test probability. The findings of our study show that Doppler-echocardiography in patients with high clinical suspicion of pulmonary embolism may represent a potentially useful screening technique for the diagnosis of the disease permitting prompt initiation of treatment. However, the method does not allow to exclude pulmonary embolism in all patients with intermediate or high clinical suspicion of the disease.
    Tags: *Echocardiography, Doppler, Dilatation, Pathologic, Heart Ventricles/pathology, Humans, Lung/*diagnostic imaging, Predictive Value of Tests, Pulmonary Embolism/*diagnostic imaging, Radionuclide Imaging, ROC Curve, Sensitivity and Specificity, Tricuspid Valve/diagnostic imaging.
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  • Unger, P. F. “Quels Patients Hospitaliser À Partir D'un Service D'accueil Des Urgences (Sau)?”. Medecine Et Hygiene 56, no. 2206: 888-889. https://www.scopus.com/pages/publications/2442592528?origin=resultslist.
  • Osterwalder, J. J., and Schuhwerk, W. “Effectiveness Of Mask Ventilation In A Training Mannikin. A Comparison Between The Oxylator Em100 And The Bag-Valve Device”. Resuscitation 36, no. 1: 23-7. doi:10.1016/s0300-9572(97)00091-9.
    Abstract: The demands for an optimal ventilation apparatus are that it can be easily handled, achieves a sufficiently high ventilation volume, and minimizes gastric inflation. Our aim was therefore to carry out a study in a training mannikin to find out whether the Oxylator EM100, compared with the bag, obtains improved ventilation and a decrease in gastric inflation. In a randomized crossover study, 72 subjects were selected (24 physicians, 44 nurses and 4 auxiliary nurses), chosen from the operating theatre, emergency department and intensive care unit of two hospitals. We used the Ambu-Bag Mark III with mask No. 4, the Oxylator EM100 with a pressure setting of 35 cm H2O run in the manual setting, the Ambu-Man C mannikin as well as the Ambu-CPR computer program. The resuscitation cycles of the standard two-rescuer's adult procedure lasted 3 min each, with a 3-min pause between the crossover procedure. The participants could improve their ventilatory volume with the Oxylator EM100 by 635 ml (95% confidence interval 578-692 ml) compared with the bag ventilation. The number of subjects who could attain a mean ventilatory volume of 800 ml or more increased from 15% to 98.6% (P < 0.001). Compared with the bag, the increase of adequate respirations (> or = 800 ml) obtained by the Oxylator EM100 for the individual participants amounted to a median of 91% (P < 0.001). Moreover, conventional ventilation caused in 42% one or several instances of gastric inflation, whereas no such reactions occurred with the Oxylator EM100. The Oxylator EM100 showed significantly better results in the mannikin than the bag. Of most importance is a significant lowering of gastric inflation and less so a marked increase in ventilatory volume. Our trial procedure with a relatively high lung compliance and a high oesophageal sphincter opening simulated favorable conditions. Owing to a large in vivo variability of these magnitudes, a direct testing in real patients with circulatory arrest is indicated.
    Tags: *Masks, Adult, Cardiopulmonary Resuscitation/education/*instrumentation, Cross-Over Studies, Female, Humans, Male, Manikins, Respiration, Artificial/*instrumentation.
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  • Blochliger, C., Osterwalder, J., Hatz, C., Tanner, M., and Junghanss, T. “[Asylum Seekers And Refugees In The Emergency Department]”. Soz Praventivmed 43, no. 1: 39-48. doi:10.1007/BF01299239.
    Abstract: This cross-sectional study describes the health problems and the health care of asylum seekers and refugees from the point of view of accident & emergency (A & E) physicians at the major hospital in St. Gallen, Switzerland. The physicians filled in a detailed questionnaire and documented all consultations of asylum seekers/refugees and of a control group of patients during eleven weeks (2 x 98 consultations). 76% of these asylum seekers/refugees originated from former Yugoslavia. The distribution of the main ICD-coded diagnoses did not differ between asylum seekers/refugees and the control group after correction for age. In comparison with the asylum seekers and refugees attending GPs, injuries were much more common in the A & E department attenders (37% vs. 8%). Asylum seekers/refugees and the patients in the control group did not differ in respect to being classified as an emergency case (58% vs. 65%). There were also no differences in hospitalisation rates (29% vs. 36%). Asylum seekers/refugees who were registered with a GP attended the A & E department more often during the night than during the day compared to patients who were not registered with a GP. Consultations which have been classified as emergencies occurred more frequently during the day than at night time. The time of residence in Switzerland was negatively associated with the registration with a GP and with being classified as an emergency case. A lack of experience in caring for asylum seekers and refugees and of specific training in this field has been the major complaint by the A & E physicians. Asylum seekers should be introduced to the tasks and functions of the various sectors of the national health care system as early as possible. Registration with a GP in the community should be promoted.
    Tags: *Morbidity, Adolescent, Adult, Aged, Child, Cross-Sectional Studies, Emergency Service, Hospital/*statistics & numerical data, Family Practice/statistics & numerical data, Female, Health Services Needs and Demand/statistics & numerical data, Humans, Male, Middle Aged, Minority Groups/*statistics & numerical data, Referral and Consultation/statistics & numerical data, Refugees/*statistics & numerical data, Switzerland, Utilization Review.
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  • Cook, Stephane, Moeschler, Olivier, Michaud, Katarzyna, and Yersin, Bertrand. “Acute Opiate Overdose: Characteristics Of 190 Consecutive Cases”. Addiction 93, no. 10: 1559-1565. doi:10.1046/j.1360-0443.1998.9310155913.x.
    Abstract: Aims. To characterize the population of drug users consulting the Emergency Room (ER) of a university hospital with acute opiate overdose (AOO) and to assess rate of referral to specialized treatment programme. Design. Survey of a 12-month sample of AOO patients. Measurements. Medical and psychosocial features of the drug users, details of emergency treatment and referral by a mobile resuscitation team (SMUR) and the ER of our hospital (CHUV-Lausanne, Switzerland). In addition fatal AOO cases were collected by the Institute of Forensic Medicine (IFM) during the same period. Findings. One hundred and eighty-four cases of AOO (134 patients) were treated. The files of the IFM detailed six additional deceased cases. This population of drug users was characterized by an over-representation of men (73%), by young age (27.4 years), by a high rate of multi-drugs use (90%) and by a high rate of multiple previous overdoses (2.6). Average length of stay was 20.1 hours but 41% of cases stayed less than 8 hours. Only one patient was readmitted within an 8-hour period. When discharged, 78% returned home. Unexpectedly, 67% of patients were not referred to any therapeutic programme for drug addiction. Conclusion. This study shows the low mortality of AOO when treated but also demonstrates the need to improve psychosocial evaluation and referral of drug addicts admitted with AOO.
    Tags: adult, age, article, drug overdose, emergency ward, fatality, female, gender, hospitalization, human, major clinical study, male, medical care, multiple drug abuse, opiate, opiate addiction, patient referral, psychosocial care, treatment planning, university hospital.
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  • Deluze, Ch., and Bodmer, R. “Emergency Treatment Of Allergic Reaction; [Urgences A Domicile: Allergies]”. Medecine Et Hygiene 56, no. 2224: 1815-1816. https://www.scopus.com/pages/publications/0032582057?origin=resultslist.
    Abstract: The anaphylactic shock is one of the most dramatic emergency situations in allergologic practice. Adrenaline (Epinephrine) should be administered as quickly as possible in combination with corticosteroids. Any patient who has suffered a severe anaphylactic reaction should be referred to an allergologist in order to clarify the underlying pathophysiologic mechanism and organise adequate preventive and therapeutic measures.
    Tags: adrenalin, adrenalin hydrogen tartrate, aged, allergic reaction, anahelp, anaphylactic shock, atenolol, case report, clemastine fumarate, clinical trial, corticosteroid, emergency treatment, human, hypertension, intramuscular drug administration, male, medical specialist, pathophysiology, prednisolone, review, subcutaneous drug administration, terfenadine, treatment planning, ultracortene, unclassified drug.
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  • Moeschler, Olivier, and Yersin, Bertrand. “Treatment And Monitoring Of Acute Opiate Overdose; [Overdose D'opiaces: Quel Traitement, Quelle Surveillance?]”. Medecine Et Hygiene 56, no. 2218: 1505-1510. https://www.scopus.com/pages/publications/0032529106?origin=resultslist.
    Abstract: Virtually every emergency medicine physician comes into contact with victims of opioid poisoning. Initial emergency treatment of opioid overdose is rather simple and effective with the exception of patients in cardiac arrest: ventilatory support is followed by filtrated administration of IV naloxone, a narcotic antagonist. The correct emergency department evaluation and the definition of a safe minimal period of careful observation after opiate overdose to prevent recurrent toxicity is still debated. Although it is recommended that patients be observed for a minimum of 6 to 8 hours for evidence of relapse or the development of pulmonary edema, this is often not accepted by the patients themselves in daily practice. Care to victims of opiate overdose includes psychosocial evaluation and referral to drug addiction treatment programs.
    Tags: artificial ventilation, cardiopulmonary arrest, drug overdose, first aid, heart arrest, heroin dependence, human, intoxication, intramuscular drug administration, intravenous drug administration, lung edema, naloxone, narcotic antagonist, opiate, opiate addiction, psychosocial care, relapse, respiration depression, review.
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1997

  • Perrier, A., Buswell, L., Bounameaux, H., Didier, D., Morabia, A., de Moerloose, P., Slosman, D., Unger, P. F., and Junod, A. “Cost-Effectiveness Of Noninvasive Diagnostic Aids In Suspected Pulmonary Embolism”. Arch Intern Med 157, no. 20: 2309-16. doi:10.1001/archinte.157.20.2309.
    Abstract: BACKGROUND: Noninvasive instruments such as plasma D-dimer measurement (DD) and lower-limb compression ultrasonography (US) are being increasingly advocated to reduce the number of necessary angiograms in patients having suspected pulmonary embolism (PE) and a nondiagnostic lung scan. We therefore designed a decision analysis model (1) to evaluate the cost-effectiveness of combining these noninvasive diagnostic aids with lung scan and angiography in the diagnosis of PE and (2) to determine the optimal sequence and combination of tests taking into account the clinical probability of PE. METHODS: We performed a cost-effectiveness analysis based on literature data, including data from a management study in our institution. Six diagnostic strategies were compared with the reference, ie, lung scan followed when nondiagnostic (low or intermediate probability) by angiography. In all strategies, PE was ruled out by a normal or near-normal scan, a negative DD (plasma level below 500 micrograms/L), or a negative angiogram. Pulmonary embolism was diagnosed and anticoagulant treatment was undertaken in the presence of a high-probability lung scan, deep vein thrombosis showed by US, or a positive angiogram. In case of a nondiagnostic scan (low or intermediate probability), patients could be either treated or not treated, or undergo other tests, according to the selected strategy. RESULTS: Under baseline conditions (prevalence of PE, 35%), strategies combining DD and US with lung scan, angiography being done only in case of an inconclusive noninvasive workup (DD level > 500 micrograms/L, normal US, and nondiagnostic lung scan), were most cost-effective. This approach yielded a 9% incremental cost reduction and a 37% to 47% decrease in the number of necessary angiograms compared with the reference strategy (scan +/- angiography). For patients with a low clinical probability of PE (< or = 20%), withholding treatment from those with a low-probability lung scan without performing an angiogram proved safe and highly cost-effective (30% cost reduction), provided US showed no deep vein thrombosis. CONCLUSION: The DD test and US are cost-effective in the diagnostic workup of PE, whether performed after or before lung scan, thus allowing centers devoid of lung scanning and/or angiography facilities to screen patients with suspected PE and avoid costly referrals. In patients with a low clinical probability, a low-probability lung scan, and a normal US, treatment may be withheld without resorting to angiography.
    Tags: *Decision Support Techniques, Algorithms, Angiography/economics, Biomarkers/blood, Cost-Benefit Analysis, Diagnosis, Differential, Humans, Models, Theoretical, Prevalence, Pulmonary Embolism/blood/*diagnosis/diagnostic imaging/*economics, Radionuclide Imaging, Sensitivity and Specificity, Ultrasonography/economics.
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  • Fresard, F., and Vermeulen, B. “[Emergency Medicine For The Practitioner: Abdominal Pain]”. Rev Med Suisse Romande 117, no. 4: 281-4. https://www.ncbi.nlm.nih.gov/pubmed/9281020.
    Tags: Abdominal Pain/*diagnosis, Acute Disease, Adult, Aged, Diagnosis, Differential, Family Practice, Gastrointestinal Hemorrhage/*diagnosis/therapy, Humans, Male, Medical History Taking, Pancreatitis/*diagnosis/therapy.
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  • Rey-Bellet, P., David, S., Gaille, G., and Yersin, B. “[Temporary Medicosocial Admission: Alternative To Hospitalization Of Elderly Persons?]”. Soz Praventivmed 42, no. 1: 11-20. doi:10.1007/BF01299574.
    Abstract: The orientation of elderly patients, temporarily disabled, to acute care beds is inappropriate because of its adverse effects on functional status and its costs. The creation of short-stay units (SSU) in nursing homes provides an alternative to acute care hospitalization. The aim of this retrospective study, involving the first 64 patients oriented to the SSU from the emergency center, was to evaluate this new health care network. The analysis was focused on the rate of appropriate orientation (site of living at four month; subsequent medical events), as well as the functional quality of this health care network. Information were collected from medical records of the 64 patients oriented to SSU and 64 sex- and age-matched patients admitted during the same period, and the opinion of the network's partners. The mean age of patients and controls was 82 years. Four months after admission to the SSU, the orientation was considered appropriate in 58% of the cases (living at home without subsequent hospitalization), doubtful in 8%, and inappropriate in 33%; 27% of patients and 13% of controls were living definitely in nursing homes (p < 0.1). No medical or social characteristics was correlated to inappropriate orientations. In conclusion, the creation of SSU may be considered as an improvement in the care of elderly patients. The main problem of this orientation was the high percentage of patients living permanently in a nursing home four months later. Accurate assessment's tools capable to predict the subsequent decrease of the functional status should be used in the daily practice in order to improve the orientation of elderly patients.
    Tags: *Continuity of Patient Care, *Health Services for the Aged, Aged, Aged, 80 and over, Cohort Studies, Female, Hospitalization, Humans, Length of Stay, Male, Middle Aged, Nursing Homes/statistics & numerical data, Retrospective Studies, Skilled Nursing Facilities/*statistics & numerical data, Switzerland.
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  • Vermelen, B., Restellini, A., Cerruti, F., and Unger, P. F. “Acute Abdominal Distress At Home: What To Do?; [La Douleur Abdominale Aiguë Et Suraiguë En Ambulatoire : Que Faire ?]”. Medecine Et Hygiene 55, no. 2179: 1869-1872. https://www.scopus.com/pages/publications/2442560370?origin=resultslist.
    Abstract: Abdominal pain is a frequent reason for out patient consultations. Acute abdominal pain is characterised by certain serious signs like peritoneal irritation, ileus, abdominal distension, high fever. An acute abdomen becomes acute abdominal distress when vital parameters show a state of shock that will necessitate therapeutical surgery within the hour. Once an acute abdominal distress situation has been identified, the abdominal care system must be very functional. The survival of the patient will depend upon the quality of the decision taken by the emergency dispatching center, as well as the quality of care during medical transport and the performance of the emergency team.
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  • Osterwalder, J. J. “Naloxone Hazards Overstated - Author's Reply”. Journal Of Toxicology-Clinical Toxicology 35, no. 2: 219-220. doi:10.3109/15563659709001199.
  • Fery, S. “Role Of The Nurse In The Initial Treatment Of Cerebrovascular Accidents; [Role De L'infirmiere Dans La Prise En Charge Des Accidents Vasculaires Cerebraux]”. In, 6:577-581, Elsevier Masson s.r.l., 1997. doi:10.1016/S1164-6756(97)80050-3.
    Tags: cerebrovascular accident, conference paper, emergency medicine, France, nurse, nursing, stroke.
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1996

  • Kleeman, D., Hauser, M., and Simmen, H. P. “[A Case From Practice (370). Rectal Foreign Body]”. Praxis (Bern 1994) 85, no. 51-52: 1666-8. https://www.ncbi.nlm.nih.gov/pubmed/9026881.
    Tags: *Rectum, Adult, Foreign Bodies/*diagnostic imaging/therapy, Humans, Male, Radiography.
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  • Osterwalder, J. J. “[The Comatose Patient: Initial Considerations And Measures]”. Praxis (Bern 1994) 85, no. 50: 1626-9. https://www.ncbi.nlm.nih.gov/pubmed/8999493.
    Abstract: The aim of assessing the emergency patient's threshold of consciousness is to diagnose and manage reversible and treatable conditions fast and effectively. Diagnosis and treatment procedures can be summarized on three levels. First assessment and treatment of hypoxia and shock, second: differentiation of types of coma, in order to decide further treatment measures and the choice of hospital admittance, and third: initiation of antidotes and other appropriate preclinical therapies.
    Tags: *Algorithms, *Emergencies, Coma/classification/*diagnosis/*therapy, Combined Modality Therapy, Diagnosis, Differential, Emergency Medical Services, Glasgow Coma Scale, Humans, Neurologic Examination.
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  • Knoblauch, A., Steiner, B., Bachmann, S., Trachsler, G., Burgheer, R., and Osterwalder, J. “Accidents Related To Manure In Eastern Switzerland: An Epidemiological Study”. Occup Environ Med 53, no. 9: 577-82. doi:10.1136/oem.53.9.577.
    Abstract: OBJECTIVES: Liquid manure systems and manure pits are major hazards in the agricultural workplace. The incidence of accidents related to manure is unknown. The objective of this study was to survey the liquid manure facilities of farms in eastern Switzerland and find the incidence of accidents related to manure in the region. METHODS: Retrospective cohort study and cross sectional survey of 210 farms in eastern Switzerland. RESULTS: The incidence of accidents related to manure was found to be 10.4/1000 person-years. Most accidents were categorised as minor--that is, had a benign outcome for the people involved or involved animals only. One in 33 of the farms surveyed was the scene of an accident related to manure each year. CONCLUSIONS: The medical literature on accidents related to manure mostly reports accidents with catastrophic outcomes. This study shows that this type of accident is only the tip of the iceberg. Most of the accidents reported in this study belong to a category that has hitherto been un-noticed and unreported. The term "accident related to manure" covers a broad range of events, and those resulting in serious human illness or death represent only a small part of this spectrum. A wide variety of liquid manure systems were found on the farms surveyed. Very few liquid manure facilities conformed to published safety standards.
    Tags: *Agriculture, *Manure, Accidents, Occupational/*statistics & numerical data, Adult, Child, Cohort Studies, Cross-Sectional Studies, Humans, Incidence, Retrospective Studies, Switzerland.
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  • Osterwalder, J. J. “[The Abcd Of Resuscitation]”. Ther Umsch 53, no. 8: 611-4. https://www.ncbi.nlm.nih.gov/pubmed/8830415.
    Abstract: Reanimation is divided into two phases. The first phase, primary ABCD, consists of verifying the patient's responsiveness, activating the emergency system, requesting a defibrillator, establishing and maintaining the airway's patency, checking respiration, initiating artificial respiration when necessary, checking the circulation, in the absence of a pulse beginning with chest compressions, and identifying the heart rhythm on the monitor. In particular, one should determine if the rhythm is ventricular fibrillation. Ventricular fibrillation is the most frequent cause of sudden cardiac arrest, estimated to occur in 70 to 80% of cases. The basic measures should not delay the earliest possible use of defibrillation. Only then follows the second phase, secondary ABCD, consisting of intubation, adequate ventilation, intravenous infusion, medications, further defibrillation when appropriate and the determination of treatable causes.
    Tags: *Algorithms, Blood Circulation, Electric Countershock, Heart Arrest/diagnosis/*therapy, Humans, Respiration, Artificial, Resuscitation/*methods.
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  • Gaspoz, J. M., Unger, P. F., Urban, P., Chevrolet, J. C., Rutishauser, W., Lovis, C., Goldman, L., et al. “Impact Of A Public Campaign On Pre-Hospital Delay In Patients Reporting Chest Pain”. Heart 76, no. 2: 150-5. doi:10.1136/hrt.76.2.150.
    Abstract: OBJECTIVE: To decrease pre-hospital delay in patients with chest pain. DESIGN: Population based, prospective observational study. SETTING: A province of Switzerland with 380000 inhabitants. SUBJECTS: All 1337 patients who presented with chest pain to the emergency department of the Hopital Cantonal Universitaire of Geneva during the 12 months of a multimedia public campaign, and the 1140 patients who came with similar symptoms during the 12 months before the campaign started. MAIN OUTCOME MEASURES: Pre-hospital time delay and number of patients admitted to the hospital for acute myocardial infarction (AMI) and unstable angina. RESULTS: Mean pre-hospital delay decreased from 7h 50 min before the campaign to 4 h 54 min during it, and median delay from 180 min to 155 min (P < 0.001). For patients with a final diagnosis of AMI, mean delay decreased from 9 h 10 min to 5 h 10 min and median delay from 195 min to 155 min (P < 0.002). Emergency department visits per week for AMI and unstable angina increased from 11.2 before the campaign to 13.2 during it (P < 0.02), with an increase to 27 (P < 0.01) during the first week of the campaign; visits per week for non-cardiac chest pain increased from 7.6 to 8.1 (P = NS) during the campaign, with an increase to 17 (P < 0.05) during its first week. CONCLUSIONS: Public campaigns may significantly reduce pre-hospital delay in patients with chest pain. Despite transient increases in emergency department visits for non-cardiac chest pain, such campaigns may significantly increase hospital visits for AMI and unstable angina and thus be cost effective.
    Tags: *Emergencies, *Health Education, Angina, Unstable/therapy, Chest Pain/*therapy, Costs and Cost Analysis, Female, Humans, Male, Middle Aged, Myocardial Infarction/therapy, Prospective Studies, Switzerland, Time Factors.
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  • Grobety, M., Depairon, M., Essinger, A., Bizzini, G., Luthy, J. C., and Yersin, B. “[Value Of Doppler Ultrasonic Studies In The Diagnosis Of Deep Venous Thrombosis Of The Lower Limbs]”. Schweiz Med Wochenschr 126, no. 27-28: 1196-201. https://www.ncbi.nlm.nih.gov/pubmed/8766628.
    Abstract: To compare the operating characteristics of the venous echo-doppler and that of venous phlebography in our setting, 90 consecutive patients admitted on suspicion of deep vein thrombosis of one leg underwent both examinations. Phlebography confirmed the diagnosis in 46 patients (51%). The sensitivity, specificity, and positive and negative predictive values of the echo-doppler were 91, 92, 94 and 90% respectively. For the subgroup of patients with proximal deep vein thrombosis, these values were 97, 97, 97 and 97%, respectively; for the subgroup with distal deep vein thrombosis, these values were 60, 95, 75 and 90%, respectively. This study confirms the excellent performance of the venous echo-doppler for the diagnosis of deep vein thrombosis of the leg in our hospital. However, in the subgroup of patients with distal deep vein thrombosis, only the sensitivity of the venous echo-doppler is relatively low and the diagnosis may still require color echo-doppler or phlebography.
    Tags: Diagnosis, Differential, Female, Humans, Leg/*blood supply, Male, Middle Aged, Phlebography, Predictive Value of Tests, Reproducibility of Results, Sensitivity and Specificity, Thrombophlebitis/*diagnostic imaging, Ultrasonography, Doppler/methods.
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  • Halperin, D. S., Bouvier, P., Jaffe, P. D., Mounoud, R. L., Pawlak, C. H., Laederach, J., Wicky, H. R., and Astie, F. “Prevalence Of Child Sexual Abuse Among Adolescents In Geneva: Results Of A Cross Sectional Survey”. Bmj 312, no. 7042: 1326-9. doi:10.1136/bmj.312.7042.1326.
    Abstract: OBJECTIVE: To measure the cumulative prevalence of child sexual abuse in a representative sample of the adolescent population of Geneva. DESIGN: Cross sectional survey with an anonymous self administered questionnaire centred on a factual description of sexual activities. SETTING: 68 classes (17 schools) randomly selected from the 201 ninth grade classes of the public school system in Geneva. SUBJECTS: 1193 adolescents aged 13-17 years, of whom 1116 (93.5%; 568 girls, 548 boys) consented to the study and returned completed questionnaires. RESULTS: 192 (33.8%) girls and 60 (10.9%) boys reported having experienced at least one sexually abusive event. The prevalence of abuse involving physical contact was 20.4% (116 cases) among girls and 3.3% (18) among boys. The prevalence of abuse involving some form of penetration was 5.6% (32 cases) among girls and 1.1% (six) among boys. One third of the abused adolescents had experienced more than one abusive event and 46.5% (92/198) had experienced the first event before age 12. Abuse by a family member was reported by 20.5% (36/176) of abused girls and 6.3% (3/48) of abused boys. Abusers were known to victims in two thirds of cases. Ninety per cent of abusers were male and 35.3% (71/201) came from the victim's peer group. Over 80% of participants found the questionnaire interesting, clearly formulated, and useful. CONCLUSIONS: Child sexual abuse is a universal social phenomenon. Adolescents themselves can contribute to research and so help in the search for more efficient prevention and intervention strategies.
    Tags: *Child Abuse, Sexual, Adolescent, Child, Female, Humans, Male, Prevalence, Sex Factors, Switzerland/epidemiology, Truth Disclosure.
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  • Perrier, A., Bounameaux, H., Morabia, A., de Moerloose, P., Slosman, D., Didier, D., Unger, P. F., and Junod, A. “Diagnosis Of Pulmonary Embolism By A Decision Analysis-Based Strategy Including Clinical Probability, D-Dimer Levels, And Ultrasonography: A Management Study”. Arch Intern Med 156, no. 5: 531-6. doi:10.1001/archinte.156.5.531.
    Abstract: BACKGROUND: Assessment of the clinical probability of pulmonary emboli sm, plasma D-dimer measurement, and lower-limb venous compression ultrasonography have all been advocated in the workup of suspected pulmonary embolism, to minimize the requirement for pulmonary angiography in patients with nondiagnostic lung scans. However, their contribution has not been assessed prospectively. METHODS: Three hundred eight consecutive patients who came to the emergency department with suspected pulmonary embolism were managed according to a diagnostic protocol that included clinical probability assessment, lung scan, and sequential noninvasive tests: plasma D-dimer measurement by enzyme-linked immunosorbent assay (a concentration <500 microgram/L ruled out pulmonary embolism) and lower-limb B-mode venous compression ultrasonography (a positive finding was diagnostic of venous thromboembolism). Patients without pulmonary embolism according to the diagnostic workup did not receive anticoagulant treatment. The safety of this approach was assessed by a 6-month follow-up. RESULTS: of the 308 patients, 106 (34%) had a diagnostic lung scan (normal in 43 and high probability in 63). For the remaining 202 patients, noninvasive workup was diagnostic in 125 (62%). Pulmonary embolism was ruled out by a low clinical probability and a nondiagnostic scan in 48 patients and a D-dimer level less than 500 microgram/L in 53; pulmonary embolism was established by a high clinical probability and a nondiagnostic scan in seven patients and by a finding of a deep vein thrombosis on ultrasonography in 17. Therefore, only 77 of these 202 patients underwent pulmonary angiography (negative in 55; positive in 22). At 6-month follow-up (completed for 99.4% of the study population), only two of the 199 patients in whom the diagnostic protocol had ruled out pulmonary embolism (1.0% [95% confidence interval, 0.1 to 3.6]) had a thromboembolic event (pulmonary embolism, one; deep vein thrombosis, one). CONCLUSIONS: This decision analysis strategy yielded a definitive noninvasive diagnosis in 62% of patients with a nondiagnostic scan and appears to be safe.
    Tags: *Decision Support Techniques, Adolescent, Adult, Aged, Aged, 80 and over, Antifibrinolytic Agents/*analysis, Female, Fibrin Fibrinogen Degradation Products/*analysis, Follow-Up Studies, Humans, Lung/diagnostic imaging, Male, Middle Aged, Probability, Prospective Studies, Pulmonary Embolism/*diagnosis/diagnostic imaging, Thrombophlebitis/*diagnostic imaging, Ultrasonography.
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  • Osterwalder, Joseph J. “Naloxone-For Intoxications With Intravenous Heroin And Heroin Mixtures-Harmless Or Hazardous? A Prospective Clinical Study”. In, 34:409-416, 1996. doi:10.3109/15563659609013811.
    Abstract: Background: Naloxone is standard medication for the treatment of heroin intoxications. No large-scale studies have yet been carried out to determine its toxicity in heroin intoxications. Methods: We have undertaken an investigation as to the frequency, type and degree of severity of complications attributable to naloxone administration. Subjects treated between 1991 and 1993 with naloxone for intravenous drug intoxications were prospectively evaluated. Main Outcome Measurements: Development of ventricular tachycardia or fibrillation; atrial fibrillation; asystole; pulmonary edema; convulsions; vomiting; and violent behavior within ten minutes after parenteral administration of naloxone. Results: Six of 453 intoxicated subjects (1.3%;95% confidence interval 0.4%-3%) suffered severe adverse effects within ten minutes after naloxone administration (one asystole; three generalized convulsions; one pulmonary edema; and one violent behavior). After the ten minute period, no further complications were observed. Conclusions: The short time between naloxone administration and the occurrence of complications, as well as the type of complications, are strong evidence of a causal link. In 1000 clinically diagnosed intoxications with heroin or heroin mixtures, from 4 to 30 serious complications can be expected. Such a high incidence of complications is unacceptable and could theoretically be reduced by artificial respiration with a bag valve device (hyperventilation) as well as by administering naloxone in minimal divided doses, injected slowly. © 1996 Informa UK Ltd All rights reserved.
    Tags: Adolescent, Adult, Aggression, aspiration, clinical trial, Cocaine, conference paper, Confidence Intervals, convulsion, diamorphine, Female, flumazenil, Heart Arrest, heart fibrillation, heart ventricle tachycardia, Heroin, human, Humans, Injections, Intramuscular, Injections, Intravenous, intoxication, intramuscular drug administration, intravenous drug administration, lung edema, major clinical study, Male, meta analysis, Middle Aged, Naloxone, Narcotic Antagonists, Overdose, Prospective Studies, Pulmonary Edema, Seizures, Street Drugs, Substance Abuse, Intravenous, vomiting.
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  • Desmeules, J., Deluze, Ch, Arroyo, J., Piguet, V., Vischer, T. L., and Dayer, P. “Pain And Neuroplasticity: Practical Implications; [«Mémoire» De La Douleur Et Neuroplasticité: Implications Pratiques]”. Medecine Et Hygiene 54, no. 2110: 591-597. https://www.scopus.com/pages/publications/0029993706?origin=resultslist.
    Abstract: This review evaluates the central sensitisation as one of the mechanisms that could contribute to the persistence of pain. Nociceptive primary afferents have the capacity to induce a state of increased excitability or central sensitisation in dorsal horn neurones. This contributes to the mechanical hypersensitivity (allodynia or hyperalgesia) accuring after peripheral tissue or nerve injury. This plasticity of the nervous system seems to be more easily prevented than treated. Although numerous strategies are developed for the design of novel analgesics in these conditions the major effort should be directed to a rapid symptomatic treatment of intense or prolonged pain.
    Tags: allodynia, analgesic agent, article, human, hyperalgesia, local anesthetic agent, n methyl dextro aspartic acid receptor, nervous system, nonsteroid antiinflammatory agent, opiate, pain, plasticity, spinal cord dorsal horn.
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  • Büla, Ch J., and Yersin, B. “Assessment And Triage Of Elderly Medical Patients In The Emergency Room; [Evaluation Et Orientation Des Patients Âgés Admis Dans Les Centres D'urgences Hospitaliers]”. Medecine Et Hygiene 54, no. 2126: 1440-1442. https://www.scopus.com/pages/publications/9944265105?origin=resultslist.
    Abstract: Elderly patients assessment and triage is a complex problem, frequently encountered in the emergency room. Several features, such as the presence of multiple chronic diseases, cognitive, sensory and psychosocial impoirmsnts, make the elderly patient especially difficult to assess. We describe several strategies that have been designed to improve triage decisions for the elderly patient in the emergency room, and process of care in the Canton de Vaud health care organization. The use of multidimensional measures of function, such as developed for comprehensive geriatric assessment, is another strategy currently assessed, that might help to better define the level of care needed by emergency room alderly patients and, thus, avoid orientation to inappropriate health care settings.
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1995

  • Kakar, F., Bassani, F., Romer, C. J., and Gunn, S. W. “The Consequence Of Land Mines On Public Health”. Prehosp Disaster Med 11, no. 1: 2-10. doi:10.1017/s1049023x00042278.
    Abstract: An estimated 110 million land mines scattered in 64 countries continue to terrorize people and destroy human lives long after wars and fighting have ceased. Despite efforts to clear these devices, their numbers continue to increase and their presence constitutes a substantial threat to public health in affected countries. Direct consequences include both the physical and emotional injuries from the impact, flying debris, and structural collapse associated with their detonation. Indirect consequences include increases in the incidence of waterborne diseases, diarrhea, malnutrition, infectious diseases, and spread of the human immunodeficiency virus associated with the increased use of blood. Those at highest risk of these later consequences are mostly the disadvantaged poor, especially children. Psychiatric disorders, such as post-traumatic stress disorder, occur in those not directly injured as well as those physically wounded by the explosion. Besides efforts to ban production, stockpiling and export of land mines, a comprehensive and integrated health program aimed at the prevention, treatment, and rehabilitation of those injured directly or indirectly by land mines is needed urgently. Strategies should include mine-awareness programs, enhanced transport of those directly injured, training the villagers in first aid, augmenting the capacity and quality of treatment facilities, improving the psychological support and treatment capabilities, development of rehabilitation programs, and the institution and enhancement of public-health programs directed at the indirect consequences associated with the presence of land mines. Land mines constitute a major public health problem in the world that must be addressed.
    Tags: *Explosions/prevention & control/statistics & numerical data, *Global Health, *Public Health/statistics & numerical data, *Violence, Adult, Blast Injuries/etiology/prevention & control/rehabilitation, Child, Humans, Risk Factors, World Health Organization.
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  • Vernazza, P. L., Gresser, S., Koller, C., and Osterwalder, J. J. “Condom Semen Samples For Unlinked Anonymous Hiv Testing”. Lancet 346, no. 8980: 962-3. doi:10.1016/S0140-6736(95)91581-8.
    Tags: *Condoms, Feasibility Studies, Female, HIV Antibodies/*analysis, HIV Seropositivity, Humans, Male, Semen/*immunology, Sex Work.
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  • Osterwalder, J. J. “Patients Intoxicated With Heroin Or Heroin Mixtures: How Long Should They Be Monitored?”. Eur J Emerg Med 2, no. 2: 97-101. doi:10.1097/00063110-199506000-00009.
    Abstract: Our investigation was carried out in subjects intoxicated with heroin or heroin mixtures to find out the time interval during which delayed life-threatening complications become manifest, such as pulmonary oedema or relapse into respiratory depression or coma after naloxone treatment. We studied prospectively all drug intoxications between 1991 and 1992. Of the 538 intoxications, we assessed in detail 160 outpatients who lived within the catchment area of our hospital. The outcome variables studied were (1) rehospitalization for pulmonary oedema, (2) relapse into coma, and/or (3) death and cause within 24 h after release from hospital. Deaths occurring outside our hospital have to be reported, as decreed by law, to the Institute for Forensic Medicine. The results of our investigation showed no rehospitalization owing to pulmonary oedema or coma, but one death, outside the hospital, owing to delayed pulmonary oedema. This delayed complication had an incidence of 0.6% (95% confidence interval 0-3.8%). A reintoxication could be excluded in this patient. Based on reliable report, the pulmonary oedema occurred between approximately 2 1/4 and 8 1/4 hours after intoxication. In the literature, only two cases of delayed pulmonary oedema have been reported with reliable time statements (4 and 6 h after hospitalization). We therefore conclude that surveillance for at least 8 h is essential after successful treatment to exclude delayed pulmonary oedema in patients intoxicated with heroin or heroin mixtures.
    Tags: Adolescent, Adult, Benzodiazepines/poisoning, Cannabis/poisoning, Drug Interactions, Drug Overdose/diagnosis/mortality/therapy, Emergency Service, Hospital, Emergency Treatment/*methods, Ethanol/poisoning, Female, Glasgow Coma Scale, Heroin Dependence/mortality/therapy, Heroin/*poisoning, Humans, Male, Monitoring, Physiologic/*methods, Narcotics/*poisoning, Prospective Studies, Survival Rate, Switzerland/epidemiology, Time Factors.
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  • Osterwalder, J. J. “Is Textbook Knowledge Of Sonography Also Valid In Emergency Medicine?; [Gilt Das Lehrbuchwissen Der Sonographie Auch In Der Notaufnahme?]”. In, 125:2499-2501, 1995. https://www.scopus.com/pages/publications/0029610586?origin=resultslist.
    Abstract: Textbook knowledge of sonography is not immediately applicable in emergencies where the favourable prerequisites characterizing the standard case are often lacking. The question therefore arises of what textbook knowledge is also viable in the average emergency unit, under what circumstances and for which clinical questions. The answer to this differentiated question is a graded concept with 'primary emergency sonography', 'extended' and 'standard sonography'. The indications and advantages of 'primary emergency sonography' in contrast to standard procedure are discussed in detail. The key to success depends on meticulous introduction and training, strict compliance with indications and principle, and rigorous surveillance by an experienced ultrasonic specialist. In addition further scientific examination of the concept is necessary.
    Tags: conference paper, echography, Emergencies, Emergency Medical Services, emergency medicine, human, Humans, medical education, quality control, Ultrasonography.
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  • Locher, S., Osterwalder, J., and Lange, J. “Liver Injuries, Spleen Injuries And Combined Liver-Spleen Injuries: Diagnosis, Therapy And Results; [Leber-, Milz- Und Kombinierte Leber-Milzverletzung: Diagnostik, Therapie Und Ergebnisse]”. Aktuelle Chirurgie 30, no. 3: 124-131. https://www.scopus.com/pages/publications/0029075441?origin=resultslist.
    Abstract: 126 patients with liver and spleen injuries from 1985-1993 were retrospectively analysed. We compared patients with liver injuries without spleen injuries (LI, n = 37), patients with spleen injuries without liver injuries (SI, n = 54) and patients with both liver and spleen injuries (SLI, n = 35). Diagnosis of intraabdominal bleeding was made by sonography in 53 cases, by computed tomography in 32 cases, by diagnostic peritoneal lavage in 21 cases and by means clinical examination in 15 cases. In 10 cases there was no diagnosis of bleeding. After 1989 diagnostic peritoneal lavage was replaced completely by sonography. Diagnosis of the injured organ(s) was made in 11 cases post mortem, in 49 cases during operation (laparotomy or laparoscopy), in 32 cases by sonography and in 46 cases by computed tomography. Non-operative treatment was performed in 9 of 54 (SI), in 10 of 37 (LI) and in 2 of 35 (SLI). Three patients of the group SI and two patients of both other groups had to undergo operation secondarily. Splenectomy was performed in 89% of all operated splenic injuries, whereas resectional therapy in liver injuries became necessary only in 19%. Temporary tamponade of the liver was performed in 11% of all operated liver injuries. The mortality rate was 19% for all patients, corresponding mortality rates were 4% (SI), 22% (LI) and 40% (SLI) respectively. 50% of the patients who died with spleen injuries died of bleeding from the spleen, 88% of the patients who died with liver injuries died of bleeding from the liver and 50% of the patients who died with combined injuries died of bleeding from either liver and/or spleen. 20 of 24 (83%) dead patients died of bleeding complications during the first 24 hours of hospitalization. In 5 of these 20 patients was no bleeding from either spleen or liver. Two patients died of septic-toxic multiorgan failure, two patients died from severe cerebral injuries. Even though spleen injuries and liver injuries had comparable injury scores, spleen injury mortality rate is only 1/6 of liver injury mortality rate. Diagnostic peritoneal lavage was replaced by abdominal sonography. The decisive factor for the indication to operation is haemodynamic instability/shock combined with free intraabdominal fluid. In haemodynamic stable conditions and under frequent haemodynamic surveillance diagnosis of free intraabdominal fluid and/or diagnosed liver or spleen lesions are no indication for operation. After non-operative management haemodynamic instability, a decreasing hemoglobin concentration progressing intraabdominal fluid or progressing intracapsular haematomas form an indication for secondary operation. The critical factor in the treatment of liver and spleen injured patients is the blood loss and its consequences. More than 80% of the dead patients died within the first day of hospitalisation due to bleeding problems. The condition to improve this is a more efficient preclinic emergency system combined with a high standard of clinical management.
    Tags: article, bleeding, controlled study, diagnosis, echography, emergency medicine, female, hemodynamics, human, liver injury, major clinical study, male, mortality, results, spleen injury, therapy.
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  • Halperin, D. S. “Emergency Pediatrics: Specific Features Of A Developing Discipline; [Pediatrie D'urgence: Specificites D'une Discipline En Developpement]”. Medecine Et Hygiene 53, no. 2059: 353-361. https://www.scopus.com/pages/publications/0028817246?origin=resultslist.
    Abstract: Emergency pediatrics has emerged in the last few years as a specific field of pediatrics. It has a broad scope of activity that encroaches on other fields such as general pediatrics, pediatric surgery (in particular traumatology) and anesthesiology-intensive care medicine. Emergency pediatrics is also built up on a systemic approach of the medical emergency, where hospital care only constitutes one facet of a global intervention that includes as partners: parents, day nurseries, schools, medical practitioners, referring hospitals, poison centers, as well as ambulance services, among others. This hybrid nature does not, however, replace the specificity of emergency pediatrics, which this article aims to delineate; on the contrary, it emphasizes the demands of a discipline that deserves to hold a significant position within the health care system.
    Tags: article, child, emergency medicine, emergency treatment, human, injury, nalbuphine, opiate, pediatrics, preschool child, quality control, school child, standard.
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1994

  • Morabia, A., Steinig-Stamm, M., Unger, P. F., Slosman, D., Schneider, P. A., Perrier, A., and Junod, A. F. “Applicability Of Decision Analysis To Everyday Clinical Practice: A Controlled Feasibility Trial”. J Gen Intern Med 9, no. 9: 496-502. doi:10.1007/BF02599219.
    Abstract: OBJECTIVE: To determine whether decision analysis is applicable to routine management of suspected pulmonary embolism in an emergency care setting. DESIGN: Controlled feasibility trial. SETTING: Emergency center of a university hospital. PATIENTS: Outpatients (n = 84) admitted with clinical and scintigraphic evidence of pulmonary embolism. INTERVENTIONS: Patients were treated either with the usual clinical work-up for pulmonary embolism (control group) or using a decision analysis model with three options: no action: angiography followed by treatment if positive; treatment without angiography. RESULTS: All six senior residents in the decision analysis group agreed to fully participate for the 16 months of the study. Summarizing the decision analysis model in a graph was critical to obtain acceptance from all the physicians. Decision analysis (n = 43) and control (n = 41) patients underwent similar numbers of angiographies. However, angiographies for patients who had intermediate clinical probabilities of pulmonary embolism, between 25 and 75%, were more frequent in the decision analysis group (9/13 = 69%) than in the control group (7/20 = 35%). Agreement between clinical probability and lung-scan result was stronger in the decision analysis group. CONCLUSIONS: Decision analysis was successfully used to manage all patients suspected of having pulmonary embolism admitted to an emergency center during the 16-month trial. There was no insuperable obstacle to acceptance of clinical decision analysis by the physicians. Decision analysis may have resulted in a better discrimination between low and intermediate clinical probabilities of pulmonary embolism.
    Tags: *Decision Support Techniques, Adult, Aged, Aged, 80 and over, Emergencies, Feasibility Studies, Humans, Likelihood Functions, Male, Middle Aged, Pulmonary Embolism/*diagnosis/diagnostic imaging/*therapy, Radiography.
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  • Heller, M., Stoy, W. A., Shuman, L. J., Wolfe, H., and Zavada, C. A. “Effectiveness Of Interactive Videodisc Instruction For The Continuing Education Of Paramedics”. Prehosp Disaster Med 9, no. 3: 165-70; discussion 171. doi:10.1017/S1049023X00041285.
    Abstract: OBJECTIVES: To evaluate the effectiveness of interactive videodisc (IVD) instruction of paramedics through the use of computer analysis of trip sheets. DESIGN/SETTING: Prospective, controlled, in an urban 9-1-1, paramedic, emergency medical services (EMS) system with total call volume of 62,000/year; 15,000 advanced life support (ALS). INTERVENTIONS: All 150 paramedics in the system received eight hours of IVD instruction covering five subject areas: 1) airway; 2) head/cervical trauma; 3) chest; 4) shock; and 5) cardiac arrest. Trip sheets from 9,943 runs in the pre-IVD period were subjected to computer analysis, and a compliance score was generated using previously developed algorithms that assigned a weight to each omission and commission. After a nine-month IVD training period, 4,303 cases were collected and analyzed in the post-IVD period. Statistical analyses were made using "Student's" t-test and Chi-square with alpha set at 0.05. EXCLUSIONS: Only those records of adult patients who fit one of the five protocols were eligible for computer analysis. Of the 9,943 cases in the pre-IVD group, 480 (4.8%) were excluded, all due to inadequate data recording by the paramedics. A statistically similar portion, 233 (5.4%) of the 4,303 post-IVD instruction cases were excluded (p = .15). RESULTS: Overall the mean compliance score of the pre-IVD group was 0.65 +/- 0.19 (+/- SD). The post-IVD group score was 0.65 +/- 0.19 (p = 0.99). Analysis of scores for each algorithm also showed no significant differences. This study had an observed power of .94 to detect a difference in compliance as small as 0.030. CONCLUSION: Eight hours of IVD instruction did not result in improved paramedic performance as judged by computer analysis of trip sheets.
    Tags: *cd-i, Adult, Algorithms, Clinical Competence, Curriculum, Education, Continuing/*methods, Emergency Medical Technicians/*education, Humans, Medical Records, Prospective Studies.
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