[The question of secondary medical transfer in Belgium: the experience conducted at the University Hospital Center of Liège]

Evaluation of the aid of an emergency mobile unit to transfer monitorized patients to a University hospital, in the political context of regional care network offering highly qualified but restricted tertiary area centres, and an open prospective study conducted over the 5 first months in 2006. The call regulation was assessed by the emergency physician of the transfer team and all missions were concluded with an evaluating report. An amount of 197 requests were taken into account from which 80 % were addressed between 8 am and 8 pm. The mean average time interval for missions was 59 minutes (base to base) and the distance covered was 20.7 km as a mean. In essence, indications for medical secondary transfer regarded patients in need for acute coronary care (42.6%), specific intensive care (26.4%) and neurosurgical interventions (19.3%). We noted that endotracheal intubation occurred in only one case. Mortality during such a transfer activity was absent. Medical transfer unit allows the development of specific high qualified network resources owing to the secondary addressee of patients. However, the weak incidence of complication questions the practice of systematic medical accompanying during such transfers.

[Coronary dissection and non-penetrating chest trauma]

The occurrence of an acute myocardial infarction after non-penetrating chest trauma is an extremely rare complication. We report a case of dissection of the left anterior descending artery in a 43 year old man after being punched in the chest. Using data from a literature search relish revealed 76 cases; we review the characteristics of the pathology and its incidence. We also characterize its etiology, anatomy and path physiology. We then consider the diagnostic and therapeutic implications.

[Pulmonary arterial hypertension due to COPD]

In this paper we review the current knowledge on pulmonary hypertension (PH) occurring in COPD. PH is defined as a mean pulmonary arterial pressure at rest greater than 20 mmHg measured by right heart catheterisation. PH is usually present during exercise before appearing at rest. PH in COPD increases the risk of hospitalisation and darkens the disease prognosis. Chronic hypoxemia is the major contributor to PH, but remodelling of arterial wall and mechanical factors such as hyperinflation also play a role. Transthoracic echocardiography is the most useful non invasive investigation, but right heart catheterisation is necessary to ascertain the diagnosis. Long term 02 supplementation is the basis of the treatment while vasodilatators may worsen hypoxemia.

[Idiopathic retroperitoneal fibrosis: unusual cause of abdominal pain. A case report]

Retroperitoneal fibrosis is an uncommon inflammatory disease which is characterized by the development of a fibrous process that surrounds the major vessels and organs located within the retroperitoneum. Isolated as an idiopathic expression or associated with several other diseases in its secondary form, retroperitoneal fibrosis remains relatively of rare occurrence and as a result, is devoid of either diagnostic or therapeutic definitive recommendations. We report the observation of one case admitted in the emergency room for abdominal pain induced by left hydronephrosis. Radiographic exploration with contrast-enhanced studies evidenced retroperitoneal fibrosis causing left ureteric obstruction. Therapeutic approach was based on corticosteroids and ureteral drainage which prevented recurrence while fibrosis was almost reversed six months later.

[The value of mobile intensive care unit (MICU): does it remain to be proven?]

Recent international guidelines about emergency situations (ILCOR / ERC) pointed to the need of the whole "chain of survival". ALS, Advanced Life Support (the last and "medical" part of the chain ) is important and influences survival rate. If no doubt exists about "what" and "when" to do in such situations, there is no consensus in industrialized countries about "who" should be in charge of such out-of-hospital acute diagnosis and treatment: emergency physicians, emergency nurses, emergency medical technicians (EMT), other "new" professionals ? ... A description of the MICU system in Belgium is given.

Computed tomographic pulmonary angiography and prognostic significance in patients with acute pulmonary embolism

BACKGROUND

Patients with acute pulmonary embolism (APE) present with a broad spectrum of prognoses. Computed tomographic pulmonary angiography (CTPA) has progressively been established as a first line test in the APE diagnostic algorithm, but estimation of short term prognosis by this method remains to be explored.

METHODS

Eighty two patients admitted with APE were divided into three groups according to their clinical presentation: pulmonary infarction (n = 21), prominent dyspnoea (n = 29), and circulatory failure (n = 32). CTPA studies included assessment of both pulmonary obstruction index and right heart overload. Haemodynamic evaluation was based on systolic aortic blood pressure, heart rate, and systolic pulmonary arterial pressure obtained non-invasively by echocardiography at the time of diagnosis of pulmonary embolism.

RESULTS

The mortality rate was 0%, 13.8% and 25% in the three groups, respectively. Neither the pulmonary obstruction index nor the pulmonary artery pressure could predict patient outcome. In contrast, a significant correlation with mortality was found using the systolic blood pressure (p<0.001) and heart rate (p<0.05), as well as from imaging parameters including right to left ventricle minor axis ratio (p<0.005), proximal superior vena cava diameter (p<0.001), azygos vein diameter (p<0.001), and presence of contrast regurgitation into the inferior vena cava (p = 0.001). Analysis from logistic regression aimed at testing for mortality prediction revealed true reclassification of 89% using radiological variables.

CONCLUSION

These results suggest that CTPA quantification of right ventricular strain is an accurate predictor of in-hospital death related to pulmonary embolism.

[Metabolic emergencies related to diabetes mellitus: ketoacidosis and hyperosmolar state]

Diabetic ketoacidosis and hyperglycaemic hyperosmolar state are relatively frequent metabolic emergencies. Such entities complicate type 1 and type 2 diabetes mellitus, respectively. Diagnosis is ultimately provided by blood and urine analysis. The pathophysiology is mainly based on insulin privation regarding ketoacidosis and resistance to insulin in hyperglycaemic crisis, with an additional deleterious role of counterregulatory hormones. Prognosis of such complications remains generally severe. Management is based on insulin infusion, fluid resuscitation as well as concomitant compensation for electrolytes losses.

[Treatment of exacerbated asthma]

Asthma exacerbations constitute a common medical emergency, which in the past has been shown to be poorly managed. Although its management has recently improved, it remains suboptimal. For instance, acute life-threatening asthma is still responsible for 2000 death each year in France. More than two thirds of deaths should be avoided by a prompt and adjusted treatment. Initial assessment of the severity of the exacerbation is fundamental. The clinical story, physical examination and objective measurement of airflow obstruction by peak flow meter should permit to quickly establish an adapted treatment. The aim of this paper is, once general considerations about clinical approach and currently used treatments have been made, to propose a home and a hospital-based management of the asthma exacerbations.

Effect of Hemodiafiltration on Pulmonary Hemodynamics in Endotoxic Shock

Hemofiltration can improve pulmonary hemodynamics during septic shock. The main objective of the study was to determine whether hemodiafiltration (HDF) would also have beneficial effects on pulmonary hemodynamics during septic shock. In the Endo group, six anesthetized pigs received a 0.5 mg/kg endotoxin infusion over 30 min. In the HDF group (n = 6), HDF was started 30 min after the end of the endotoxin infusion, while in the Control group (n = 4) they received HDF but no endotoxin infusion. Pulmonary hemodynamics were analyzed in detail with a four-element windkessel model. Although in the Control group, HDF did not alter pulmonary hemodynamic parameters, in the HDF group, it was responsible for an amplification of the deleterious pulmonary vascular response to endotoxin insult. Our results show that HDF must be used cautiously in septic shock since it can precipitate right heart failure by increasing pulmonary vascular resistance.

Effects of U-46619 on pulmonary hemodynamics before and after administration of BM-573, a novel thromboxane A2 inhibitor

We studied the effects on pulmonary hemodynamics of U-46619, a thromboxane A2 (TXA2) agonist, before and after administration of a novel TXA2 receptor antagonist and synthase inhibitor (BM-573). Six anesthetized pigs (Ago group) received 6 consecutive injections of U-46619 at 30-min interval and were compared with six anesthetized pigs (Anta group) which received an increasing dosage regimen of BM-573 10 min before each U-46619 injection. Consecutive changes in pulmonary hemodynamics, including characteristic resistance, vascular compliance, and peripheral vascular resistance, were continuously assessed during the experimental protocol using a four-element Windkessel model. At 2 mg/kg, BM-573 completely blocked pulmonary hypertensive effects of U-46619 but pulmonary vascular compliance still decreased. This residual effect can probably be explained by a persistent increase in the tonus of the pulmonary vascular wall smooth muscles sufficient to decrease vascular compliance but not vessel lumen diameter. Such molecule could be a promising therapeutic approach in TXA2 mediated pulmonary hypertension as it is the case in pulmonary embolism, hyperacute lung rejection and endotoxinic shock.

Effects of BM-573, a novel thromboxane A2 inhibitor, on pulmonary hemodynamics in endotoxic shock

Thromboxane A2 is considered to be partially responsible for the increase in pulmonary vascular resistance observed after endotoxin administration and to participate in proinflammatory reactions. The effects of a novel dual TXA2 synthase inhibitor and TXA2 receptor antagonist (BM-573) on pulmonary hemodynamics were investigated in endotoxic shock. 30 mins before the start of a 0.5 mg/kg endotoxin infusion, 6 pigs (Endo group) received a placebo infusion and 6 other pigs (Anta group) received a BM-573 infusion. In Endo group, pulmonary artery pressure increased from 25 +/- 1.8 (T0) to 42 +/- 2.3 mmHg (T60) (p < 0.05) after endotoxin infusion while, in Anta group, it increased from 23 +/- 1.6 (T0) to 25 +/- 1.5 mmHg (T60). This difference is due to a reduction in pulmonary vascular resistance in Anta group while pulmonary arterial compliance changes in Endo group remained comparable with the evolution in Anta group. In Endo group, PaO2 decreased from 131 +/- 21 (T0) to 74 +/- 12 mmHg (T300) (p < 0.05), while in Anta group, PaO2 was 241 +/- 31 mmHg at the end of the experimental period (T300). These results demonstrate that TXA2 plays a major role in pulmonary vascular changes during endotoxin insult. Concomitant inhibition of TXA2 synthesis and of TXA2 receptors by BM-573 inhibited the pulmonary vasopressive response during the early phase of endotoxin shock as well as the deterioration in arterial oxygenation.

[Comparison of a nurse-directed weight-based heparin nomogram with standard empirical doctor-based heparin dosage]

OBJECTIVE

To assess efficiency of a nurse directed weight-based nomogram (NWN) for heparin dosage without training.

STUDY DESIGN

Prospective, comparative, before/after intervention study.

PATIENTS AND METHODS

In a university medical intensive care unit, 19 patients receiving unfractionned intravenous heparin, following standard medical prescriptions (SHT), were compared to 19 patients submitted to NWN (80 U kg(-1) bolus, starting infusion at 18 U kg(-1) h(-1) and secondary dosage adaptations following a specific nomogram).

RESULTS

Dose of heparin bolus and starting dose infusion were significantly greater in NWN group than in the SHT group. The delay in achieving a predetermined therapeutic APTT level of at least 60 s was 6 (1-76) hours in the SHT group and 4 (3- 32) hours in the NWN group. The target APTT (60-85 s) was obtained after 13.5 (1-76) hours and 9.5 (3-32) hours in the two groups, respectively. Although reduction in delay seemed to favour anticoagulation dictated by the NWN protocol, the difference failed to reach statistical significance. Percentage of target APTT over total number of APTT values per patient was significantly higher in the NWN group (41 [0-87] vs. 31% [0-54]) in the SHT group. Strict observance of anticoagulation by using NWN tended to be better than that in SHT group.

CONCLUSIONS

NWN protocol was easy to use without previous training. NWN was associated with the best anticoagulation state although its superiority was less evident than expected.

Alteration of left ventriculo-arterial coupling and mechanical efficiency during acute myocardial ischemia

AIM

Myocardial revascularisation being frequently performed during acute myocardial ischemia, in a hostile hemodynamic environment, we evaluated left ventriculo-arterial (VA) coupling, left ventricular (LV) mechanical efficiency, and the mechanical properties of the systemic vasculature during acute myocardial ischemia.

METHODS

In 6 pigs, vascular properties [characteristic impedance (R(1)), peripheral resistance (R(2)), compliance (C), inductance (L), arterial elastance (E(a))] were estimated with a windkessel model. LV function was assessed by the slope (E(es)) of end-systolic pressure-volume relationship (ESPVR), and stroke work (SW) - end-diastolic volume (EDV) relation. Pressure-volume area (PVA) was referred to as myocardial oxygen consumption. VA coupling was defined as E(es)/E(a), and mechanical efficiency as SW/PVA. After baseline recordings, the left anterior descending coronary artery was ligated and hemodynamic measures obtained every 30 minutes for 3 hours. Data are expressed as mean (SEM).

RESULTS

Coronary occlusion induced an ESPVR rightward shift, and decreased E(es) from 3.67 (0.33) to 1.92 (0.20) mmHg/ml and the slope of the SW - EDV relationship from 72.3 (3.4) to 40.4 (4.5) mmHg (p<0.001), while E(a) increased from 3.33 (0.56) to 4.65 (0.29) mmHg/ml (p<0.005). This was responsible for a dramatic alteration of VA coupling from 1.22 (0.11) to 0.44 (0.07), (p<0.001). While R2 increased from 1.72 (0.30) to 2.38 (0.16) mmHg x s x ml(-1) (p<0.05) and C decreased from 0.78 (0.16) to 0.46 (0.08) ml/mmHg (p<0.05), R(1) and L were unchanged. Coronary occlusion decreased SW from 4056 (223) to 2580 (122) mmHg.ml (p<0.001), while PVA and SW/PVA decreased from 5575 (514) to 4813 (317) mmHg x ml (NS), and from 0.76 (0.04) to 0.57 (0.03) (p<0.001), respectively.

CONCLUSION

Acute myocardial ischemia severely altered left ventriculo-arterial coupling and LV mechanical efficiency. Impaired left VA coupling was due to a combination of augmented arterial elastance, secondary to early vasoconstriction later associated with decreased arterial compliance, and decreased LV contractility.

[Clinical case of the month. Pulmonary toxicity due to gemcitabine for NSCLC with brain metastasis]

Gemcitabine pulmonary toxicity is rare and represents a difficult diagnosis. A 61 year old female treated with gemcitabine for a metastatic non-small cell lung cancer (NSCLC) developed during the fifth chemotherapy cycle an acute respiratory distress syndrome with fever, tachypnea, marked hypoxemia and a diffuse interstitial-alveolar infiltrate on chest radiograph. No infectious or opportunistic etiology or cardiovascular disease was demonstrated. Withdrawal of gemcitabine and administration of corticosteroids led to symptomatic improvement. This acute pneumonitis was likely drug induced.

[Clinical case of the month. Porto-pulmonary hypertension syndrome associated with severe hypoxemia]

We report the case of a patient with liver cirrhosis who was admitted to the emergency room for rapid occurrence of dyspnea and severe hypoxemia at rest. Lung CT-scan and echocardiography did not disclose any right-to-left shunt and right-sided heart catheterization evidenced major precapillary pulmonary hypertension. The present feature supports the hypothesis that the pulmonary complications of cirrhosis, the hepatopulmonary syndrome and the portopulmonary hypertension, which are usually considered as mutually exclusive, may coexist. In such circumstances, the right failing heart is the major determinant to the immediate prognosis.

[Emergency practice: specifics in the management of complex multiple trauma]

Almost twenty years ago, Trunkey showed that deaths due to trauma followed a trimodal distribution over time. Half of these deaths were delayed by at least one to two hours after the initiating insult. This interval (the "golden hour") can be exploited, especially in specialized trauma centers (where the most severely injured patients are cared for), to aggressively treat these patients, thereby reducing morbidity and mortality. In Belgium, this hierarchy of trauma care centers is non-existent; patients are distributed within the healthcare system randomly, depending on the localisation of the accident and the directives of the unified "100" call centre. Because this limits the number of cases any one centre treats, this type of arrangement acts to inhibit the acquisition of competency in the handling of these complex patients. The relative lack of experience of individual emergency departments leads to difficulties in establishing diagnostic and treatment priorities for the most severely injured trauma victims. The approach to these patients must follow very precise guidelines, established scientifically in order to minimize the impact of the injury on life and maximize chances of satisfactory functional recovery. In this paper, we describe the general principles of the initial approach to victims of complex multiple trauma.

[Emergency medicine: general principles governing the hospital management of victims of multiple trauma]

The management of the trauma victim admitted to the emergency department must be rapid and efficient. Within the first hour, vital functions must be stabilised while a systematic survey of all injuries is carried out. This survey must be as complete as possible, and depends on the patient's status and response to initial resuscitative measures. The need for urgent surgical intervention, therapeutic radiology, or other treatment modalities must be quickly established. This systematic approach, which follows a seven step sequence, can only be carried out by a well-trained team. Because at this time emergency and SMUR are often staffed with general practitioners, and because the trauma centers do not yet exist in Belgium, the application of the treatment protocol presented in this paper is a pre-requisite to quality of care for these patients. It is the only means to end, once and for all, the improvised or intuitive, and often erroneous, approach to these patients.

[Clinical case of the month. An unusual presentation of superior vena cava syndrome]

We report the case of a 48-year-old man who was admitted to our emergency department because of a superior vena caval syndrome from which the symptoms occurred only during exercise. His past history included an episode of lower limb deep venous thrombosis. Because an atrio-ventricular partial block was fortuitously evidenced, the patient was submitted to a pacemaker insertion. A few years later, the patient suffered from rapid dyspnea on exercise, associated with facial cyanosis and systemic hypotension. The exploration by phlebography evidenced that the inferior vena cava was completely obstructed. Therefore the venous return from the lower part of the body to right heart was obtained through hypertrophy of the vena azygos. In addition, the presence of cardiac pacing electrodes induced a stenosis at the level of the superior vena cava, just before its entrance into the right atrium. Such a venous network accounted for the occurrence of a chronic superior vena caval syndrome associated with peripheral arterial hypotension during exercise. Treatment consisted of a superior vena caval percutaneous transluminal balloon angioplasty followed by a Wallstent insertion. This procedure led to a correction of all hemodynamic abnormalities responsible for reported pathophysiological limitations to stress.

[Application of the Simplified Acute Physiology Score II (SAPS II) in a medical intensive care unit]

OBJECTIVE

Our study was to assess the validity of SAPS II (New Simplified Acute Physiology Score) to predict the probability of in hospital mortality, in a cohort of patient admitted to a medical intensive care unit.

STUDY DESIGN

Prospective study.

PATIENTS AND METHODS

Out of 467 the 525 patients admitted were included. SAPS score and in hospital mortality prediction were calculated for each of them.

RESULTS

In this group, SAPS II offered a satisfactory discrimination power with an area under the curve of 0.843. However, calibration showed a lack of fit (chi 2 = 28.5, P < 0.001), with an overall under prediction of mortality (observed versus expected ratio of 1.12).

CONCLUSION

This SAPS II lower predicting accuracy in a specific population and for individual outcome prediction may reduce its interest in clinical decision-making.

[Consensus on the clinical approach to erectile dysfunction in patients with cardiovascular disease]

The most common physical risk factors for erectile dysfunction (ED) are atherosclerosis, heart disease, hypertension and diabetes. Since accessibility to easy and efficacy drug for ED therapy, GPs are increasingly at the front line in the management of ED and are often best-placed to discuss this problem with cardiovascular male patients. This consensus aims to provide practical advice on the management of ED in patients with diagnosed cardiovascular disease and also addresses the assessment of the cardiovascular risk in restoring sexual activity in these patients. A risk assessment algorithm has been drawn up to aid clinicians in deciding the level of cardiovascular risk that would be associated with a return of sexual activity as well as criteria for referral to specialists for further cardiac evaluation. Treatment options are briefly reviewed and follow-up process identified.