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The aim of this study was to assess the variation in the use of head computed tomography (CT) scan in patients attending EDs with ground-level fall-related minor head injury. Secondary objectives were: i) to measure the prescription rate of appropriate head CT scan, ii) to identify patients' and EDs characteristics associated with head CT scan prescription iii) to explore potential correlation between head CT scan use and traumatic intracranial hemorrhage (ICH) yield rate in this population. This research was a planned sub-analysis of a cross-sectional prospective multicentric study performed in 63 EDs in France (EPI-TC study). Patients sustaining ground-level fall-related with minor head injury were included in this sub-analysis. The main outcome was head CT scan performed during ED stay. Variations in the use of head CT scan were described depending on each ED and French region. Multiple fixed effects mixed logistic regression model was performed to identify factors associated with head CT scan. A total of 631 patients admitted for head injury after ground-level fall were included. Median age was 79 [63-88] years. A head CT scan was performed in 409 patients (64.8%, CI95% 61.0-68.5); 19.6% (CI95% 15.8-23.7) of them were appropriated; and 29 (7.1%, CI95% 4.8-10.0) showed a traumatic ICH. At regional level, head CT scan prescription rate ranged from 45.5% (CI95%: 24.4-67.8) to 84.6% (CI95% 54.5-98.1). Head CT scan use was not correlated with the yield rate of traumatic ICH. In multivariable analysis, preinjury antiplatelets (OR 29.2, CI95%: 12.2-69.9), anticoagulants (OR 69.9, CI95%: 20.0-243.9), syncope (OR 6.9, CI95%: 2.0-24.2), post-trauma amnesia (3.2, CI95%: 1.0-10.5) and post-trauma loss of consciousness (OR 5.6, CI95%: 2.0-15.9) were associated with head CT scan use. Head CT scan use in patient presenting to EDs with head injuries after ground-level falls is highly variable. High rate of head CT scan use is not correlated with high traumatic intracranial hemorrhage yield rate. The use of a clinical decision rule dedicated to this population would be suitable for harmonizing our practices.

Background In out-of-hospital cardiac arrest (OHCA), bystander initiated cardiopulmonary resuscitation (CPR) increases the chance of return of spontaneous circulation and survival with a favourable neurological status. Socioeconomic disparities have been highlighted in OHCA field. In areas with the lowest average socioeconomic status, OHCA incidence increased, and bystander CPR decreased. Evaluations were performed on restricted geographical area, and European evaluation is lacking. We aimed to analyse, at a national level, the impact of area-level social deprivation on the initiation of CPR in case of a witnessed OHCA. Methods We included all witnessed OHCA cases with age over 18 years from July 2011 to July 2018 form the OHCA French national registry. We excluded OHCA occurred in front of rescue teams or in nursing home, and patients with incomplete address or partial geocoding. We collected data from context, bystander and patient. The area-level social deprivation was estimated by the French version of the European Deprivation Index (in quintile) associated with the place where OHCA occurred. We assessed the associations between Utstein variables and social deprivation level using a mixed-effect logit model with bystander-initiated CPR. Results We included 23,979 witnessed OHCA of which 12,299 (51%) had a bystander-initiated CPR. More than one third of the OHCA (8,326 (35%)) occurred in an area from the highest quintile of social deprivation. The higher the area-level deprivation, the less the proportion of bystander-initiated CPR (56% in Quintile 1 versus 48% in Quintile 5). The In the multivariable analysis, bystander less often began CPR in areas with the highest deprivation level, compared to those with the lowest deprivation level (OR=0.69, IC95%: 0.63-0.75). Conclusions The level of social deprivation of the area where OHCA occurred was associated with bystander-initiated CPR. It decreased in the more deprived areas although these areas also concentrate more younger patients.

Multiple studies have evaluated copeptin, a surrogate for arginine vasopressin, in the diagnosis of acute myocardial infarction (AMI) with mixed results. A systematic review and collaborative meta-analysis were performed for diagnosis of AMI and assessment of prognosis in patients presenting to the emergency department with chest pain. MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing copeptin in such patients. Study investigators were contacted, and many provided previously unpublished data. Random-effects methods were used to compare the data for copeptin, troponin, and their combination. There were a total of 9,244 patients from the 14 included studies. Mean age was 62 years; 64% were men; and 18.4% were ultimately diagnosed with AMI. Patients with AMI had a higher presentation copeptin level than those without AMI (22.8 vs 8.3 pmol/L, respectively, p <0.001). Although troponin had better diagnostic accuracy than copeptin for AMI, the combination of copeptin and troponin significantly improved the sensitivity (0.905 [0.888 to 0.921] vs 0.686 [0.661 to 0.710], respectively, p <0.001) and negative predictive value (0.97 [0.964 to 0.975] vs 0.93 [0.924 to 0.936], respectively, p <0.001) compared with troponin alone. Elevation in copeptin carried a similar risk of all-cause mortality to an elevation in troponin (odds ratio 5.84 vs 6.74, respectively, p = 0.67). In conclusion, copeptin not only identifies patients at risk of all-cause mortality, but its addition to troponin improved the sensitivity and negative likelihood ratio for diagnosis of AMI compared with troponin alone. Thus, copeptin may help identify patients who may be safely discharged early from the emergency department.

Background Acute dyspnea is a frequent cause to call the Emergency Medical Call Center (EMCC). The main challenge for EMCC dispatchers is to quickly identify patients that will require respiratory support in order to provide them with the most accurate prehospital response. Our main objective was to derivate a score assessable during the first call to detect the most severe patients needing medical assistance. Methods This prospective observational cohort study was conducted in four different French EMCC from January 22nd to March 7th 2024. Patients over the age of 18 years old that called once the EMCC for acute dyspnea were included in our study. The primary endpoint was an immediate respiratory support requirement (i.e. high-flow oxygen, non-invasive ventilation or mechanical ventilation after intubation) before or at the Emergency Department Registration. Variables of interest to predict respiratory support were prospectively collected in each EMCC. A multivariate analysis by stepwise logistic regression was used to select variables associated with the primary endpoint and to create in the TeLePhon Respiratory Score (TeLePoR score). The TeLePoR score was compared to medical dispatcher intuition for predicting respiratory support. Results Six hundred and forty-nine patients were analyzed, including 49 (8%) that required immediate respiratory support. The risk factors included in the TeLePoR score were: altered ability to speak complete sentences (OR = 8.62; CI95% = [3.49–21.3]), abdominal respiration (OR = 2.42; CI95% = [1.23–4.76]), altered consciousness (OR = 2.05; CI95% = [0.90–4.65]) and self-report breathing discomfort > 7/10 (OR = 1.83; CI95% = [0.96–3.47]) respectively. Considering these factors, TeLePoR score presented a 0.810 AUC. Medical dispatcher intuition was not statistically superior to TelePoR score to predict immediate respiratory support (AUC = 0.836 vs. 0.810; p  = 0.431). Conclusion TeLePoR score is a simple scoring system including 4 variables to predict immediate respiratory support in patients calling the EMCC for acute dyspnea.

IntroductionDyspnea is a common chief complaint leading to emergency department (ED) visits. Multiple conditions may cause or be associated with dyspnoea, including bacterial pneumonia, acute heart failure (AHF), exacerbation of chronic obstructive pulmonary disease (COPD) or asthma and pulmonary embolism. Each of these diagnoses has a specific treatment recommended by international guidelines. Inappropriate treatment in the ED is more frequent among elderly patients and is independently associated with in-hospital mortality. Point-of-care ultrasound is immediately available at the bedside. Lung and cardiac ultrasound (LuCUS) offers excellent diagnostic accuracy for bacterial pneumonia, AHF and COPD exacerbations, even in elderly patients. The primary objective of the LUC REED trial is to evaluate the impact of a LuCUS-guided strategy versus standard care on reducing inappropriate treatment of dyspnoea in elderly ED patients.Methods and analysisThe LUC REED trial is a prospective, interventional, multicentre, stepped-wedge randomised controlled trial designed to assess the superiority of a LuCUS-guided strategy over standard care in ensuring treatment appropriateness for dyspnoea in elderly ED patients. The study will include 504 patients over 2 years. Patients aged >65 years presenting with acute dyspnoea and signs of severity (respiratory rate ≥22 and SpO2 <92% on room air) will be enrolled. Each ED (cluster) will start with a control phase. Every 3 months, one centre will transition to the intervention phase (LuCUS-guided strategy). The primary outcome is treatment inappropriateness within the first hour after inclusion, assessed by comparing administered treatment to the final diagnosis adjudicated by two experts.Ethics and disseminationEthics final approval was obtained from the Institutional Review Board of France—Est IV on 4 April 2025 (2024-A01678-39). Results will be published in peer-reviewed international journals.Trial registration numberNCT06807983.

Background During simulation training, the confederate is a member of the pedagogical team. Its role is to facilitate the interaction between participants and the environment, and is thought to increase realism and immersion. Its influence on participants' performance in full-scale simulation remains however unknown. The purpose of this study was to observe the effect of the presence of confederates on the participants’ performance during full-scale simulation of crisis medical situations. Methods This was a prospective, randomized study comparing 2 parallel groups. Participants were emergency medicine residents engaging in a simulation session, with or without confederates. Participants were then evaluated on their Crisis Resource Management performance (CRM). The overall performance score on the Ottawa Global Rating Scale was assessed as primary outcome and the 5 non-technical CRM skills as secondary outcomes. Results A total of 63 simulation sessions, including 63 residents, were included for statistical analysis ( n  = 32 for Control group and 31 for Confederate group). The mean Overall Performance score was 3.9 ± 0.8 in the Control group and 4.0 ± 1.1 in the Confederate group, 95% confidence interval of the difference [-0.6; 0.4], p  = 0.60. No significant differences between the two groups were observed on each CRM items (leadership, situational awareness, communication, problem solving, resource utilization) Conclusion In this randomized and controlled study, the presence of confederates during full-scale simulated practice of crisis medical situations does not seem to influence the CRM skills performance of Emergency medicine residents. Trial registration This study does not need to be registered on Clintrial as it does not report a health care intervention on human participants.

IntroductionCurrent guidelines for patients presenting to the emergency department (ED) with chest pain without ST-segment elevation myocardial infarction (STEMI) on ECG are based on serial troponin measurements. A clinical tool able to identify very low-risk patients who could forgo a troponin test and low-risk patients requiring only one troponin measurement would be of great interest. To do so, the HEAR and HEART score, standing for history, ECG, age, risk factors±troponin were prospectively assessed, but not combined and implemented in clinical practice. The objective of the eCARE study is to assess the impact of implementing a diagnostic strategy based on a HEAR score <2 or a HEART score <4 (HEAR-T strategy) to rule out non-STEMI without or with a single troponin measurement in patients presenting to the ED with chest pain without obvious diagnosis after physical examination and an ECG.Methods and analysisStepped-wedge cluster-randomised control trial in 10 EDs. Patients with non-traumatic chest pain and no formal diagnosis were included and followed for 30 days. In the interventional phase, the doctor will be asked not to perform a troponin test to look for an acute coronary if the HEAR score is <2 and not to perform an additional troponin test if the HEAR score is ≥2 and HEART score is <4. The main endpoint is the non-inferiority of the rates of major adverse cardiac events occurring between a patient’s discharge and the 30-day follow-up against current recommended guidelines.Ethics and disseminationThe study was approved by an institutional review board for all participating centres. If successful, the eCARE study will cover a gap in the evidence, proving that it is safe and efficient to rule out the hypothesis of an acute myocardial infarction in some selected very low-risk patients or based on a single troponin measurement in some low-risk patients.Trial registration numberNCT04157790.

Most patients with renal colic are discharged from the emergency department (ED) after evaluation and pain alleviation. These patients may not require urgent imaging by computed tomography. We derived a clinical prediction score in patients with renal colic to identify those at very low risk for complications and alternative diagnoses requiring urgent intervention. This retrospective chart review was carried out in 2 ED at an urban university hospital from January to December 2015. All patients with a diagnosis of renal colic were included. The primary outcome was an intervention required for renal colic or alternative diagnoses within 7 days of ED presentation. A stepwise logistic regression was used to assess factors associated with the outcome. A score was derived as a weighted sum of these predictors and its performance was calculated. The database was submitted to the French National Commission for Data Protection and Liberties (CNIL): declaration n°2164898v0 (03/22/2018). 871 with complete data were analyzed. In 94 (11%) patients, an intervention was performed for obstructive urolithiasis or alternative diagnosis. Five factors were most predictive of intervention: age > 45 years (1 point), a history of urologic surgery (1 point), pulse > 100 bpm (1 point), temperature > 37.8 °C (2 point), and urine dipstick negative for blood (1 point), yielding a score of 0–6 points (the Complicated uroLithiasis and Alternative Diagnosis (CLAD) score). The area under the curve of the receiver operating characteristic curve was 0.82 (95% CI 0.77–0.87). We derived a clinical score for renal colic that predicted the presence of obstructive urolithiasis and acute alternative diagnoses requiring intervention.

Background Head injuries are the leading cause of trauma in Emergency Departments (EDs). Recent studies have shown epidemiological changes in patients consulting ED for head injuries. The main objective of this study was to describe the profile of head injury patients consulting in the EDs in France and assess i) head injury severity across age groups; ii) the delay between the occurrence of head injury and ED arrival; iii) factors associated with traumatic intracranial hemorrhage (ICH). Methods This cross-sectional study collected patient data over a three-day period in March 2023. All adult patients (≥ 18 years old) admitted to the ED with a head injury (defined as a trauma to the head) were included. TBI severity was classified according to patients’ initial Glasgow Coma Scale score in the ED: severe (3–8); moderate (9 -12); mild (13–15); and simple head trauma in the absence of transient or persistent neurological symptoms. Results Among the 71 participating EDs, 26,008 patients visited EDs and a total of 1070 patients (4.1%, IC 95 3.9—4.4) presented a head injury were included in the study, with a median age of 68.5 [37–85] years old. Most of the patients (66.7%) were referred to ED after a call to the Emergency Medical Dispatcher (EMD). The median time from head injury to ED visit was 2 h [1.0 – 5.5]. Ground-level falls were the leading cause of head injury (60.3%). Most of patient presented a simple head trauma ( n  = 715, 66.8%) followed by mild TBI ( n  = 337, 31.5%). CT head scans were performed for 636 patients (59.6%), of which 58 were positive. Traumatic ICH prevalence was 5.4% (95% CI: 4.1–6.9) and three patients (0.3%) required an urgent neurosurgical intervention. Neither preinjury anticoagulant ( p  = 0.97) nor antiplatelet ( p  = 0.93) use was associated with an increased risk of traumatic ICH. Conclusions One head injury patient out of two presenting in the ED is aged over 65 years. Patients referred by EMD were more likely to visit ED promptly. The majority of older patients underwent a head CT scan and preinjury anticoagulant use was not associated with increased risk of traumatic ICH.

Background Mild traumatic brain injury is the leading cause of arrivals to emergency department due to trauma in the 65-year-old population and over. Recent studies conducted in ED suggested a low intracranial lesion prevalence. The objectives of this study were to assess the prevalence and risk factors of intracranial lesion in older patients admitted to emergency department for mild traumatic brain injury by reporting in the emergency department the precise anamnesis of injury and clinical findings. Methods Patients of 65 years old and over admitted in emergency department were prospectively included in this monocentric study. The primary outcome was the prevalence of intracranial lesion threw neuroimaging. Results Between January and June 2019, 365 patients were included and 66.8% were women. Mean age was 86.5 years old (SD = 8.5). Ground-level fall was the most common cause of mild traumatic brain injury and occurred in 335 patients (91.8%). Overall, 26 out of 365 (7.2%) patients had an intracranial lesion. Compared with cutaneous frontal impact (medium risk group), the relative risk of intracranial lesion was 2.54 (95% CI 1.20 to 5.42) for patients with temporoparietal or occipital impact (high risk group) and 0.12 (95% CI 0.01 to 0.93) for patients with facial impact or no cutaneous impact (low risk group). There was not statistical increase in risk of intracranial injury with patients receiving antiplatelets (RR = 1.43; 95% CI 0.68 to 2.99) or anticoagulants (RR = 0.98; 95% CI 0.45 to 2.14). Conclusion Among patients of 65 years old and over, the prevalence of intracranial lesion after a mild traumatic brain injury was similar to the younger adult population. The cutaneous impact location on clinical examination at the emergency department may identify older patients with low, medium and high risk for intracranial lesion.