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Mise en place et évaluation d’une procédure de prise en charge des fractures de Pouteau-Colles dans un service d’urgences. Nous avons préalablement réalisé une procédure écrite et audiovisuelle fondée sur la littérature internationale. Cette procédure, réalisée avec nos collègues orthopédistes, aborde les pièges cliniques, l’interprétation des critères radiographiques de déplacement, les critères de choix entre un traitement conservateur et chirurgical, les indications et la technique de réduction, l’analgosédation et l’immobilisation. Nous avons analysé rétrospectivement le suivi de cette procédure. Les dossiers de 106 patients présentant une fracture de Pouteau-Colles ont été revus parmi 174 fractures du radius distal. Soixante-et-une parmi ces 106 fractures (58 %) ont été décrites comme fractures déplacées et ont été immédiatement opérées (n= 32), réduites par les médecins des urgences (n= 20) ou plâtrées sans réduction (n= 9). Deux procédures de réduction sur vingt ont été considérées comme insuffisantes. La réalisation d’une sédation en vue de la réduction n’est mentionnée que chez dix des vingt patients. La mise en place d’une procédure est le premier pas pour améliorer l’autonomie et la qualité de la prise en charge des fractures de Pouteau-Colles par les médecins urgentistes. Leur formation doit se poursuivre en s’aidant de technologies audiovisuelles et de formations pratiques. Implementation and evaluation of a procedure for Pouteau-Colles’ fracture management in an emergency department. We first built up a written and audiovisual procedure based on the international literature. This procedure, realized with our orthopaedist colleagues, approaches clinical pitfalls, interpretation of the radiographic criteria of displacement, criteria of choices between conservative and surgical treatment, indications and technique of reduction, analgosedation and immobilization. We retrospectively analysed the procedure accuracy. The cases of 106 patients presenting a fracture of Pouteau-Colles were studied among 174 fractures of the distal radius. Sixty-one among these 106 fractures (58%) were described as displaced fractures and consequently were operated on immediately (n= 32), were reduced by emergency physicians (n= 20) or casted without reduction (n= 9). Two procedures of reduction out of 20 were considered as insufficient. The realization of sedation with the aim of reduction was only mentioned to 10 out of 20 patients. The implementation of a procedure is the first step to improve the autonomy and the quality of care of Pouteau-Colles’ fracture by the emergency physician. Teaching has to be continued by using audiovisual technologies and practical formations.

Summary: Background:Age‐adjusted D‐dimer cut‐off has recently been proposed to increase D‐dimer usefulness in older patients suspected of pulmonary embolism (PE).

Background: A pulmonary embolism (PE) is thought to be associated with atrial fibrillation (AF). Nevertheless, this association is based on weak data. Objectives: To assess whether the presence of AF influences the clinical probability of PE in a cohort of patients with suspected PE and to confirm the association between PE and AF. Patients/methods: We retrospectively analyzed the data from two trials that included 2449 consecutive patients admitted for a clinically suspected PE. An electrocardiography (ECG) was systematically performed and a PE was diagnosed by computer tomography (CT). The prevalence of AF among patients with or without a PE was compared in a multivariate logistic regression model. Results: The prevalence of PE was 22.8% (519/2272) in patients without AF and 18.8% (25/133) in patients with AF (P = 0.28). After adjustment for confounding factors, AF did not significantly modify the probability of PE (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.42–1.11). However, when PE suspicion was based on new‐onset dyspnea, AF significantly decreased the probability of PE (OR 0.47, 95% CI 0.26–0.84). If isolated chest pain without dyspnea was the presenting complaint, AF tended to increase the probability of PE (OR 2.42, 95% CI 0.97–6.07). Conclusions: Overall, the presence of AF does not increase the probability of PE when this diagnosis is suspected. Nevertheless, when PE suspicion is based on new‐onset dyspnea, AF significantly decreases the probability of PE, as AF may mimic its clinical presentation. However, in patients with chest pain alone, AF tends to increase PE probability.

Background:If the prevalence of pulmonary embolism (PE) differs significantly between the US and Europe, this observation could reduce the generalizability of diagnostic protocols for PE derived in either location.Objective:To determine possible causes and potential clinical consequences of these PE prevalence differences.Methods:Secondary analysis of three prospectively collected multicenter samples (two French and one from the US) including 3174 European and 7940 American PE‐suspected patients in Emergency departments (ED) (117 for Europe and 12 for US). Comparison of clinical features, resource use and outcomes of European‐ and US‐suspected PE populations in ED.Results:European patients evaluated for PE were significantly older and had a higher clinical pretest probability (CPP) for PE. The final PE prevalence was significantly higher in Europe, in the overall sample (26.5% vs. 7.6%) and in each level of CPP. Suspected European patients categorized as low CPP had a higher posttest probability than US low CPP patients. Suspected US patients categorized as high CPP had a much lower posttest probability of PE than in Europe. The mean number of tests performed for one PE diagnosis was lower in Europe (7.4 vs. 21.6). Among patients diagnosed with PE, European patients had a higher mean severity of illness score and a higher PE‐mortality rate (3.4% vs. 0.7%).Conclusions:Among patients suspected of a PE and those ultimately diagnosed with a PE, European patients had higher acuity, a higher pretest probability and worse outcome than US patients. The present study underscores the importance of disease prevalence for pretest probability scoring approaches and for significance interpretation of imaging tests.

Résumé: Le recours à la gazométrie artérielle constitue jusqu’à présent un acte quotidien du médecin urgentiste, tant à visée d’aide au diagnostic, au pronostic et à la décision thérapeutique pour son patient. Cependant, il s’agit d’une procédure douloureuse et invasive exposant le patient ainsi que le soignant à un risque faible mais réel de complications. Depuis quelques années, divers auteurs se sont intéressés aux techniques alternatives permettant de diminuer le recours à la gazométrie artérielle: l’analyse des gaz du sang veineux et la saturométrie par oxymétrie pulsée. L’objectif de cet article consiste à revoir les indications de l’analyse des gaz du sang et à préciser les circonstances dans lesquelles la gazométrie artérielle peut raisonnablement être évitée ou remplacée par une technique alternative. Des exemples concrets y sont abordés, ainsi que des exercices pratiques, un projet de procédure écrite et le rappel de notions fondamentales en physiologie respiratoire appliquée.

Background:The Pulmonary Embolism Rule‐out Criteria (PERC) rule is a clinical diagnostic rule designed to exclude pulmonary embolism (PE) without further testing. We sought to externally validate the diagnostic performance of the PERC rule alone and combined with clinical probability assessment based on the revised Geneva score. Methods:The PERC rule was applied retrospectively to consecutive patients who presented with a clinical suspicion of PE to six emergency departments, and who were enrolled in a randomized trial of PE diagnosis. Patients who met all eight PERC criteria [PERC(−)] were considered to be at a very low risk for PE. We calculated the prevalence of PE among PERC(−)patients according to their clinical pretest probability of PE. We estimated the negative likelihood ratio of the PERC rule to predict PE. Results:Among 1675 patients, the prevalence of PE was 21.3%. Overall, 13.2% of patients were PERC(−). The prevalence of PE was 5.4% [95% confidence interval (CI): 3.1–9.3%] among PERC(−)patients overall and 6.4% (95% CI: 3.7–10.8%) among those PERC(−)patients with a low clinical pretest probability of PE. The PERC rule had a negative likelihood ratio of 0.70 (95% CI: 0.67–0.73) for predicting PE overall, and 0.63 (95% CI: 0.38–1.06) in low‐risk patients. Conclusions:Our results suggest that the PERC rule alone or even when combined with the revised Geneva score cannot safely identify very low risk patients in whom PE can be ruled out without additional testing, at least in populations with a relatively high prevalence of PE.

Background:Volumetric capnography is technically more demanding but theoretically better than the time‐based alveolar deadspace fraction (Paco2 – Etco2)/Paco2as a bedside diagnostic tool for excluding pulmonary embolism (PE) in outpatients. Objective:We compared both diagnostic accuracy in patients with a suspected PE and positive D‐dimer enzyme‐linked immunosorbent assay results. Patients and methods:In this clinical multicenter trial with prospective inclusion and 3‐month follow‐up, alveolar deadspace fraction was compared by receiver operating characteristic (ROC) analysis with other parameters derived from volumetric capnography. Results:Capnography was performed in 239 patients, and 205 tests (86%) were conclusive. The incidence of PE was 33%. The alveolar deadspace fraction accuracy expressed with ROC curve analysis was 0.73 ± 0.04. The diagnostic performances of parameters from volumetric capnography were not significantly better. Sixteen per cent [95% confidence interval (CI) 12–21%] of patients presented a (Paco2 – Etco2)/Paco2ratio under the cut‐off value of 0.15, with a low clinical probability. This combination excluded PE, with a sensitivity of 96% (95% CI 89–99%) and a negative likelihood ratio of 0.17 (95% CI 0.09–0.33%). Conclusion:Volumetric capnography failed to show superiority to alveolar deadspace fraction measurements [(Paco2 – Etco2)/Paco2] for exclusion of PE in outpatients with positive D‐dimer test results. Future studies should clarify the safety of excluding PE in patients combining low clinical probability with positive D‐dimer results and (Paco2 – Etco2)/Paco2ratios below the cut‐off value of 0.15.

Background:Compression ultrasonography (US) confined to the proximal veins is usually performed to detect deep vein thrombosis (DVT) in patients with suspected pulmonary embolism (PE). Recent studies suggested a limited yield of proximal US when multislice computed tomography (MSCT) was used. Objectives:To assess whether performing an additional distal vein US would increase the diagnostic yield of the test. Patients and methods:Data of 855 consecutive outpatients included in a multicenter randomized controlled trial were analyzed. Patients were investigated by a sequential diagnostic strategy including clinical probability assessment, D‐dimer measurement, proximal US and MSCT. Proximal US was completed by an examination of the distal veins, the result of which was not disclosed to the physician in charge of the patient. Results:US was positive in 21% of patients, of whom 10% (53/541) had proximal DVT and 11% (59/541) isolated distal DVT. Of the 59 patients with distal DVT, 21 (36%) had no PE on MSCT. Twenty of those 21 patients were not given anticoagulant therapy and had an uneventful follow‐up. The diagnostic performance of distal US for the diagnosis of PE was as follows: sensitivity 22% [95% confidence interval (CI) 17–29]; specificity 94% (95% CI  91–96); positive likelihood ratio 3.9 (95% CI  2.4–6.4). Conclusions:In patients with suspected PE, distal US has limited diagnostic performance, and its additional use only modestly increases the yield of US. Moreover, it carries a high false‐positive rate, impeding the use of distal US as a confirmatory test for PE.

Background:Troponins (cTnI and cTnT), N‐terminal pro‐Brain Natriuretic Peptide (NT‐proBNP), myoglobin, heart‐type fatty acid‐binding protein (H‐FABP) and fibrin D‐Dimer are emergent candidates for risk stratification in pulmonary embolism (PE). Objective:To compare the respective prognostic values of biomarker with non‐massive PE to predict an adverse outcome at 3 months. Patients/Methods:One hundred and forty‐six consecutive patients with non‐massive PE were included in this multicenter prospective study. The combined outcome consisted of intensive care monitoring on admission, death or hospitalization attributable to either a PE‐related complication [defined by PE/deep vein thrombosis (DVT) relapse or major bleeding under anticoagulation] or to dyspnoea with or without chest pain during follow‐up. Results:The outcome was met in 12% of patients. In univariate analysis, a NT‐proBNP level above 300 pg/ml was the strongest predictor of unfavorable outcome with an odds ratio (OR) of 15.8 [95% confidence interval (CI): 2.05–122). ORs for the other variables were: 8.0 for D‐dimer >2000 ng/ml (95% CI: 1.1–64), 4.7 for H‐FABP >6ng/ml (95% CI:1.5–14.8), 3.5 for cTnI >0.09 ng/ml (95% CI:1.2–9.7), 3.4 for myoglobin >70 ng/ml (95% CI:0.9–12.2). Receiver operating curve (ROC) analysis indicated that NT‐proBNP was the best predictor [area under the curve (AUC) 0.84; 95%CI: 0.76–0.92; P < 0.0001] with a negative predictive value of 100% (95% CI: 91–100) at 300 pg/ml. At that cut‐off, the true negative rate for NT‐proBNP was 40%. In multivariate analysis, NT‐proBNP was the only significant independent predictors. Conclusions:NT‐proBNP appears to be a good risk stratification marker in identifying low‐risk patients with non‐massive PE who could be treated in an outpatient setting.

Certaines observations montrent que l’ingestion de hautes doses de méthadone peut exposer à des hypoglycémies parfois réfractaires, par un mécanisme mal identifié [1]. Nous rapportons trois observations documentées par un dosage d’insulinémie et de C-peptide, et pour lesquelles un apport exogène d’insuline ou de médicaments hypoglycémiants a pu être exclu.