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The major challenges facing our healthcare system foster the emergence of new inter-professional roles such as the Specialized Nurse Practitioner. These professionals, recognized by a legal framework, hold advanced practice medical and nursing skills obtained after a 120-credit Master's-level university training. In 2018, the Emergency Department (ED) of the Centre Hospitalier Universitaire Vaudois was one of the first departments in Switzerland to implement such a role. Three years on, their clinical expertise and the developments in research, training and clinical projects make these professionals major assets in meeting the complex needs of patients and ED teams., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

People with autism spectrum disorder visit emergency departments more frequently than the rest of the population. Their ability to communicate with their environment may not only be limited but also different from the interactions of non-autistic people. In addition, the multiple sensory stimulations present in the emergency departments are likely to make interactions, and therefore the care of patients with an autism spectrum disorder more difficult. Understanding these difficulties and the special attentions to consider will allow better care for them. This article highlights the various points of attention to be had in order to offer quality welcoming and care to patients with an autism spectrum disorder., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

The diagnosis of acute coronary syndrome with ST segment elevation (STEMI) is based on clinical symptoms suggestive of acute myocardial ischemia and precise ECG criteria. STEMI is due to an acute occlusion or subocclusion of a coronary artery, generating a transmural ischaemia, requiring coronary angiography with urgent coronary revascularization. However, some authors consider the current STEMI ECG criteria to be too restrictive: up to 30 % of patients who do not meet these criteria present with critical coronary artery stenosis or acute coronary occlusion. Atypical electrocardiographic patterns, known as "STEMI equivalents", can be found in some cases and justify a rapid cardiological evaluation. We present a pragmatic review of five STEMI equivalents., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

During an event, the organizer is responsible for ensuring compliance with all standards, including in the medical and health field. It is therefore up to them to set up a display capable of handling potential patients. The planning of this display requires a preliminary risk assessment, including an estimate of the probability of occurrence and the potential severity in the event of occurrence. There are few decision-making tools available to plan such a device; the impact of major events, particularly on the surrounding care structures, or the sizing of such devices remains a poorly studied field. This article provides an update on recommendations and trends in this area, illustrated by the experience of the 2019 Fête des Vignerons., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article. Les résultats présentés dans cet article sont tirés du travail de Master en médecine de Mme O. Gasser ;18 travail qui a fait l’objet d’une autorisation de la Commission d’éthique de la recherche du Canton de Vaud (CER-VD) et de l’État-major cantonal de conduite (EMCC).

Alerting emergency medical services, rapidly initiating chest compressions at the correct depth and frequency and delivering an electric shock as quickly as possible remain the key points of the updated guidelines for adult cardiopulmonary resuscitation (CPR). Following their five-year systematic review, both the American Heart Association (AHA) and the European Resuscitation Council (ERC) are reinforcing their messages in favour of simple and early actions, while adding nuances regarding drugs, and suggesting that the chain of survival should continue beyond the acute hospital phase. Here is an overview of the reminders and novelties of the AHA and ERC 2020 guidelines., Competing Interests: Les Drs Nicolas Beysard, Quentin Guélat et Ludovic Maudet sont instructeurs ACLS AHA. Le Pr Pierre-Nicolas Carron n’a déclaré aucun conflit d’intérêts en relation avec cet article.

Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Emergency departments are on the front line in the management of COVID-19 cases, from screening to the initial management of the most severe cases. The clinical presentation of COVID-19 range from non-specific symptoms to adult acute respiratory distress syndrome (ARDS). Diagnosis is based on PCR from a nasopharyngeal swab and emergency treatment rely on oxygen therapy. Patient's orientation (home, hospitalization, admission in intensive care unit) is a central aspect of emergency management. The shift from a strategy of systematic recognition of potential cases to the one of epidemic mitigation required hospital emergency medicine services to implement crisis management measures, to guarantee admission and hospitalization capacity., Competing Interests: les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article

The COVID-19 epidemic required rapid and frequent adaptations from the prehospital emergency medical services (EMS). The exposure of EMS providers is significant, particularly during procedures at risk of aerosolization such as advanced airways management or cardiopulmonary resuscitation. EMS personal need to be equipped with appropriate personal protective equipment and trained in its use. Interhospital transfers from COVID-19 patients are complex and involve mainly intubated patients. The possible shortage of resources may motivate the implementation of dedicated pre-hospital triage and orientation recommendations, which should be consistent with the hospital processes., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Airborne sports are becoming more popular, despite an increased risk of potentially serious accidents. Most accidents are caused by pilot errors, unforeseen climatic conditions or a poor environmental assessment. Cases caused by material defects are rare. Accidents often involve damage to the spine and lower limbs, with impaired functional prognosis. Implementation of safety regulations as well as the promotion of protection material has certainly allowed some reduction in the risk of accident, the emphasis on quality training must however be continued., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Professionalisation of emergency medicine is currently booming. In order to offer the best care, emergency physician can refer to several new studies : 1) in a cerebral stroke, the 0° head position doesn't offer any benefit ; 2) hyperoxygenation in acute patients could raise mortality ; 3) epinephrine in prehospital cardiac arrest favors return of spontaneous circulation but worsens the neurological prognosis ; 4) systematic cross-checking reduces the risk of adverse events in the emergency department ; 5) ultrasensitive troponins better detect myocardic events, but raises the number of unusefull invasive procedures and 6) combined pre-test probability score and D-dimers potentially allows to rule out aortic dissection., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Boerhaave syndrome is a rare condition, usually associated with a delay in diagnosis. It is fatal in the absence of therapy. The nonspecific nature of the clinical signs contributes to the poor outcome. This syndrome should be suspected in patients with severe chest or abdominal pain, associated with a history of vomiting, clinical signs of pneumomediastinum (subcutaneous emphysema, pleural effusion) and rapid clinical deterioration. Prompt diagnosis and initial management by the primary care physician and the emergency department physician are key elements of a better outcome. This article will review the pathogenesis, clinical manifestations, diagnosis and treatment of Boerhaave syndrome in adults., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

We confronted some of the most prevalent prehospital misconceptions with the available literature. We found that: the diminution of a retrosternal pain following nitrate administration is not predictive of a cardiac origin of the pain ; survival of traumatic cardiac arrest may not be as bad as usually believed ; peripheral venous administration of vasopressors through proximal catheters during short times may be considered as a safe temporary alternative to central venous access ; using the pulse palpation usually lead to an under-estimation of the systolic blood pressure ; applying a pelvic belt at the level of the iliac crests doesn't aggravate an open-book fracture; there is no 90 mmHg threshold values below which mortality increases in traumatic brain injuries., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

In emergency situations, regularly trained technical skills return as automatisms. This is so with the positioning of our critical patients. According to their signs and symptoms (e.g. respiratory distress, unconsciousness, hypotension), they will be installed immediately in a semi-sitting position, in the recovery position, in the Trendelenburg position or with raised legs. But are these gestures repeated and transmitted to successive generations of caregivers really effective and safe? Do we understand the original context and purpose in which these positions were invented? Here we review three of the most common positions in emergency medicine, reminding ourselves of their contextual origin, as well as existing evidence and limits to their use. It is up to you to judge whether they remain relevant in your clinical practice., Competing Interests: Les auteurs déclarent n’avoir aucun conflit d’intérêts lié au présent article.

Cardiopulmonary resuscitation (CPR) guidelines have been updated in October 2015. The 2010 guidelines are reaffirmed: immediate call for help via the local dispatch center, high quality CPR (frequency between 100 and 120/min, compression depth between 5 and 6 cm) and early defibrillation improve patient's survival chances. This article reviews the essential elements of resuscitation and recommended advanced measures.

The year 2015 was marked by several publications questioning the practice of emergency medicine. The systematic administration of oxygen in STEMI patients offers no benefit. Similarly, medical expulsive therapy in patients with ureteric stones was questioned. Administration of steroids for acute radiculopathy showed only short-term, but no mid-term pain improvement. Several studies have demonstrated the benefit combining intraarterial and intravenous thrombolytic therapy for ischemic stroke. However, studies assessing optimal management strategy for patients hospitalized with community acquired pneumonia, showed conflicting results. Finally, these developments occur in the context of an aging population and increase of pre-hospital management for the elderly, raising the question of how to reduce hospital admissions in this population.

Demographic evolution results in a growing use of emergency department by elderly patients. They require special care to avoid any further degradation of cognitive and functional abilities already compromised by the disease or injury that led them to hospital in the first place. Through a clinical case, we list the risks related to the care of these particular patients in the emergency department. Early recognition of those risks and careful management of these patients' specific needs can significantly contribute to reduce lengths of stay, an important outcome from both the individual patient's and society's perspective.

In elderly patients, a blunt trauma of the chest is associated with a significant risk of complications and mortality. The number of ribs fractures (≥ 4), the presence of bilateral rib fractures, of a pulmonary contusion, of existent comorbidities or acute extra-thoracic traumatic lesions, and lastly the severity of thoracic pain, are indeed important risk factors of complications and mortality. Their presence may require hospitalization of the patient. When complications do occur, they are represented by alveolar hypoventilation, pulmonary atelectasia and broncho-pulmonary infections. When hospitalization is required, it may allow for the specific treatment of thoracic pain, including locoregional anesthesia techniques.

The neurogenic shock is a common complication of spinal cord injury, especially when localized at the cervical level. Characterized by a vasoplegia (hypotension) and bradycardia, the neurogenic shock is secondary to the damage of the sympathetic nervous system. The clinical presentation often includes tetraplegia, with or without respiratory failure. Early treatment aims to minimize the occurrence of secondary spinal cord lesions resulting from systemic ischemic injuries. Medical management consists in a standardized ABCDE approach, in order to stabilize vital functions and immobilize the spine. The hospital care includes performing imaging, further measures of neuro-resuscitation, and coordinated surgical assessment and treatment of any other injury.

New evidences published this year are susceptible to change the management of several medical emergencies. Combined antiplatelet therapy might be beneficial for the management of TIA or minor stroke and rapid blood pressure lowering might improve the outcome in patients with intracerebral hemorrhage. A restrictive red cell transfusion strategy is indicated in case of upper digestive bleeding and coagulation factors concentrates are superior to fresh frozen plasma for urgent warfarin reversal. Prolonged systemic steroid therapy is not warranted in case of acute exacerbation of BPCO, and iterative physiotherapy is not beneficial after acute whiplash. Finally, family presence during cardiopulmonary resuscitation may reduce post-traumatic stress disorder among relatives.

Mushroom poisoning is a regular complaint for consultation in emergency facilities. These situations are usually benign and symptomatic treatment is sufficient. However, severe damage can occur, potentially life-threatening. We review the various syndromes associated with the toxins involved, their management and the major signs that are suggestive of serious injury and requiring hospitalization.

The notion of "First Responder" (FR) refers to the system of first-aid volunteers who act to initiate the first-aid care before the classical emergency help arrives. In 2011, the French-speaking Switzerland counts 19 groups, divided up between four cantons (Fribourg, Vaud, Neuchâtel, Valais). The geographical distribution of those FR shows the stakes of these peripherical areas, with the accessibility difficulties for the emergency services, and a low demography of ambulances and doctors. The number of interventions carried out by the FR has significantly increased during the last years. The association of a quality formation, an excellent knowledge of the ground and a quick intervention has a positive impact on the survival of the patients with vital emergency or traumatic conditions.

We review some of the most influential papers from 2012 in the different aspects of emergency medicine, such as prehospital medicine, resuscitation, early diagnosis and timely ED discharge and treatment. In particular, intramuscular benzodiazepines have been shown to be efficient in prehospital status epilepticus, epinephrines usefulness in cardiopulmonary resuscitation has been challenged, colloids have been shown to be deleterious in the treatment of severe sepsis and septic shock, the time window for thrombolysis in acute stroke will probably be extended, acute pyelonephritis treatment duration can be decreased, new D-dimers thresholds for older patients may prevent further diagnosis tests, and hs-Troponin may allow earlier discharge of low coronary risk patients.

Professionalisation of emergency medicine and triage before most of emergency consultations led to a major reduction in exposure of general practitionners (GP) to vital emergencies, which participates in reduction of their aptitudes to manage such emergencies. The risk for a GP to face a vital emergency is weak nowaday, but did not totaly disappear. Therefore, it seems important for the GPs to maintain the skills required to manage these emergencies properly. These skills would be capacity in recognizing symptoms and signs of alarm (red flags), applying life support, and sorting the patients correctly. These skills will be all the more important in the future, while the role of the GP could be reinforced in response to requirement of increased efficiency.

Emergency departments are and will be at the front line to face the forthcoming increased use of the health care system by the aging baby boomers cohort. Emergency department services will need to adjust on a quantitative as well as on a qualitative basis to manage the impact of these demographic changes. Various models of care have been developed to improve the care of older geriatric patients in the Emergency department that resulted in favorable results on functional, health, as well as health services utilization outcomes. Key components of these successful models have been identified that require a high level of integration between geriatric and emergency teams.

Geriatric patients presenting to the ED are at high risk of mortality as well as of cognitive or functional decline. Thus, ED is an ideal spot for interventions that can improve their outcome. In this article, we summarize six recent studies, regarding the utilization of prognostic evaluation scores in geriatric patients presenting to the ED, adverse drug reactions, the significance of elevated troponin in patients who have remained on the ground after a fall, the rationale of performing head CT in patients without focal neurologic findings after a fall, the ideal treatment of a proximal femoral fracture and the excessive use of urinary catheters in the ED.

Emergency medicine physicians aim to stabilize or restore vital functions, establish diagnosis, initiate specific treatments and adequately orientate patients. This year, new evidences have improved our knowledge about diagnostic strategy for patients with acute non traumatic headache, treatment of acute atrial fibrillation and outpatient management of acute pulmonary embolism. Reducing injection pain of local anesthetics, reducing irradiation by using alternative diagnostic tools in appendicitis suspicion, and identification of trauma patients who benefit from tranexamic acid administration are other illustrations of the efforts to improve efficacy, safety and comfort in the management of emergency patients.

Upper gastrointestinal bleeding is a potentially serious event, usually requiring urgent endoscopic treatment. Better stratification of the risk of complication or death could optimize management and improve patient outcomes, while ensuring adequate resource allocation. Several prognostic scores have been developed, in order to identify high risk patients, who require immediate treatment, and patients at low risk for whom endoscopy may be delayed. An ideal prognostic score should be accurate, simple, reproducible, and prospectively validated in different populations. Published scores meet these requirements only partially, and thus can only be used as part of an integrative diagnostic and therapeutic process.

Hypoglycemia is a potentially serious complication of insulin therapy. Some insulin-dependent diabetic patients can benefit from continuous subcutaneous insulin infusion therapy (an "insulin pump"), which in most case improves glycemia control and decreases the occurrence of hypoglycemic episodes. However, such events may occur, particularly during initial treatment phases or pregnancy. Severe hypoglycemia is mainly managed by stopping the insulin pump and insuring an adequate carbohydrate intake. Patients with insulin pumps and their entourage should receive specific instruction in the adjustment of pump flow in the presence of dysglycemia-inducing circumstances (illness, physical exertion), as well as in anticipation of high-risk situations, such as motor-vehicle driving.

Several scores with predictive value for morbidity or mortality have been published this year. Their current purpose is to improve the direction of admissions and lengths of stay in hospital. Their use permits more directed care, especially for the elderly, and therefore could improve the proper orientation and admission of patients. Also this year, certain procedures are undergoing evaluation, namely: new assays for troponin, and non-contrast CT in the diagnosis of acute appendicitis. Furthermore in the therapeutic realm: the importance of cardiac massage and the advantages of therapeutic hypothermia in cardiac arrest, and the efficacy of oxygen therapy in cluster headache.

Major burns are characterized by an initial capillary leak which requires fluid resuscitation for hemodynamic stabilisation. While under-resuscitation was the major cause of death until the 80ies, over-resuscitation has become an important source of complications: abdominal compartment syndrome, escharotomies, impaired gas exchange and prolonged mechanical ventilation and hospital stay. The fluid creep started in the 90ies with an increasing proportion of the first 24 hours' fluid delivery above the 4 ml/kg/% BSA Parkland prediction. The first alerts were published under the form of case reports of increased mortality due to abdominal compartment syndrome and respiratory failure. The paper analyses the causes of this fluid creep, and the ways to prevent it, which includes rationing prehospital fluid delivery, avoiding early colloids and permissive hypovolemia.

Cocaine use, often not recognized, is a frequent cause of consultation in the emergency room or by primary care physicians. The use of cocaine causes numerous cardiovascular and pulmonary side effects. In this context, the occurrence of a pneumothorax represents a specific complication, often misunderstood by primary care physicians. We describe here three cases of patients who suffered from subcutaneous emphysema and pneumothorax after taking cocaine and emphasize the importance of always keeping in mind the possibility of illicit substance use in such cases, especially among young and healthy patients.

Emergency medicine is a cross-discipline characterized by its ability to identify critical threats, as well as its ability to prioritize investigations and identify appropriate treatments. Recent publications have been published on upper gastrointestinal haemorrhage, elbow fracture or brain haemorrhage, to optimize and standardize the investigations. In parallel, conditions such as cardiopulmonary arrest, spontaneous pneumothorax or stroke, benefit from recent therapeutic advances. However, emergency physicians and primary care physicians must remain critical of the numerous medical publications, as evidenced by the contradictory results concerning the interaction between proton pump inhibitors and clopidogrel.

The emergency medicine appears more and more as a transversal discipline, leaning on specific competences regularly updated with evidence-based medicine concepts. This selection of recent articles presents an update on frequent conditions, including the place of neuroimaging for patients with seizures or minor head injuries, the management of acute cocaine intoxications, the diagnosis of aortic dissections, or the management of cardiopulmonary arrest. The primary care physician will find elements of diagnostic or therapeutic strategies. This selection reflects the dynamism of emergency medicine.

Pyoderma gangrenosum is a rare ulcerative disease associated with inflammatory bowel disease, arthritis or haematological malignancies. The diagnosis of Pyoderma gangrenosum is often delayed while consideration is given to the more likely diagnoses of wound breakdown or bacterial infection. The outcome depends on early diagnosis and on excellent collaboration between the surgical team and the infectious disease specialist. We present two puzzling cases of Pyoderma gangrenosum and discuss the physiopathology, the diagnosis strategy and the management.

The study of dynamics in relation to performing in small groups has increased pedagogic knowledge about teamwork. The successful management of patients with life-threatening pathologies depends highly from a succession of teams with a specific mission as: the call centre 144, Paramedics, the ED, the Operating Theatre and the Intensive care. To enable each team to operate successfully, it is essential to coordinate their qualifications and synergism. This can be efficiently attained by simulating real situations and by following protocols dedicated to teamwork. Emergency Medicine, which is on the brink of acquiring its proper curriculum, must adopt this concept to integrate knowledge and know-how, and the art of being and doing. At this stage, the Emergency Physician will have the competence which will enable him to be a real "team leader".

Due to actual demographic evolution, emergency departments have to face a dramatic increase in admissions of elderly people. The peculiar medical and socio-demographic characteristics of these old patients emphasize the need of specific decision processes and resources allocation. An individual-based approach, related to significant ethical values, should allow better diagnostic and therapeutic attitudes. Such a way to admit, evaluate and treat older patients implies an active collaboration with patients and their relatives, but also with all medical interveners, including in particular primary care physicians.