2018 - volume 73 (5-6)
|Cardiac and vascular emergencies: from diagnosis to treatment|
|From atherosclerosis to atherothrombosis : from a silent chronic pathology to an acute critical event|
Rev Med Liege 2018, 73(5-6),224-228
Summary : Cardiovascular disease still represents, together with cancer, a major cause of morbidity and mortality. Atherosclerosis is a silent progressive process, which can start in early life and usually progresses with advancing age. Besides genetic predisposition, atherosclerosis is accelerated by the presence of several modifiable risk factors such as smoking, dyslipidaemia, arterial hypertension and diabetes mellitus. Asymptomatic atherosclerosis may lead to an acute event, mostly due to plaque rupture and secondary thrombosis. If the thrombus is occlusive, according to the artery where it occurs, the acute complication involves most often an acute coronary event or an ischaemic stroke. Major cardiovascular events (MACEs) represent the primary outcome in a majority of clinical trials. Some populations, as patients with type 2 diabetes, are especially prone to these complications due to atherothrombosis linked to subclinical accelerated atherosclerosis. In most cases, an emergency intervention is mandatory to avoid premature death or irreversible sequelae.
|Advanced nurse triage for emergency department|
Jobé J , Ghuysen A , D’Orio V
Rev Med Liege 2018, 73(5-6),229-236
Summary : To cope with overcrowding, a consequence of their constant growth, emergency departments have implemented operational strategies based on triage systems. Despite its interest, nurse triage has been limited by several hindrances, and new strategies are emerging. Among those, advanced nurse triage, allowing a nurse to initiate the diagnostic process just after categorization of the patient, seems to be promising. A study on advanced nurse triage for patients presenting with chest pain has been conducted in the emergency department of the CHU of Liège. The encouraging results obtained following this new system demonstrate a reduction of the delay to management of patients, and a reduction of the total length of stay in the emergency unit mainly during overcrowding periods. Advanced nurse triage, in addition to a conventional triage during overcrowding periods, improves management of patients in terms of time and reduces the total time spent in the emergency department.
|Syncope in the emergencry room: Differential diagnosis and risk stratification|
Marechal P , Scheen AJ , Lancellotti P
Rev Med Liege 2018, 73(5-6),237-242
Summary : Syncope is one of the most common reasons of emergency admission and hospitalisation. Management of syncope remains challenging for the medical staff as there are a multitude of possible etiologies ranging from benign to potentially life-threatening causes. Historically, 30-40% of patients presenting for syncope are hospitalized for further exploration, resulting in a significant cost to health care. The purpose of this article is to clarify the etiologies of syncope and to stratify their risk for a better managment.
|Acute coronary syndrome|
Gach O , El Husseini Z , Lancellotti P
Rev Med Liege 2018, 73(5-6),243-250
Summary : Acute coronary syndromes represent a major cause of mortality in our country. There is a very wide spectrum of clinical presentation since the actual classification of acute coronary syndromes is based on electrocardiographic presentation, that is to say based on absence or presence of ST segment elevation. When dealing with an acute chest pain, once the probability of acute coronary syndrome is established, the emergency care must follow the scientific guidelines. One of the critical steps is represented by the evaluation of ischaemic and hemorrhagic risk in order to tailor optimally antithrombotic and anticoagulation therapies and revascularization timing. This article summarizes the main points of the emergency care from the diagnosis to risk stratification.
|Acute heart failure and acute pulmonary edema|
D’orio V , Ancion A , Lancellotti P
Rev Med Liege 2018, 73(5-6),251-256
Summary : Acute heart failure is a common cause of admission in emergency department. Management requires rapid support when haemodynamic or respiratory parameters are altered. Identifying enabling factors and their specific treatment is an integral part of management. The most common clinical presentation is volume overload, whose treatment remains the combination of diuretics and vasodilators. In case of impaired perfusion, various inotropic supports may be considered, but also more and more circulatory assistance devices.
|Severe cardiac arrhythmias|
Robinet S , Van Casteren L , Delcour A , Lancellotti P
Rev Med Liege 2018, 73(5-6),251-256
Summary : Cardiac arrhythmias are a common cause of admission in the emergency department. Among these, atrio-ventricular conductive disorders and malignant ventricular arrhythmias are among the most severe, requiring prompt and appropriate management to ensure the best prognosis. Knowledge of the pathophysiology and etiology causing these arrhythmias is mandatory in order to understand its management, acute and chronic, and to facilitate the dialogue between emergency physicians and cardiologists.
|Update on myocarditis|
Moonen M , Lancellotti P
Rev Med Liege 2018, 73(5-6),269-276
Summary : Myocarditis is an illness characterized by myocardial infiltration with inflammatory cells and non-ischemic myocytic necrosis. The clinical presentation of myocarditis varies widely and diagnosis is sometimes difficult to establish. The current incidence of myocarditis is also difficult to determine as endomyocardial biopsy, the diagnostic gold standard, is unfrequently used, or even not justified. The leading causes are infections, immune-mediated injury and toxins. Prognosis is most often good but, in some patients, the disease can be fulminant with progression to cardiogenic shock, or occurrence of sudden cardiac death. Prognosis in myocarditis patients varies according to the underlying aetiology. Treatment is generally symptomatic, but in some cases, a specific therapy is appropriated as a function of the corresponding aetiology. This paper aims to review current knowledge concerning myocarditis, with particular emphasis on «urgent» situations.
Ancion A , Robinet S , Lancellotti P
Rev Med Liege 2018, 73(5-6),277-282
Summary : Cardiac tamponade is a vital emergency. It occurs when the accumulation of intra-pericardial fluid exceeds the pericardial adaptation capacity. Pericardial pressure is equalized with that of cardiac cavities and severe heart failure occurs, most often rapidly. Several clinical presentations are possible. The diagnosis is based on the assessment of pericardial effusion and its impact on the heart by echocardiography. Supportive treatments have limited effectiveness. The only emergency treatment is drainage of the pericardium by direct puncture or by surgical approach.
|Infective endocarditis:an emergency well too minimized|
Marchetta S, Dulgheru R , Oury C , Frippiat F , Lancellotti P
Rev Med Liege 2018, 73(5-6),283-289
Summary : Infective endocarditis is a rare disease that can lead to some diagnostic wandering because of its often nonspecific and polymorphic clinical manifestations. This latency is at the origin of severe cardiac and extra-cardiac complications, yet highly fatal. The clinician should always bear in mind the differential diagnosis of a patient with fever of undetermined origin, with risk factors for valve infection such as foreign material, and history recent invasive procedures (including dental procedures) or recent hospitalization. The current medical tools make it possible to highlight the infection and its complications in a fast and complete manner, so as not to delay the patient’s management, particularly with the introduction of urgent empirical antibiotherapy.
Tchana-Sato V , Sakalihasan N , Defraigne JO
Rev Med Liege 2018, 73(5-6),290-295
Summary : Aortic dissection is a life-threatening condition due to a tear in the intimal layer of the aorta or bleeding within the aortic wall, resulting in the separation of the different layers of the aortic wall. Among the risk factors, age, hypertension, dyslipidemia and genetic disorders of the connective tissue have been identified. A prompt diagnosis and an adequate treatment are important in the management of affected patients. The type of treatment depends on the location and extension of the dissection. Open surgical repair is most commonly used for dissections involving the ascending aorta and the aortic arch, whereas endovascular intervention is indicated for descending aorta dissections that are complicated. In this paper, we will review the epidemiology, and physiopathology of aortic dissection and describe the appropriate management for each type of dissection (open surgery, endovascular or medical treatment).
|Ruptured abdominal aortic aneurysm|
Tchana-Sato V , Sakalihasan N , Defraigne JO
Rev Med Liege 2018, 73(5-6),296-299
Summary : Ruptured abdominal aortic aneurysm is a cardiovascular emergency associated with a 30 day mortality as high as 70 %. However, recent progresses in the management of these patients have improved the results. From a surgical point of view, endovascular methods such as balloon occlusion and endovascular repair (EVAR) in patients with suitable anatomy are recommended in order to reduce mortality.
|Acute mesenteric ischemia|
Kerzmann A , Haumann A , Boesmans E , Detry O , Defraigne JO
Rev Med Liege 2018, 73(5-6),300-303
Summary : Acute mesenteric ischemia is a real life-threatening emergency. Mode of presentation is severe abdominal pain with sudden onset. The etiology is most of the time embolus coming from the heart or thrombosis of atherosclerotic vessel wall concerning the superior mesenteric artery. The best investigation is computed tomography with intravenous contrast media injection. Treatment consists of revascularization by open surgery or endovascular approach. Bowel resection may be necessary, as well as delayed second look surgery. This paper aims to review etiologies and therapeutics options for acute mesenteric ischemia.
|Acute limb ischemia|
Van Damme H , Boesmans E , Defraigne JO
Rev Med Liege 2018, 73(5-6),304-311
Summary : Despite major advances in the contemporary management of peripheral arterial occlusive disease, acute ischemia of the lower limb is still characterized by an important morbidity, limb threat, and mortality, and continues to pose a challenge to the vascular surgeon. Ageing of the population increases the prevalence of acute lower limb ischemia. The two principal etiologies of acute ischemia of the lower limbs are arterial embolism and in situ thrombosis of an atherosclerotic artery or of a bypass graft. Popliteal aneurysm thrombosis and vascular trauma are less common causes of severe limb ischemia. Prompt recognition and treatment of acute limb ischemia in an urgent setting are crucial, in order to shorten as much as possible the duration of the ischemia. This paper highlights diagnostic work-up (staging of the severity of ischemia) and appropriate management of acute ischemia of the lower limb. Different procedures of revascularization (operative clot removal, catheter-directed thrombolysis, bypass grafting are evaluated and their outcome results are compared.
|Lower limb venous thrombosis : Management in the acute phase|
Rev Med Liege 2018, 73(5-6),312-318
Summary : Venous thromboembolism is the third cardiovascular disease in Europe. The cornerstone of the treatment of deep vein thrombosis is anticoagulation. It aims at avoiding harmful complications : thrombosis extension and recurrence, pulmonary embolism and post-thrombotic syndrome. Due to low molecular weight heparins, and recently, to direct oral anticoagulants, most of the patients can get treatment as outpatients. Unfortunately, despite guideline publications, the management of these patients may be complicated in real life and not correspond to evidence-based medicine. This paper aims at helping the practitian when dealing with this potentially dangerous and often misleading disease. The management of the patient after a 3 to 6-month coagulation treatment will be discussed later in a dedicated paper.
|Acute pulmonary embolism : about paradox, judgments and evidences|
Ancion A , Lopez R , D’Orio V , Ghuysen A, Zandona R
Rev Med Liege 2018, 73(5-6),319-325
Summary : Pulmonary embolism (PE) is the third most common cardiovascular disease in industrialized countries. Multiple clinical presentations and non-specific symptoms lead to frequents misdiagnosis. Using and plan therapeutic and admission versus discharge strategies.
Xhignesse P , Krzesinski F , Krzesinski JM
Rev Med Liege 2018, 73(5-6),326-332
Summary : Hypertensive crisis has fortunately become rarer due to a better diagnosis and management of arterial hypertension. However, its development needs urgent management with adapted therapy according to the severity of the blood pressure levels and the associated clinical signs. After confirmation of severe hypertension (blood pressure above or equal to 180/120 mmHg), target organ lesions have to be looked for and according to their pre-sence, an urgent hospitalization has to be immediately organized. Starting active drug therapy often occurs in intensive units with the intravenous route of administration.
|Clinical management of acute stroke|
Ly J , Maquet P
Rev Med Liege 2018, 73(5-6),333-337
Summary : Stroke management dramatically changed during the last decades. Evidence shows that an early admission in a stroke unit offers the best chance of recovery to the stroke patient. The most spectacular aspect of the stroke unit activity consists of the hyperacute diagnostic and therapeutic stroke procedures, including prompt neuroimaging, intravenous thrombolysis and mechanical thrombectomy.
|The management of unruptured intracranial aneurysms|
Martin D , Otto B , Darsaut T , Scholtes F
Rev Med Liege 2018, 73(5-6),338-343
Summary : The rupture of an intracranial aneurysm is a sudden, unpredictable and potentially severe event. The responsible aneurysm has to be excluded from the cerebral circulation to avoid recurrence. More and more commonly, intracranial aneurysms are detected by coincidence. How to react to these fortuitous discoveries is unclear, because the risk of rupture is difficult to estimate. We present our approach to patients facing this situation and the decision-making process.
|Subarachnoid hemorrhage resulting from a ruptured aneurysm : management in an emergency department|
Mayele M’Peko Osawa F , Bertrand X
Rev Med Liege 2018, 73(5-6),344-350
Summary : Subarachnoid hemorrhage is a neurovascular emergency affecting relatively young adults. A ruptured cerebral aneurysm is the main non-traumatic cause. Except for the non-specific symptom of headache, which frequently occurs in subarachnoid hemorrhage, the clinical presentation is atypical, making the diagnosis difficult with possible dramatic consequences. The diagnosis is based on the CT scan without contrast, which, when negative, will be followed by a lumbar puncture. The etiologic analysis is based on an urgent arteriography, revealing the characteristics of the aneurysm such as the anatomy of the intracerebral vessels, the identification of the bleeding site and the size and location of the aneurysm. The main complications are bleeding relapse, hydrocephaly and vasospasm. Early treatment is based on the final repair of the aneurysm through two possible approaches: microvascular neurosurgical clipping or coiling via endovascular access. This article discusses the diagnostic and therapeutic aspects of subarachnoid hemorrhage.