On évoque souvent le diagnostic de l’hémorragie sous-arachnoïdienne chez les patients qui se présentent à l’urgence pour un mal de tête violent et soudain, mais dont l’examen physique est normal. La norme de soins de nos jours consiste à soumettre ces patients à une tomodensitométrie (TDM) sans substance de contraste suivie d’une ponction lombaire pour les TDM négatives. Cependant, comme la plupart des céphalées évaluées sont bénignes, la plupart des résultats de la TDM et de la ponction lombaire sont normaux.

Le présent article a pour but d’analyser l’impact d’un protocole diagnostique de rechange, où la ponction lombaire serait la première (et dans la plupart des cas, la seule) épreuve diagnostique effectuée chez les patients chez qui l’on soupçonne une hémorragie sous-arachnoïdienne et qui présentent ce symptôme isolé de mal de tête violent. Selon une hypothèse raisonnable, pour chaque 100 patients évalués, le protocole de «ponction lombaire en premier» nécessiterait 81 TDM de moins et seulement 9 ponctions lombaires additionnelles, comparativement à la stratégie diagnostique traditionnelle. Ces avantages demeurent stables même en variant les hypothèses à l’intérieur des limites cliniquement plausibles.

Nous croyons que ce protocole pourrait entraîner une utilisation beaucoup plus efficace des ressources en limitant le taux de morbidité additionnel, tout en offrant une précision diagnostique équivalente pour l’hémorragie sous-arachnoïdienne chez le patient à l’urgence qui répond au critère de mal de tête isolé violent et soudain.

Manure pits and silos are potentially dangerous, gas-containing confined spaces on the farm that may generate hazardous levels of hydrogen sulphide and nitrogen dioxide respectively. Although these inhalation injuries are uncommon, emergency physicians who work within transport distance of rural areas should be aware of the toxic agents involved and their acute management. This article reviews the toxicology, clinical manifestations and treatment of acute, farm-related hydrogen sulphide and nitrogen dioxide exposures.

A 41-year-old man was brought to the ED after a motor vehicle crash. On presentation, he demonstrated symptoms compatible with superior vena cava (SVC) syndrome, including extreme dyspnea, face and neck cyanosis and facial swelling. A chest tube was inserted and drained large amounts of sanguineous fluid. An exploratory thoracotomy revealed an extensive tumour encasing the SVC and the hilum. Biopsy confirmed the diagnosis of T-cell lymphoma.

The most common cause of SVC syndrome is malignant disease, with bronchogenic carcinoma and lymphoma being most frequent. Review of the literature uncovered only a few anecdotal reports of traumatic SVC syndrome. There are no previous reported cases of malignant SVC syndrome presenting in association with trauma.

A 37-year-old man with type I diabetes mellitus and chronic renal failure presented to the emergency department complaining of hallucinations. He was 5 days postoperative for left pars plana vitrectomy and intra-ocular lens implantation and had been taking ophthalmic atropine, tobramycin and prednisolone. He had presented 5 months earlier, on the same ophthalmic medications, with postoperative hallucinations after a right pars plana vitrectomy. Visual hallucinations are a major side effect of anticholinergic poisoning. Ophthalmic instillation of atropine has been documented to cause many central nervous sytstem symptoms, including hallucinations.

Diagnostic ultrasound (U/S) has been used in medicine for over 40 years, and reports describing the use of abdominal U/S in trauma date back to 1971. Recently, however, trauma ultrasonography has become a controversial issue in Canada.

U/S provides the speed and accuracy we associate with diagnostic peritoneal lavage (DPL) in a noninvasive format. It is safe, inexpensive, repeatable, accessible at the bedside, and requires little patient preparation. U/S is now the initial test for the assessment of blunt abdominal trauma in most European and Australasian centres. More recently U/S has become common in US trauma centres.

Although diagnostic imaging is, for the most part, the domain of radiologists, exceptions to this rule have developed. Cardiologists perform cardiac catheterization and echocardiography. Obstetricians have developed expertise in transvaginal ultrasound and fetal assessment. Why have some specialties embraced areas of imaging as theirs, while others — such as orthopedics and medicine — continue to rely on radiology? One reason is that radiologic expertise in these latter specialities is rarely required on a 24-hour basis and it can be provided without taking on an overwhelming workload. ED bedside ultrasonography, on the other hand, must be available 24 hours a day. Conditions requiring immediate (within 15 to 20 minutes) ultrasound (U/S) include expanding or leaking abdominal aneurysm, suspected ectopic pregnancy, and traumatic hemoperitoneum. When patients with these conditions are unstable they require even more rapid imaging — “real imaging” in the operating room.

Many published papers report excellent sensitivity, specificity and accuracy when non-radiologists employ ultrasound (U/S) to detect free intraperitoneal fluid in cases of blunt abdominal trauma (BAT). In this setting, it is best to view the FAST (focused abdominal sonogram in trauma) as a noninvasive diagnostic peritoneal lavage (DPL): It tells us whether there is free intraperitoneal fluid but does not determine the specific parenchymal injury. In other words it is a screening tool.

Practically speaking, bedside ultrasound is well within the scope of emergency physicians (EPs) and is gaining acceptance. The literature supports the use of limited, goal-directed ultrasound in the diagnosis of many emergent conditions. EPs should use ultrasound as a tool to answer specific questions (e.g., Is there blood in the belly?); they should not surf the body for clues. ED ultrasound offers rapid evaluation of potentially life-threatening conditions

Ah, the ultrasound controversy. Every emergency department (ED) that I’m aware of goes through this struggle. The radiology department resists the introduction of ultrasound (U/S) because, and I don’t want to oversimplify a complex issue, they are worried they will lose money.