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La Société française de médecine d'urgence a élaboré en 2016 des recommandations formalisées d'experts définissant le premier niveau de compétence en échographie clinique en médecine d'urgence. Ce niveau est maintenant complété par un deuxième niveau correspondant à une pratique plus avancée utilisant des techniques non envisagées dans le premier niveau comme l'utilisation du Doppler et nécessitant aussi une pratique et une formation plus poussées. Des champs déjà présents dans le premier référentiel sont complétés, et de nouveaux champs sont envisagés. La méthodologie utilisée est issue de la méthode « Recommandations par consensus formalisé » publiée par la Haute Autorité de santé et de la méthode Delphi pour quantifier l'accord professionnel. Ce choix a été fait devant l'insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l'existence de controverses. Ce document présente les items jugés appropriés et inappropriés par les cotateurs. Ces recommandations définissent un deuxième niveau de compétence en ECMU.

ObjectiveTo determine whether copeptin-us can rule out diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) without prolonged monitoring and serial blood sampling in patients with high-sensitive cardiac troponin I (hs-cTnT) below the 99th centile at presentation to the emergency department (ED).DesignProspective, non-randomised, individual blinded diagnostic accuracy study.SettingTwo EDs of a rural region of France.ParticipantsPatients with chest pain suspected of NSTEMI with onset within the last 12 h were considered for enrolment.InterventionsSerial clinical, electrographical and biochemical investigations were performed at admission and after 2, 4, 6 and 12 h. Hs-cTnT was measured using an assay with Dimension VISTA, Siemens. Copeptin was measured by the BRAHMS copeptin-us assay on the KRYPTOR Compact Plus system. The follow-up period was 90 days.Primary and secondary outcome measuresCopeptin, troponin, myoglobin and creatine kinase values. Clinical and paraclinical events. The final diagnosis was adjudicated blinded to copeptin result.ResultsDuring 12 months, 102 patients were analysed. Final diagnosis was NSTEMI for 7.8% (n=8), unstable angina for 3.9% (n=4), cardiac but non-coronary artery disease for 8.8% (n=9), non-cardiac chest pain for 52% (n=53) and unknown for 27.5% (n=28). There was no statistical difference for copeptin values between patients with NSTEMI and others (respectively 5.5 pmol/L IQR (3.1–7.9) and 6.5 pmol/L IQR (3.9–12.1), p=0.49). Only one patient with NSTEMI had a copeptin value above the cut-off of 95th centile at admission.ConclusionsIn this study, copeptin does not add a diagnostic value at admission to ED for patients with suspected acute coronary syndrome without ST-segment elevation and with hs-cTnT below the 99th centile.Trial registration numberClinicaltrials.gov identifier: NCT01334645.

Background For the elderly population living at home, the implementation of professional services tends to mitigate the effect of loss of autonomy and increases their quality of life. While helping in avoiding social isolation, home services could also be associated to different healthcare pathways. For elderly patients, Emergency Departments (EDs) are the main entrance to hospital where previous loss of autonomy is associated to worst hospital outcomes. Part of elderly patients visiting EDs are still admitted to hospital for having difficulties coping at home without presenting any acute medical issue. There is a lack of data concerning elderly patients visiting EDs assisted by home services. Our aim was to compare among elderly patients visiting ED those assisted by professional home services to those who do not in terms of emergency resources’ use and patients’ outcome. Methods A multicenter, prospective cohort study was performed in 124 French EDs during a 24-h period on March 2016.Consecutive patients living at home aged ≥80 years were included. The primary objective was to assess the risk of mortality for patients assisted by professional home services vs. those who were not. Secondary objectives included admission rate and specific admission rate for “having difficulties coping at home”. The primary endpoint was in-hospital mortality. Cox proportional-hazards regression model was used to test the association between professional home services and the primary endpoint. Multi variables logistic regressions were performed to assess secondary endpoints. Results One thousand one hundred sixty-eight patients were included, median age 86(83–89) years old,32% were assisted by professional home services. The overall in-hospital mortality rate was 7%. Assisted patients had more investigations performed. Home services were not associated with increased in-hospital mortality (HR = 1.34;95%CI [0.68–2.67]), nor with the admission rate (OR = 0.92;95%CI [0.65–1.30]). Assisted patients had a lower risk of being admitted for “having difficulties coping at home” (OR = 0.59;95%CI [0.38–0.92]). Conclusion Professional home services which assist one-third of elderly patients visiting EDs, were not associated to lower in-hospital mortality or to an increased admission rate. Assisted patients were associated to a lower risk of being admitted for «having difficulties coping at home».Professional home services could result in avoiding some admissions and their corollary complications. Trial registration Clinicaltrial.gov - NCT02900391, 09/14/2016, retrospectively registered

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