[How to distinguish between illness, injury or intoxication in the emergency unit?]

BACKGROUND

Clinical judgement of intoxicated patients is difficult. In the emergency department of the inner city of Oslo this is done every day.

MATERIAL AND METHODS

During a one-year period from 1998-99, a group of 429 first-time admitted intoxicated patients were included in a study. The patients and the method of observation are described.

RESULTS

75% of the patients were men; 45% reported to have consumed alcohol only, while 10% had taken a heroin overdose. The rest had used various combinations of legal and illegal drugs. Female patients were younger than male patients (29 versus 36 years, p < 0.00), and patients intoxicated only on alcohol were on the average older than patients who had taken drugs (38 versus 31 years, p < 0.00). 57 patients were hospitalized, seven of them had serious intracerebral conditions.

INTERPRETATION

Our study indicates that systematic observation over some hours, repeated clinical examinations, and the systematic use of a modified Glasgow Coma Scale makes it possible to sort out the seriously ill from "only" intoxicated patients.

[Diclofenac in the short-term prevention of recurrent colic from ureteral calculi. A placebo controlled double-blind study]

We have conducted a double-blind randomised placebo controlled trial with oral diclofenac to study the prophylactic effect on recurrence of renal colic and rate of spontaneous stone expulsion. 41 patients were given 50 mg oral diclofenac three times a day for seven days after being discharged for a colic episode from Oslo Emergency Hospital and 39 patients were given matching placebo tablets. The number of new ureteral colic episodes per accumulated patient treatment days was 64/287 in the diclofenac group and 119/273 in the placebo group (p < 0.01). The difference was greatest during the first four days of treatment. A similar trend was found for pain intensity, with the greatest difference on day one. There was no difference in reported type or frequency of side effects in the two treatment groups. Stone expulsion rate was almost identical. The effect of the treatment was not affected by fluid intake. Re-admission rates to Oslo Emergency Hospital or other hospitals were 10 and 67% (p < 0.001).

Intramuscular diclofenac versus intravenous indomethacin in the treatment of acute renal colic

OBJECTIVE

We have conducted a clinical trial to compare the pain-relieving effect and safety of diclofenac administered intramuscularly to indomethacin given intravenously.

METHODS

The study was designed as a randomized single-blind trial. It was carried out at Oslo Emergency Hospital (outpatient setting or stay < 24 h). 41 patients with a mean age of 41.6 years received 75 mg diclofenac and 42 patients with a mean age of 45.2 years were given 50 mg indomethacin. The two groups were similar in regard to baseline characteristics except gender distribution.

RESULTS

Statistically significant reduction in pain intensity was achieved after 5 min in the diclofenac group (p < 0.01), and after 10 min in the indomethacin group (p < 0.01). The probability of having pain after 1 h was 52% in the indomethacin group and 37% in the diclofenac group (p = 0.11). Rescue medication with pethidine after 2 h was given in 9 and 5 patients, respectively. Four patients in the diclofenac group reported one occurrence of adverse effect each, while 9 patients on indomethacin experienced 14 occurrences, mainly dizziness and nausea.

CONCLUSION

These findings together with a simpler mode of administration indicate that diclofenac may be preferred in the analgesic treatment of renal colic.

Oral diclofenac in the prophylactic treatment of recurrent renal colic. A double-blind comparison with placebo

We have conducted a double-blind, randomized, placebo-controlled trial with oral diclofenac to study the prophylactic effect on renal colic recurrence and spontaneous stone expulsion rate. Forty-one patients were given 50 mg oral diclofenac 3 times a day for 7 days after being discharged for a colic episode from Oslo Emergency Hospital (< 24 h stay) and 39 patients were given matching placebo tablets. The number of new renal colic episodes per accumulated patient treatment days was 64/287 in the diclofenac group and 119/273 in the placebo group (p < 0.01). This difference was greatest during the first 4 treatment days. A similar trend was found for pain intensity (0-10 cm VAS) with the greatest difference on day 1 (4.3 vs. 2.8, p = 0.05). Side effects, mainly gastrointestinal, were reported for 14% of the treatment days in both treatment groups. Stone expulsion rate was almost identical (28 vs. 29 days), regardless of stone size. Readmission rate to Oslo Emergency Hospital/other hospitals were 10 and 67% (p < 0.001). In conclusion, oral treatment with diclofenac was effective as short-term prophylaxis of new colic episodes, especially during the first 4 days, and reduces the number of hospital readmissions significantly. The stone passage rate appears not to be affected.

[Ambulatory evaluation and treatment of blunt thoracic injuries]

307 patients with chest injuries were treated in an outpatient clinic during a three month period. Ten patients developed complications such as hemothorax, pneumothorax and lung contusion, or late complications such as atelectases and pneumonia. 21 patients were hospitalized after initial evaluation. Two patients died. Pain was a symptom in 306 of the 307 patients. Other symptoms were coughing, hempoptysis, fever, nausea. Complications increased in 40 patients, with other symptoms or signs in addition to pain. These other symptoms had a 40% positive and 95% negative predictive value as regards complications. 45 out of 114 patients had a pathological chest x-ray. Positive chest x-ray had a 40% positive and 94% negative predictive value as regards complications. In four patients (1.3%) complicating injuries were not identified initially. Five of 24 patients (21%) were hospitalized unnecessarily. Chest x-ray should be performed in patients with additional symptoms and signs. Patients with no signs in addition to chest wall tenderness can be observed at home.

[Blunt thoracic injuries in Oslo]

All 327 patients treated in Oslo City Hospital for blunt chest injuries during a period of three months were registered prospectively. 274 were treated outside hospital. Traffic accidents accounted for 10% of the total number of patients, but 40% of the hospitalized patients. Accidents in the home were most numerous, with many complications and admissions to hospital. 20% of the hospitalizations, were for injuries due to violence. The registration indicates more than 1,300 patients with chest injuries per year, of whom more than 40 are severely multitraumatized. The chest injury was serious in 21 patients, moderate in 306. 13.5% of the cases were complicated by pneumo-hemothorax and lung contusion, or by late complications such as pneumonia and atelectases. Seven patients (2.1%) died. These were old, physically disabled or multitraumatized. 100 patients had extrathoracic injuries, of whom 15 had intrathoracic injuries as well. In 227 patients with thoracic injuries only, the injuries were intrathoracic in six of them. The mortality in patients with chest wall injuries only was 0.7%, as compared with 20% in patients with intrathoracic injuries.