A. Ricard-Hibon

Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial

BACKGROUND Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients. METHODS In this randomised, controlled, single-blind trial, 655 patients who needed sedation for emergency intubation were prospectively enrolled from 12 emergency medical services or emergency departments and 65 intensive care units in France. Patients were randomly assigned by a computerised random-number generator list to receive 0.3 mg/kg of etomidate (n=328) or 2 mg/kg of ketamine (n=327) for intubation. Only the emergency physician enrolling patients was aware of group assignment. The primary endpoint was the maximum score of the sequential organ failure assessment during the first 3 days in the intensive care unit. We excluded from the analysis patients who died before reaching the hospital or those discharged from the intensive care unit before 3 days (modified intention to treat). This trial is registered with ClinicalTrials.gov, number NCT00440102. FINDINGS 234 patients were analysed in the etomidate group and 235 in the ketamine group. The mean maximum SOFA score between the two groups did not differ significantly (10.3 [SD 3.7] for etomidate vs 9.6 [3.9] for ketamine; mean difference 0.7 [95% CI 0.0-1.4], p=0.056). Intubation conditions did not differ significantly between the two groups (median intubation difficulty score 1 [IQR 0-3] in both groups; p=0.70). The percentage of patients with adrenal insufficiency was significantly higher in the etomidate group than in the ketamine group (OR 6.7, 3.5-12.7). We recorded no serious adverse events with either study drug. INTERPRETATION Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis. FUNDING French Ministry of Health.

Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest.

BACKGROUND Diagnosis of acute coronary artery disease in survivors of out-of-hospital cardiac arrest (OHCA) is difficult. The role of emergency coronary angiography and percutaneous coronary intervention (PCI) in this setting is debated. The objective of this study was to assess the prevalence of coronary lesions on emergency angiography in survivors of OHCA. METHODS Seventy-two consecutive OHCA survivors underwent systematic emergency coronary angiography. Patients with critical stenoses or occlusion underwent ad hoc PCI. RESULTS Most (63.9%) OHCA survivors had angiographic coronary artery disease (> or =1 lesion >50%), but only a minority (37.5%) had clinical or angiographic evidence of an acute coronary syndrome due to either an acute occlusion (16.7%) or an irregular lesion suggestive of ruptured plaque or thrombus (25.0%). A final diagnosis of myocardial infarction was assigned in 27 patients (37.5%). Percutaneous coronary intervention was attempted and successful in 33.3% of the total cohort (n = 24). Hospital survival was 48.6%. By multivariable analysis, use of PCI was not an independent correlate of survival. ST-segment elevation on admission was an independent correlate of acute myocardial infarction (odds ratio 64.2, 95% CI 7.6-544.2, P = .0001), with high positive (82.6%) and negative (83.7%) predictive values. CONCLUSIONS A minority of OHCA patients has angiographic evidence of an acute coronary syndrome and one-third undergo PCI, but PCI is not an independent correlate of survival. The presence of ST elevation on admission was a strong independent correlate of acute myocardial infarction and may be used to triage OHCA patients to emergency angiography with a view to PCI.

Family Presence during Cardiopulmonary Resuscitation

BACKGROUND The effect of family presence during cardiopulmonary resuscitation (CPR) on the family members themselves and the medical team remains controversial. METHODS We enrolled 570 relatives of patients who were in cardiac arrest and were given CPR by 15 prehospital emergency medical service units. The units were randomly assigned either to systematically offer the family member the opportunity to observe CPR (intervention group) or to follow standard practice regarding family presence (control group). The primary end point was the proportion of relatives with post-traumatic stress disorder (PTSD)-related symptoms on day 90. Secondary end points included the presence of anxiety and depression symptoms and the effect of family presence on medical efforts at resuscitation, the well-being of the health care team, and the occurrence of medicolegal claims. RESULTS In the intervention group, 211 of 266 relatives (79%) witnessed CPR, as compared with 131 of 304 relatives (43%) in the control group. In the intention-to-treat analysis, the frequency of PTSD-related symptoms was significantly higher in the control group than in the intervention group (adjusted odds ratio, 1.7; 95% confidence interval [CI], 1.2 to 2.5; P=0.004) and among family members who did not witness CPR than among those who did (adjusted odds ratio, 1.6; 95% CI, 1.1 to 2.5; P=0.02). Relatives who did not witness CPR had symptoms of anxiety and depression more frequently than those who did witness CPR. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, or the level of emotional stress in the medical team and did not result in medicolegal claims. CONCLUSIONS Family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team, or result in medicolegal conflicts. (Funded by Programme Hospitalier de Recherche Clinique 2008 of the French Ministry of Health; ClinicalTrials.gov number, NCT01009606.).

Family Presence During Cardiopulmonary Resuscitation

Patricia Jabre, M.D., Ph.D., Vanessa Belpomme, M.D., Elie Azoulay, M.D., Ph.D., Line Jacob, M.D., Lionel Bertrand, M.D., Frederic Lapostolle, M.D., Ph.D., Karim Tazarourte, M.D., Ph.D., Guillem Bouilleau, M.D., Virginie Pinaud, M.D., Claire Broche, M.D., Domitille Normand, M.S., Thierry Baubet, M.D., Ph.D., Agnes Ricard-Hibon, M.D., Ph.D., Jacques Istria, M.D., Alexandra Beltramini, M.D., Armelle Alheritiere, M.D., Nathalie Assez, M.D., Lionel Nace, M.D., Benoit Vivien, M.D., Ph.D., Laurent Turi, M.D., Stephane Launay, M.D., Michel Desmaizieres, M.D., Stephen W. Borron, M.D., Eric Vicaut, M.D., Ph.D., and Frederic Adnet, M.D., Ph.D.

A Quality Control Program for Acute Pain Management in Out-of-Hospital Critical Care Medicine

STUDY OBJECTIVE This study was conducted to evaluate a quality control program for improving pain treatment in the out-of-hospital setting. METHODS Pain was evaluated for all patients at the beginning (T(0)) and the end (T(end)) of out-of-hospital management. During the first part of the study (part 1, n=108), the administration and choice of analgesics was left to the physicians discretion. Pain protocols were then modified to encourage the use of opioids. The effectiveness of this new pain management was analyzed (part 2, n=105) using pain scales and quality of relief. RESULTS Seventy percent of patients who expressed meaningful pain did not request analgesia, and 36% did not receive any analgesia in part 1 in contrast to 7% in part 2 of the study. The verbal rating scale and visual analog scale scores were substantially improved at T(end) versus T(0) in both periods, but the improvement was greater in part 2 (mean visual analog scale score at T(end) was 29.3+/-23 mm [+/-SD]) than in part 1 (38.6+/-25 mm). The percentage of patients who expressed satisfactory relief increased in part 2 (67% versus 49% in part 1). The mean dose of intravenous morphine was 7.2+/-6 mg. Adverse effects were rare and minor. CONCLUSION This program focusing on pain treatment plus implementation of pain protocols (with intravenous morphine) improved pain management in the field.

Epidemiology of adverse effects of prehospital sedation analgesia.

The aim of this study was to introduce a continuous monitoring of side effects related to sedation-analgesia in the field. A document was completed by physicians on board the ambulances for all prehospital interventions and checked daily by the medical staff. A total of 3605 interventions were evaluated over a 12-month period. Six hundred four patients undertook analgesia and/or sedation: group 1 (spontaneously breathing patients) n = 289 and group 2 (intubated-ventilated patients) n = 315. Sixty-four percent of patients received intravenous opioids in group 1. The anesthetic technique used for intubation was the rapid sequence induction in 70% of patients. Side effects were observed in 5.5% in group 1 (nausea: 2%, hypotension: 1%, hypoxemia: 1%) and 22% of patients in group 2 (hypotension-arrhythmia: 12%, cardiac arrest: 2%, difficult intubation: 5%, hypoxemia: 1%, pulmonary aspiration: 1%, laryngospasm/bronchospasm: 2%). No death was related to these medications. A close monitoring of side effects related to sedation-analgesia must be included in a quality program to improve patient safety in the field.

Intubating trauma patients before reaching hospital – revisited

Endotracheal intubation is widely used for airway management in a prehospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome in adult patients. The benefits, in term of outcomes of invasive airway management before reaching hospital, remain controversial. However, inadequate airway management in this patient population is the primary cause of preventable mortality. An increase in intubation failures and in the rate of complications in trauma patients should induce us to improve airway management skills at the scene of trauma. If the addition of emergency physicians to a prehospital setting is to have any influence on outcome, further studies are merited. However, it has been established that sedation with rapid sequence intubation is superior in terms of success, complications and rates of intubation difficulty. Orotracheal intubation with planned neuromuscular blockade and in-line cervical alignment remains the safest and most effective method for airway control in patients who are severely injured.

Exposition à la violence en Smur

Objectives: Evaluate the problem of violence in French EMS system and characterize assaults. Study design: Multicentric, descriptive, open study. Patients and methods: A questionnaire was given to a sample of prehospital care providers in Paris area. People were asked about assaults during their careers, typology of the assaults and consequences. Results are presented in percentage and means. Results: Two hundred seventy-six questionnaires were returned. One or more assaults were recounted by 23% (61/271) of the sample (median of 8 ± 7 years experience on the job). The injuries were bruises in 40% (17/43), wounds in 9% (4/43) and fractures in 2% (1/43). Only 4% of assaults were followed by sick leave, 15% by a complaint. After the assaults, 4% (2/45) reported having got therapy against post-traumatic stress disorder. Eighty-eight per cent reported verbal threat and 41% physical threat. Thirteen per cent (25/200) were threatened with a knife and 12% (23/200) with a gun. Only 9% (24/270) had a formal training for management of violence. Conclusion: Formal training in the management of violent encounters and prevention of post-traumatic stress should be developed.OBJECTIVES Evaluate the problem of violence in French EMS system and characterize assaults. STUDY DESIGN Multicentric, descriptive, open study. PATIENTS AND METHODS A questionnaire was given to a sample of prehospital care providers in Paris area. People were asked about assaults during their careers, typology of the assaults and consequences. Results are presented in percentage and means. RESULTS Two hundred seventy-six questionnaires were returned. One or more assaults were recounted by 23% (61/271) of the sample (median of 8 +/- 7 years experience on the job). The injuries were bruises in 40% (17/43), wounds in 9% (4/43) and fractures in 2% (1/43). Only 4% of assaults were followed by sick leave, 15% by a complaint. After the assaults, 4% (2/45) reported having got therapy against post-traumatic stress disorder. Eighty-eight per cent reported verbal threat and 41% physical threat. Thirteen per cent (25/200) were threatened with a knife and 12% (23/200) with a gun. Only 9% (24/270) had a formal training for management of violence. CONCLUSION Formal training in the management of violent encounters and prevention of post-traumatic stress should be developed.

Prehospital noninvasive ventilation can help in management of patients with limitations of life-sustaining treatments

Objective To evaluate the possible place of noninvasive positive pressure ventilation (NPPV) as a reversible and adjustable option offering the possibility of sustaining life until the hospital stay for patients with advanced life-support limitations and life-threatening respiratory distress in the prehospital setting. Methods Patients managed by a physician-staffed Emergency Medical Service unit were retrospectively included if they met the three inclusion criteria: a respiratory failure with oxygen saturation (pulse oximetry) less than 90% (or respiratory exhaustion) under oxygen 15 l/min and a do-not-intubate discussion (according to the physician on-scene) and impossibility of conducting the discussion of withholding advanced life support on-scene. Results Twelve patients were included. NPPV was a continuous positive airway pressure for eight patients and a bilevel positive airway pressure given by a ventilator for four patients. All the patients improved from respiratory point of view; respiratory rate decreased from 34±13 to 27±10 (P = 0.009) and pulse oximetry increased from 86±5 to 94±3% (P<0.01). NPPV was stopped in one case because of discomfort and worsening of consciousness, despite improved respiratory status. Conclusion This pilot series is promising and suggests that it could be a good option in case of limitations of life-sustaining treatments in the prehospital setting. A large controlled multicenter study, evaluating the use of NPPV in this context, would be very valuable.

Feasibility of cardiac output estimation by ultrasonic cardiac output monitoring in the prehospital setting.

The possible benefits of ultrasonic cardiac output monitoring (USCOM) in emergency medicine practice could be significant if evaluated in a goal-directed protocol. The aim of this study was to perform a feasibility study in a physician-staffed prehospital emergency medicine system. This study enrolled a convenient sample of 50 patients with circulatory distress. Main criteria were visualization of acceptable curves and obtaining interpretable values. Acceptable curves and interpretable values (main criterion) were obtained for 35 patients (70%). In case of failure, the patient was very often dyspneic (80 vs. 23%, when the technique was successful, P<0.001). Mean duration of USCOM examination was 105±60 s. The acceptable success rate for a new technique we observed and the high easy-to-use score suggests that the use of USCOM is feasible in prehospital emergency medicine.