Alain Margenet

Unanticipated difficult airway management in the prehospital emergency setting: prospective validation of an algorithm.

Background: Difficult intubation management algorithms have proven efficacy in operating rooms but have rarely been assessed in a prehospital emergency setting. We undertook a prospective evaluation of a simple prehospital difficult intubation algorithm. Methods: All of our prehospital emergency physicians and nurse anesthetists were asked to adhere to a simple algorithm in all cases of impossible laryngoscope-assisted tracheal intubation. They received a short refresher course and training in the use of the gum elastic bougie (GEB) and the intubating laryngeal mask airway (ILMA), which were techniques to be used as a first and a second step, respectively. In cases of difficult ventilation with arterial desaturation, IMLA was to be used first. Cricothyroidotomy was the ultimate rescue technique when ventilation through ILMA failed. Patient characteristics, adherence to the algorithm, management efficacy, and early complications were recorded (August 2005–December 2009). Results: An alternative technique to secure the airway was needed in 160 of 2,674 (6%) patients undergoing intubation. Three instances of nonadherence to the algorithm were recorded. GEB was used first in 152 patients and was successful in 115. ILMA was used first in 8 patients and second in the 37 GEB-assisted intubation failures. Forty-five patients were successfully mask-ventilated, and 42 were blindly intubated before reaching the hospital. Cricothyroidotomy was used successfully in a patient with severe upper airway obstruction as a result of pharyngeal neoplasia. Early intubation-related complications occurred in 52% difficult cases. Conclusion: Adherence to a simple algorithm using GEB, ILMA, and cricothyroidotomy solved all difficult intubation cases occurring in a prehospital emergency setting.

Efficacy and safety of the EZ-IO™ intraosseous device: Out-of-hospital implementation of a management algorithm for difficult vascular access

OBJECTIVE Intraosseous access is a rapid and safe alternative when peripheral vascular access is difficult. Our aim was to assess the safety and efficacy of a semi-automatic intraosseous infusion device (EZ-IO) when using a management algorithm for difficult vascular access in an out-of-hospital setting. METHODS This was a one-year prospective, observational study by mobile intensive care units. After staff training in the use of the EZ-IO device and provision of a management algorithm for difficult vascular access, all vehicles were equipped with the device. We determined device success rate and ease of use, resuscitation fluid volume and drugs administered by the intraosseous route, and complications at insertion site. RESULTS A total of 4666 patients required vascular access. The EZ-IO device was used in 30 cardiac arrest patients (25 adults; 5 children) and 9 adults with spontaneous cardiac activity. The success rate for first insertion was 84%. Overall success rate (max. 2 attempts) was 97%. The device was used for fluid resuscitation in 16 patients (mean volume: 680ml), adrenaline administration in 24 patients, and rapid sequence induction in 2 patients. There was only one local complication (transient local inflammation). CONCLUSIONS On implementation of an algorithm for the management of difficult vascular access, the EZ-IO device proved safe and highly effective in both adult and paediatric patients in an out-of-hospital emergency setting. It is a suitable device for consideration as a first-line option for difficult vascular access in this setting.

Predictive factors for positive coronary angiography in out-of-hospital cardiac arrest patients.

Objectives Coronary angiography is often performed in survivors of out-of-hospital cardiac arrest, but little is known about the factors predictive of a positive coronary angiography. Our aim was to determine these factors. Methods In this 7-year retrospective study (January 2000–December 2006) conducted by a French out-of-hospital emergency medical unit, data were collected according to Utstein style guidelines on all out-of-hospital cardiac arrest patients with suspected coronary disease who recovered spontaneous cardiac activity and underwent early coronary angiography. Coronary angiography was considered positive if a lesion resulting in more than a 50% reduction in luminal diameter was observed or if there was a thrombus at an occlusion site. Results Among the 4621 patients from whom data were collected, 445 were successfully resuscitated and admitted to hospital. Of these, 133 were taken directly to the coronary angiography unit, 95 (71%) had at least one significant lesion, 71 (53%) underwent a percutaneous coronary intervention, and 30 survived [23%, 95% confidence interval (CI): 16–30]. According to multivariate analysis, the factors predictive of a positive coronary angiography were a history of diabetes [odds ratio (OR): 7.1, 95% CI: 1.4–36], ST segment depression on the out-of-hospital ECG (OR: 5.4, 95% CI: 1.1–27.8), a history of coronary disease (OR: 5.3, 95% CI: 1.4–20.1), cardiac arrest in a public place (OR: 3.7, 95% CI: 1.3–10.7), and ventricular fibrillation or ventricular tachycardia as initial rhythm (OR: 3.1, 95% CI: 1.1–8.6). Conclusion Among the factors identified, diabetes and a history of coronary artery were strong predictors for a positive coronary angiography, whereas ST segment elevation was not as predictive as expected.

Bispectral index monitoring is useless during cardiac arrest patients' resuscitation ,,♦

AIM It has been suggested that out-of-hospital bispectral (BIS) index monitoring during advanced cardiac life support (ACLS) might provide an indication of cerebral resuscitation. The aims of our study were to establish whether BIS values during ACLS might predict return to spontaneous circulation, and whether BIS values on hospital admission might predict survival. MATERIALS AND METHODS This was a prospective observational study in 92 patients with cardiac arrest who received basic life support from a fire-fighter squad and ACLS on arrival of an emergency medical team on the scene. BIS values, electromyographic activity, and signal quality index were recorded throughout resuscitation and out-of-hospital management. RESULTS Seven patients had recovered spontaneous cardiac activity by the time the medical team arrived on scene. Of the 92 patients, 62 patients died on scene and 30 patients returned to spontaneous cardiac activity and were admitted to hospital. The correlation between BIS values and end-tidal CO(2) during the first minutes of ACLS was poor (r(2)=0.02, P=0.19). Of the 30 admitted patients, 27 died. Three were discharged with no disabilities. There was no significant difference in BIS values on admission between the group of patients who died and the group who survived (P=0.78). CONCLUSIONS Although BIS monitoring during resuscitation was not difficult, it did not predict return to spontaneous cardiac activity, nor survival after admission to intensive care. Its use to monitor cerebral function during ACLS is therefore pointless.

Capnography monitoring in nonintubated patients with respiratory distress.

OBJECTIVE The objective was to assess agreement between end-tidal carbon dioxide values measured by a handheld capnometer (Petco(2)) and values measured by a blood gas analyzer (Paco(2)) in nonintubated patients with respiratory distress in an out-of-hospital setting. METHODS This prospective study compared Petco(2) values obtained by an end-tidal capnometer (Microcap Plus; Oridion Capnography Inc, Needham, Mass) to Paco(2) values by the Bland and Altman statistical method. RESULTS A total of 50 patients were included. Continuous Petco(2) monitoring was easily performed in all 50 patients during ambulance transport, but blood gas analysis failed in 1 patient. Agreement between the 2 methods was poor with a bias (mean difference) between Petco(2) and Paco(2) measurements of 12 mm Hg and a precision (SD of the difference) of 8 mm Hg. The gradient between Petco(2) and Paco(2) was greater than 5 and 10 mm Hg in 41 and 25 patients, respectively. CONCLUSIONS Petco(2) measurements poorly reflected Paco(2) values in our population of nonintubated patients with respiratory distress of various origins.

An observational study of noninvasive positive pressure ventilation in an out-of-hospital setting

OBJECTIVE Out-of-hospital clinical experience with noninvasive bilevel positive airway pressure (BiPAP) ventilation is extremely limited compared to inhospital management. The aims of this study were to assess the feasibility of out-of-hospital BiPAP ventilation in patients with acute respiratory distress of various origins, and to look for specific factors associated with failure of this respiratory support. METHODS This 2-year prospective observational study assessed the failure rate of out-of-hospital BiPAP ventilation, the difficulties encountered, and factors predictive of failure by multivariate analysis. RESULTS Overall, 138 patients were treated by out-of-hospital BiPAP for congestive heart failure (56%), chronic obstructive pulmonary disease exacerbation (28%), and acute respiratory failure (16%). Failure rate was 26% (35/138; 95% confidence interval, 18%-33%) (11 before and 24 after reaching hospital). Independent risk factors were the cause of respiratory distress (chronic obstructive pulmonary disease exacerbation; acute respiratory failure) and an audible air leakage. CONCLUSIONS The failure rate of BiPAP initiated out-of-hospital was no different from previous reports for inhospital failure rates. Failure was attributable to similar causes.

Overnight duty impairs behaviour, awake activity and sleep in medical doctors.

Background The impact of prolonged work cycles among senior doctors remains disputed. We evaluated the effects of overnight duty on awake activity and sleep quality in senior doctors in emergency medical specialties. Methods Thirty-six healthy doctors were monitored during a 2-week period including three separate 84 h on-call cycles. An on-call cycle consisted of the night and the day before night duty; the night duty itself and the subsequent 2 days and nights after night duty. The first day after night duty could either be worked or not. Actigraphy was used to measure physical activity and to evaluate sleep duration and quality. A standardized questionnaire was used to assess daytime performance and night sleep quality. Results Night actigraphy demonstrated that on-call work induced a significant reduction in sleep duration that was not recovered during the subsequent two nights. Sleep during the night duty itself was fragmented and of poor quality. Awake activity was significantly impaired on the day after night duty. Although subjectively night sleep quality did not differ between the nights before and after night duty, all subjective daytime parameters were impaired the day after night duty, and mood, fatigue and concentration remained altered on the second day. Working the day after night duty impaired objective measurements of daytime activity and sleep quality during the subsequent two nights. Conclusions On-call night work in acute specialties induces sleep debt associated with prolonged impairment of awake activity, sleep quality and performance. Not working the following day after an on-call night allows partial recovery of sleep quality to begin.

Enquête nationale sur la prise en charge de l’intubation difficile en médecine d’urgence préhospitalière☆

OBJECTIVES Difficult intubation rate is higher in the prehospital setting than in the operating room. Goal of this survey was to assess compliance of the French prehospital mobile emergency unit (Smur) to the recent French guidelines for the difficult airway management. STUDY DESIGN National phone survey. METHODS A phone questionnaire was proposed to one senior emergency physician of all 380 French Smur. Seven questions were asked about intubation devices used, availability of a written difficult intubation algorithm and intubation training of the Smurs physicians. RESULTS Guidelines of the recent French consensus conference on difficult intubation are only partly followed by the Smur. Only 60% of the Smur perform systematic rapid intubation sequence, plastic laryngoscope blades are used by more than 50% of the Smur and less than 50% of the Smur have a written difficult intubation management algorithm available. The Gum elastic Bougie is available in 58% of the Smur and the intubating laryngeal mask airway in 71%, whereas initial formation for difficult intubation devices used is provided to the emergency physicians in only 58% of the Smur. CONCLUSION This survey shows that the French guidelines for the difficult airway management are only partially followed by the French Smur. An effort should be made for a larger diffusion of these guidelines towards the emergency physicians working in the Smur.

Article originalEnquête nationale sur la prise en charge de l’intubation difficile en médecine d’urgence préhospitalièreNational survey on out-of-hospital difficult intubation management☆

OBJECTIVES Difficult intubation rate is higher in the prehospital setting than in the operating room. Goal of this survey was to assess compliance of the French prehospital mobile emergency unit (Smur) to the recent French guidelines for the difficult airway management. STUDY DESIGN National phone survey. METHODS A phone questionnaire was proposed to one senior emergency physician of all 380 French Smur. Seven questions were asked about intubation devices used, availability of a written difficult intubation algorithm and intubation training of the Smurs physicians. RESULTS Guidelines of the recent French consensus conference on difficult intubation are only partly followed by the Smur. Only 60% of the Smur perform systematic rapid intubation sequence, plastic laryngoscope blades are used by more than 50% of the Smur and less than 50% of the Smur have a written difficult intubation management algorithm available. The Gum elastic Bougie is available in 58% of the Smur and the intubating laryngeal mask airway in 71%, whereas initial formation for difficult intubation devices used is provided to the emergency physicians in only 58% of the Smur. CONCLUSION This survey shows that the French guidelines for the difficult airway management are only partially followed by the French Smur. An effort should be made for a larger diffusion of these guidelines towards the emergency physicians working in the Smur.

Article originalMise en place d’un système de gestion informatique de la pharmacie au sein d’un service médical d’urgence et de réanimation : impact sur les dépensesIntroduction of a bar coding pharmacy stock replenishment system in a prehospital emergency medical unit: Economical impact

OBJECTIVE To assess economical impact after introduction of a bar coding pharmacy stock replenishment system in a prehospital emergency medical unit. STUDY DESIGN Observational before and after study. METHODS A computer system using specific software and bare-code technology was introduced in the pre hospital emergency medical unit (Smur). Overall activity and costs related to pharmacy were recorded annually during two periods: the first 2 years period before computer system introduction and the second one during the 4 years following this system installation. RESULTS The overall clinical activity increased by 10% between the two periods whereas pharmacy related costs continuously decreased after the start of pharmacy management computer system use. Pharmacy stock management was easier after introduction of the new stock replenishment system. The mean pharmacy related cost of one patient management was 13 Euros before and 9 Euros after the introduction of the system. The overall cost savings during the studied period was calculated to reach 134,000 Euros. CONCLUSION The introduction of a specific pharmacy management computer system allowed to do important costs savings in a prehospital emergency medical unit.