Baptiste Vallé

Nitrous Oxide for Early Analgesia in the Emergency Setting: A Randomized, Double-blind Multicenter Prehospital Trial

OBJECTIVES Although 50% nitrous oxide (N(2) O) and oxygen is a widely used treatment, its efficacy had never been evaluated in the prehospital setting. The objective of this study was to demonstrate the efficacy of premixed N(2) O and oxygen in patients with out-of-hospital moderate traumatic acute pain. METHODS This prospective, randomized, multicenter, double-blind trial enrolled patients with acute moderate pain (numeric rating scale [NRS] score between 4 and 6 out of 10) caused by trauma. Patients were assigned to receive either 50/50 N(2) O and oxygen 9 L/min (N(2) O group) or medical air (MA) 9 L/min (MA group), in ambulances from two nurse-staffed fire department centers. After the first 15 minutes, every patient received N(2) O and oxygen. The primary endpoint was pain relief at 15 minutes (T15), defined as a NRS ≤ 3 of 10. The NRS was measured every 5 minutes. Secondary endpoints were treatment safety and adverse events, time to analgesia, and patient and investigator satisfaction with analgesia. RESULTS Sixty patients were included with no differences between groups in age (median = 34 years, interquartile range [IQR] = 23 to 53 years), sex (37 males, 66%), and initial median NRS of 6 (IQR = 5 to 6). At T15, 67% of the patients in the N(2) O group had an NRS score of 3 or lower versus 27% of those in the MA group (delta = 40%, 95% confidence interval [CI] = 17% to 63%; p < 0.001). The median pain scores were lower in the N(2) O group at T15, 2 (IQR = 1 to 4) versus 5 (IQR = 3 to 6). There was a difference at 5 minutes that persisted at all subsequent time points. Four patients (one in the N(2) O group) experienced adverse events (nausea) during the protocol. CONCLUSIONS This study demonstrates the efficacy of N(2) O for the treatment of pain from acute trauma in adults in the prehospital setting.

Quality of publications in emergency medicine

OBJECTIVE The objective of this study is to describe emergency medicine (EM) publications in terms of methodology, approval by institutional review board, method of consent, external validity, and setting (eg, prehospital or emergency department). METHODS The 12 top-ranked emergency journals were selected. We manually reviewed the last 30 original articles in each EM journal, to represent more than 2 months of publications for all EM journals (range, 2-6 months). Only clinical original articles on human subjects were included. To ensure accurate data transcription, each article was read at least twice by 2 different reviewers and graded by written criteria using an extraction standard chart. RESULTS Over the articles reviewed, 330 were analyzed. One hundred eighty-nine (57.3%) were prospective studies; 29 (8.8%) were randomized studies. Two hundred twenty-six studies (68.5%) mentioned an institutional review board approval or a waiver of authorization, and an informed consent was not mentioned in 227 (68.8%) of studies. Fifty-nine (17.9%) were conducted in a prehospital setting. Two hundred thirty-eight (72.1%) of these studies were at single-center institutions; the Unite States contributed 158 (47.9%) of the total publications. CONCLUSION This study describes publications in the field of EM. Randomized studies represent 9% of publications, most studies are cross-sectional, and more than half have a retrospective design. We found that, in one-third of the studies, an institutional review board review was not mentioned and informed consent was not specified in two-thirds of the studies. Emergency medicine research volume, quality, and grants activity must increase in order for EM to progress within academic medicine.

Use of intravenous lipid 20% emulsion for the treatment of a voluntary intoxication of flecainide with refractory shock

The use of intravenous fat emulsion (IFE) has been well described in a systematic review of human and animal studies. 1 Cases of successful early use of lipid emulsion for cardiotoxic effects induced by local anesthetics or other lipophilic drugs, such as calcium-channel antagonists or beta-blockers, have recently been published. 2,3 We report the fi rst case of IFE therapy for the treatment of a voluntary fl ecainide poisoning with refractory shock. A 72-year-old French female patient, whose main medical history included a rhythmic heart disease treated with fl ecainide and a depressive syndrome with multiple suicide attempts, was rescued at home by a fi rst-aid team after voluntarily ingesting drugs. At the scene, an empty plate of 15 tablets of fl ecainide (100 mg), a plate of 15 tablets of oxazepam (10 mg), and a plate of 30 tablets of levothyroxin (50 μ g) were found; the time of ingestion was unknown. The patient was taken to the intensive care unit of the nearest hospital. Clinical examination revealed a drowsy patient, with an enolic breath and without coma. Respiratory rate was 30 breaths per minute, oxygen saturation was 88% without oxygen supply, blood pressure was 70/50 mmHg, and heart rate was 55 beats per minute. An electrocardiogram revealed a widening of QRS complexes longer than 0.2 sec with a prolongation of the QT interval. However, despite being treated with aggressive supportive care, including fl uid resuscitation (750 mL of 4.2% sodium bicarbonate with hydroxyethyl starch 1500 mL), mechanical ventilation, and an increasing dose of vasopressors (up to 6 mg/h of epinephrine), it was decided to transfer her to the university reference hospital for the possible implementation of circulatory assistance. After the failure of conventional pharmacological therapy and regarding the similarities of fl ecainide with molecules of the class of local anesthetics from the electrophysiological point of view, 4 an infusion of Intralipid ® 20% in the form of a bolus of 1.5 mL/kg associated with a continuous infusion of 0.25 mL/min was started. The patient was then transferred with a medical team (emergency physician, nurse, and ambulance driver) to the university hospital. During the following 30 min, hemodynamic stabilization allowed a dramatic decrease in the dose of epinephrine (1 mg/h during the transfer) without any further complication. On arrival at the reference hospital, the patient ’ s blood pressure was 111/80 mmHg and her pulse rate was 75 beats per minute. An ECG showed a marked shortening of the QRS complexes. The evolution was a progressive hemodynamic improvement without implementation of circulatory assistance. After 20 days of hospitalization in ICU because of aspiration pneumonia, the patient was weaned from oxygen therapy without after effects. She was secondarily hospitalized in a psychiatric unit for the management of her major depressive disorder. According with De Roock, 5 who reminds us that lipid emulsion therapy does not entirely fulfi ll the criteria for antidotal therapy, this case is a reminder that lipid emulsions should be considered as a second-line treatment for poisonings with cardiotropic drugs after conventional treatment and can even be used during medical transfer between two hospitals.

User satisfaction with maritime telemedicine

We assessed the satisfaction of onboard caregivers with the maritime telehealth service provided by the Centre de Consultations Médicales Maritimes (CCMM). We conducted a survey of captains and caregivers by email. Of the 385 surveys sent out, 165 (43%) were completed. Eighty four percent of responders (n = 110) thought that waiting time was satisfactory or very satisfactory, and 97% (n = 128) were satisfied or very satisfied with their relationship with the remote physician. Thirty eight per cent of participants (n = 50) considered that the physician understood the medical problem very well; understanding was good in 58% of cases (n = 76) and bad in only 4% of cases (n = 5). Sixty two per cent of participants (n = 83) sent pictures before consultation. The respondents were also satisfied with the telephone advice overall, the competence of the physicians providing the advice, the length of time spent waiting, the verbal prescription and the medical advice given. Onboard caregivers were generally well satisfied with the maritime teleconsultations and the advice provided by the CCMM physicians.

Circuitous diagnosis in concealed self-poisoning with Nerium oleander*

To the Editor: A 60-year-old male prisoner, with a known history of depression, collapsed while walking in the garden of the prison. At examination, the physician noted that he complained of gastrointestinal discomfort, nausea, abdominal pain and cold sweat. His blood pressure was 90/60 mmHg, heart rate 64 beats per minute and Glasgow Coma Scale score 11. There were no signs of seizure. The fi rst diagnosis suspected by the physician was an acute myocardial infarction. An electrocardiography (ECG) was performed, which excluded this cause. Deliberate self-poisoning was not at fi rst suspected because the patient had consistently refused antidepressant treatment and was not taking any other drug. He was followed by a psychiatrist once a month. The patient was transported under medical supervision to the emergency department. After admission, he continued to

Suspected Hypokalaemia Following Liquorice Ingestion on Board Ship

Emilie Dehours*, Baptiste Vallé†, Marie Eve Rougé-Bugat‡, Battefort Florent*, Vincent Bounes* and Nicolas Franchitto§ *Department of Emergency Medicine, Toulouse-Purpan University Hospital, Toulouse, France; Department of Emergency Medicine, Bordeaux-Pellegrin University Hospital, Bordeaux, France; Department of Primary Care, University of Toulouse School of Medicine, Toulouse, France; Poisons and Toxicovigilance Centre, Toulouse-Purpan University Hospital, Toulouse, France

Suicide attempt by intravenous potassium self-poisoning: a case report.

Introduction. Overdose of potassium is not as frequently encountered in clinical practice as hyperkalaemia due to acute or chronic renal disease. However, potassium overdoses leading to serious consequences do occur. Case Presentation. A 20-year-old nurse student presented with a cardiac arrest with asystole rhythm. Beside the patient were found four 50-mL syringes and empty vials of potassium chloride (20 mL, 10%). After initial resuscitation with epinephrine, 125 mL of a 4.2% intravenous solution of sodium bicarbonate were injected which resulted in the recovery of an effective cardiac activity. The patient recovered without sequelae. Conclusion. The difficulty in this case was to recognize the potassium poisoning. The advanced resuscitation with the use of a specific treatment helped to resuscitate the patient.

Pancreatic cholangiocarcinoma as an ST-elevation myocardial infarction with thrombolytic therapy.

We report the case of a 46-year-old patient who presented a chest pain with ST-segment elevation in precordial leads V1 (2 mm), V2 (4 mm), and V3 (3 mm). Thrombolytic therapy was initiated with the combination tenecteplase tissue plasminogene activator, aspirin, and heparin. Further electrocardiogram and cardiac enzymes measured every 2 hours during the first 24 hours remained normal, and after a computed tomography of the abdomen, the patient was taken to surgery for an exploratory abdominal operation that revealed pancreatic cholangiocarcinoma. No adverse effects were attributed to the initial thrombolytic therapy. Finally, myocardial ischemia was excluded because the electrocardiogram, cardiac enzymes, and a 1-month later cardiac stress test remained normal and because no coronary event occurred during the first year after surgery. Our case shows that it is sometimes difficult to make the share, in prehospital field, between coronary syndrome and other pathology, particularly digestive pathology. However, in the appropriate chest pain patient with presumed acute myocardial infarction, ST-segment elevation remains the primary criterion for the initiation of thrombolytic therapy, primary angioplasty, and/or other pharmacologic interventions.

Using D-Dimer to Diagnose Painless Acute Aortic Dissection: A Case Report

Introduction. Aortic dissection is a cardiovascular emergency; the most frequent symptom is chest pain, but clinical presentation can be varied and atypical. Case Presentation. We report the case of a 66-year-old Caucasian male who presented a syncope immediately followed by a left-arm weakness while driving his car. Clinical examination was normal, but bilateral jugular vein distension was noted. Electrocardiogram and chest radiography were unremarkable. Among blood tests performed, troponin I test result was negative, and D-dimer test concentration was >4000 ng/mL. Since D-dimer test result was positive, chest computer tomography angiogram was performed and found a thoracic aortic dissection. Conclusion. Our case report shows that acute aortic dissection diagnosis is difficult and must be associated with the interpretation of various clinical signs and D-dimer measurement. It could be helpful for the emergency physician to have a pretest probability D-dimer like in pulmonary embolism diagnosis.