Éric Piette

Basic concepts in the use of thoracic and lung ultrasound.

Purpose of review Recent advances were made in the field of point-of-care ultrasound (POCUS). Thoracic and lung ultrasound have become a rapid and accurate method of diagnosis of hypoxic diseases. The purpose of this article is to review the recent literature on POCUS, emphasizing on its use in the operating room. Recent findings Many international critical care societies published guidelines on the use of ultrasound in the installation of central venous access. More recently, evidenced-based guidelines on the use of POC lung ultrasound were published. Lung ultrasound has shown its superiority over conventional chest radiography in the diagnosis of many disorders of significant importance in anesthesiology, particularly the pneumothorax. Summary POC thoracic and lung ultrasound is used in many critical medicine fields. The aim of this review is to describe the basic lung ultrasound technique and the knowledge required in order to diagnose and treat the hypoxic patient. Emphasis is on disorder such as pleural effusion, alveolar interstitial disease, as well as pneumothorax, which is of particular importance in the field of anesthesiology.

Current views on acute to chronic pain transition in post-traumatic patients: risk factors and potential for pre-emptive treatments.

E year in the United States, 2.6 million hospital admissions and 36 million emergency department visits are accounted for by trauma patients. Proportionally similar ratios are reported in Canada. In many cases, acute pain from tissue damage subsides normally with wound healing. Yet, in many patients, maladaptive sensitization of the nervous system may trigger chronic pain syndromes that eventually persist for years after that healing has taken place. While the definition of chronic pain may vary, it is generally considered as an ongoing pain state experienced on most days and persisting for at least 3 months. Patients presenting with chronic pain experience persistent manifestations of allodynia, hyperalgesia, and spontaneous pain, making it a major cause of disability. Allodynia is characterized by a painful sensation triggered by normally nonpainful stimuli such as light brushes of the skin or the simple touch of clothes. Hyperalgesia is an exaggerated pain intensity perception for a painful stimuli. ‘‘Spontaneous’’ pain would occur in the absence of identified stimuli and is often considered a major clinical issue in the manifestation of a neuropathic pain state. Underlying inflammation or the physiologic consequences of the summation of allodynic and hyperalgesic stimuli during the course of time may contribute to the physiologic background of apparent ‘‘spontaneous’’ experiences. In Canada, the costs associated with chronic pain total more than those of cancer, heart disease, and human immunodeficiency virus combined, with direct health care costs reaching more than

Impact of Age, Sex and Route of Administration on Adverse Events after Opioid Treatment in the Emergency Department: A Retrospective Study

6 billion per year. Overall, 60% of active people living with chronic pain will eventually lose their job, incur an income loss, or see their professional responsibilities decrease, depending on the level of disability incurred. The total cost to society amounts to

Impact of Age on Pain Perception for Typical Painful Diagnoses in the Emergency Department

37 billion per year when global productivity loss and sick leaves are included. This figure compares well with a recent evaluation in the United States where the global financial cost was estimated to be

Prehospital Advanced Cardiac Life Support for Out‐of‐hospital Cardiac Arrest: A Cohort Study

560 to

Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest

635 billion annually. We sought to explore the acute to chronic pain transition in posttraumatic patients and the potential of preemptive treatments in at-risk patients. To identify the prevalence, risk factors, and preemptive treatments of chronic pain in the trauma population, we queried the MEDLINE and EMBASE databases with Ovid. Boolean operators were used to create combinations of the following keywords: chronic pain, posttraumatic pain, risk factors, post-surgical pain, post-operative pain, spinal cord injury, traumatic brain injury, orthopedicor limb trauma, burns, burn trauma, thoracic trauma, torso/chest trauma. We limited our search to humans and English or French languages. Relevant articles were identified by the authors from the abstract and the bibliography; disagreements were resolved by discussion. Studies on chronic pain in posttraumatic patients are relatively scarce, although chronic pain develops with significantly high prevalence in various types of posttraumatic patients (Table 1). Globally, chronic pain occurrence across all categories of trauma patients lies between 11% and 96%, depending on the nature of the traumas (as detailed below). A specialized workgroup from the International Association for the Study of Pain has subdivided the general diagnostic of ‘‘chronic pain’’ into more specific taxonomic groups in an effort to refine the current model of the clinical manifestations of chronic pain. Some of these detailed diagnostics refer to generalized pain syndromes, and others refer to specific locations in the neck, head, limbs, thorax, or internal organs and indicate their eventual link to musculoskeletal, neurologic or psychological components (e.g., spinal and radicular pain syndromes, stump pain, complex regional pain syndromes). Up to now, although chronic pain prevalence were reported for several trauma categories, only a few studies were designed to identify which were the factors that could be associated with a transition from acute to chronic pain. Psychosocial and medical aspects, such as lasting anxiety or depressive states, sleep disorders, acute pain intensity, sex, or age, are among the commonly proposed predisposing factors (discussed below). However, recent analyses generally conclude that methodological improvements in the design of clinical studies are first needed before robust risk profiles can be drawn for trauma patients. The prevention of the closely related postsurgical chronic pain, which occurs after iatrogenic tissue injury, is documented more substantially and may constitute a practical source of information for trauma specialists. REVIEW ARTICLE

Potential impact of a prehospital redirection system for refractory cardiac arrest

Opioids are an important avenue for the treatment of pain among individuals presenting to the emergency department. Unfortunately, opioid administration can lead to several complications including nausea/vomiting, oxygen desaturation and hypotension. The authors aimed to determine the incidence of such adverse events among 31,742 patients who were treated with opioids in the emergency department of a single large tertiary care hospital in Montreal, Quebec.

Vital Signs Are Not Associated with Self-Reported Acute Pain Intensity in the Emergency Department

BACKGROUND Age-related differences in pain perception have been demonstrated in experimental settings but have been investigated scarcely and without valid scale in the clinical framework. OBJECTIVES To examine the effect of age on pain perception for recognized painful diagnoses encountered in the emergency department (ED). METHODS A post-hoc analysis of real-time archived data was performed in a tertiary urban and a secondary regional ED. We included all consecutive adult patients (≥18 years) with the following diagnosis at discharge: renal colic, pancreatitis, appendicitis, headache/migraine, dislocation and extremities fractures, and a pain evaluation of ≥1 (0-10, verbal numerical scale) at triage. The primary outcome was to compare for each of these diagnoses the level of pain intensity between four age groups (18-44; 45-64; 65-74; 75+ years). RESULTS A total of 15,670 patients (48% women) were triaged with a mean pain intensity of 7.7 (SD=2.0). Women exhibited greater pain scores than men for pancreatitis, headache/migraine, and extremity fracture. Renal colic, pancreatitis, appendicitis, and headache/migraine showed a linear decrease in pain scores with age whereas dislocation and extremity fractures did not present age differences. Mean differences in pain intensity scores between young adults (18-44 years) and patients aged ≥75 years were 0.79 (95% confidence interval [95% CI] 0.5-1.1) for renal colic, 1.1 (95% CI 0.7-1.4) for pancreatitis, 0.70 (95% CI 0.2-1.2) for appendicitis, and 0.86 (95% CI 0.6-1.1) for headache/migraine. CONCLUSION Older patients perceive similar pain for dislocation and extremity fractures and less for visceral and headache/migraine pain; however, these age differences may not be clinically important.

Lung Sliding Identification Is Less Accurate in the Left Hemithorax

OBJECTIVES Out-of-hospital advanced cardiac life support (ACLS) has not consistently shown a positive impact on survival. Extracorporeal cardiopulmonary resuscitation (E-CPR) could render prolonged on-site resuscitation (ACLS or basic cardiac life support [BCLS]) undesirable in selected cases. The objectives of this study were to evaluate, in patients suffering from out-of-hospital cardiac arrest (OHCA) and in a subgroup of potential E-CPR candidates, the association between the addition of prehospital ACLS to BCLS and survival to hospital discharge, prehospital return of spontaneous circulation (ROSC), and delay from call to hospital arrival. METHODS This cohort study targets adult patients treated for OHCA between April 2010 and December 2015 in the city of Montreal, Canada. We defined potential E-CPR candidates using clinical criteria previously described in the literature (65 years of age or younger, initial shockable rhythm, absence of ROSC after 15 minutes of prehospital resuscitation, and emergency medical services-witnessed collapse or witnessed collapse with bystander cardiopulmonary resuscitation). Associations were evaluated using multivariate regression models. RESULTS A total of 7,134 patients with OHCA were included, 761 (10.7%) of whom survived to discharge. No independent association between survival to hospital discharge and the addition of prehospital ACLS to BCLS was found in either the entire cohort (adjusted odds ratio [AOR] = 1.05 [95% confidence interval {CI} = 0.84-1.32], p = 0.68) or among the 246 potential E-CPR candidates (AOR = 0.82 [95% CI = 0.36-1.84], p = 0.63). The addition of prehospital ACLS to BCLS was associated with a significant increase in the rate of prehospital ROSC in all patients experiencing OHCA (AOR = 3.92 [95% CI = 3.38-4.55], p < 0.001) and in potential E-CPR candidates (AOR = 3.48 [95% CI = 1. 76-6.88], p < 0.001) compared to isolated prehospital BCLS. Delay from call to hospital arrival was longer in the ACLS group than in the BCLS group (difference = 16 minutes [95% CI = 15-16 minutes], p < 0.001). CONCLUSIONS In a tiered-response urban emergency medical service setting, prehospital ACLS is not associated with an improvement in survival to hospital discharge in patients suffering from OHCA and in potential E-CPR candidates, but with an improvement in prehospital ROSC and with longer delay to hospital arrival.

Reversible atrioventricular block associated with closure of atrial septal defects using the amplatzer device

AIMS Patients suffering from out-of-hospital cardiac arrest (OHCA) are frequently transported to the closest hospital. Percutaneous coronary intervention (PCI) is often indicated following OHCA. This studys primary objective was to determine the association between being transported to a PCI-capable hospital and survival to discharge for patients with OHCA. The additional delay to hospital arrival which could offset a potential increase in survival associated with being transported to a PCI-capable center was also evaluated. METHODS This study used a registry of OHCA in Montreal, Canada. Adult patients transported to a hospital following a non-traumatic OHCA were included. Hospitals were dichotomized based on whether PCI was available on-site or not. The effect of hospital type on survival to discharge was assessed using a multivariable logistic regression. The added prehospital delay which could offset the increase in survival associated with being transported to a PCI-capable center was calculated using that regression. RESULTS A total of 4922 patients were included, of whom 2389 (48%) were transported to a PCI-capable hospital and 2533 (52%) to a non-PCI-capable hospital. There was an association between being transported to a PCI-capable center and survival to discharge (adjusted odds ratio = 1.60 [95% confidence interval 1.25-2.05], p < .001). Increasing the delay from call to hospital arrival by 14.0 min would offset the potential benefit of being transported to a PCI-capable center. CONCLUSIONS It could be advantageous to redirect patients suffering from OHCA patients to PCI-capable centers if the resulting expected delay is of less than 14 min.