F. Templier

Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to ventricular fibrillation.

IntroductionSince 2003, we have routinely used percutaneous coronary intervention (PCI) and mild therapeutic hypothermia (MTH) to treat patients < 80 years of age after out-of-hospital cardiac arrest (OHCA) related to ventricular fibrillation. The aim of our study was to evaluate the prognostic impact of routine PCI in association with MTH and the potential influence of age.MethodsWe studied 111 consecutive patients resuscitated successfully following OHCA related to shock-sensitive rhythm. They were divided into five groups according to age: < 45 years (n = 22, group 1), 45 to 54 years (n = 27, group 2), 55 to 64 years (n = 22, group 3), 65 to 74 years (n = 23, group 4) and ≥75 years (n = 17, group 5). Emergency coronary angiography was performed in hemodynamically stable patients < 80 years old, regardless of the electrocardiogram pattern. MTH was targeted to a core temperature of 32°C to 34°C for 24 hours.ResultsMost patients (73%) had coronary heart disease, although its incidence in group 1 was lower than in other groups (41% versus 81%; P = 0.01). In group 1, all patients but one underwent coronary angiography, and 33% of them underwent associated PCI. In group 5, only 53% of patients underwent a coronary angiography and 44% underwent PCI. Overall in-hospital survival was 54%, ranging between 52% and 64% in groups 1 to 4 and 24% in group 5. Time from collapse to return of spontaneous circulation was associated with mortality (odds ratio (OR) = 1.05 (25th to 75th percentile range, 1.03 to 1.08); P < 0.001), whereas PCI was associated with survival (OR = 0.30 (25th to 75th percentile range, 0.11 to 0.79); P = 0.01).ConclusionsWe suggest that routine coronary angiography with potentially associated PCI may favorably alter the prognosis of resuscitated patients with stable hemodynamics who are treated with MTH after OHCA related to ventricular fibrillation. Although age was not an independent cause of death, the clinical relevance of this therapeutic strategy remains to be determined in older people.

Difficulties encountered by physicians in interpreting focused echocardiography using a pocket ultrasound machine in prehospital emergencies.

Objective Pocket ultrasound devices (PUDs) increase the scope of transthoracic echocardiography. We assessed the ability of emergency physicians (EPs) to obtain and interpret views using PUDs in prehospital emergencies. Materials and methods Nine EPs underwent a 2-day training program focused on acquisition of four views and on evaluation of left ventricular function, right ventricular size, the inferior vena cava, and detection of pericardial effusion. Then, EPs used a PUD to perform transthoracic echocardiography in patients with shock or acute respiratory failure. The quality and interpretation of views were graded by an expert as not obtained/inadequate, adequate, or optimal. Agreement between the expert and the physicians was evaluated using Cohen’s &kgr; test. Results One hundred consecutive exams were evaluated in patients with shock or acute respiratory failure. Parasternal long-axis and short-axis views, and a subcostal view were not obtained or inadequate in 56, 54, and 54 patients, respectively. An apical four-chamber view was not obtained or inadequate in 33 patients. One, two, or three views were graded as adequate or optimal in 86, 65, and 35 patients. Agreement between physicians and experts for left ventricular systolic function, right ventricular size, and pericardial effusion was weak [&kgr; 0.37 (0.17; 0.59), 0.27 (0.023; 0.53), and 0.33 (−0.008; 0.67)]. Agreement for inferior vena cava evaluation was very weak [0.13 (−0.17; 0.43)]. Conclusion After a very short training program, echocardiography using a PUD in prehospital emergencies was feasible in half of patients. Acquisition of technical skills is reasonable, but accurate evaluation of cardiac function may require more extensive training.

Noninvasive ventilation use in French out-of-hospital settings : a preliminary national survey

OBJECTIVE The objective of our study was to describe noninvasive ventilation (NIV) practices (pressure support ventilation and continuous positive airway pressure) in French out-of-hospital mobile intensive care units (SMUR) and their compliance with national consensus guidelines. METHOD Online inquiry into practices of NIV among managers of French SMUR. Analyzed data include types of NIV devices and use of NIV. RESULTS Upon 218 SMUR referenced within the SAMU de France database, 118 questionnaires (54%) were processed. Noninvasive ventilation equipment: 91% of the SMUR with at least one type of NIV device (continuous positive airway pressure only=82%; pressure support ventilation only=59%; both=50%) but frequently not with recommended devices. Use of NIV: for acute cardiogenic pulmonary edema, practices were compliant with recommendations in 80% of cases, although there was still room for improvement. For other pathologies, practices were very heterogeneous, not always properly assessed, and frequently not compliant with recommendations. CONCLUSION To conclude, NIV use in the out-of-hospital setting in France seems to meet current recommendations for acute cardiogenic pulmonary edema but not for other pathologies. This could be improved by the use of written procedures, conduction of further studies, and promotion of compliance through education.

Fréquence et prise en charge des pathologies allergiques en réanimation pré-hospitalière

Resume Objectifs Les pathologies allergiques etant peu decrites en pre-hospitalier, nous avons souhaite en evaluer les modes de presentation, la frequence et les modalites de prise en charge. Methode Etude retrospective incluant les dossiers medicaux concernant les interventions primaires de notre SMUR. Deux periodes ont ete definies en fonction de la mise en place dans le service d’une procedure therapeutique « allergie » : P 1 (1 er juillet 2000 – 30 novembre 2001) et P 2 (1 er decembre 2001 – 30 juin 2003) correspondant respectivement aux dossiers des patients pris en charge avant et apres la mise en place de la procedure. Elements analyses : differents tableaux cliniques, therapeutiques administrees, devenir des patients, impact de la procedure therapeutique sur les pratiques medicales. Resultats Les situations cliniques les plus souvent rencontrees sont l’urticaire superficielle et l’urticaire profonde sans atteinte ORL. Les traitements prescrits sont en adequation avec les donnees de la litterature pour les pathologies les plus graves. Les corticoides sont, meme pour les pathologies les moins importantes, tres largement utilises au detriment des antiH1, meme si l’utilisation de ces derniers augmentent nettement entre les deux periodes. Les patients sont orientes dans 63,3 % des cas vers un service d’Urgences. La procedure therapeutique est respectee dans 25,4 % des situations en periode 2. Conclusion Les SMUR sont rarement confrontes a la pathologie allergique et la prise en charge est peu homogene. Des recommandations s’appuyant sur la litterature sont necessaires pour harmoniser les pratiques.

How Ventilation Is Delivered During Cardiopulmonary Resuscitation: An International Survey

BACKGROUND: Recommendations regarding ventilation during cardiopulmonary resuscitation (CPR) are based on a low level of scientific evidence. We hypothesized that practices about ventilation during CPR might be heterogeneous and may differ worldwide. To address this question, we surveyed physicians from several countries on their practices during CPR. METHODS: We used a Web-based opinion survey. Links to the survey were sent by e-mail newsletters and displayed on the Web sites of medical societies involved in CPR practice from December 2013 to March 2014. RESULTS: 1,328 surveys were opened, and 548 were completed (41%). Responses came from 54 countries, but 64% came from 6 countries. Responders were mostly physicians (89%). From this group, 97% declared following specific CPR guidelines. Regarding practices, 28% declared always or frequently adopting only continuous chest compressions without additional ventilation. With regard to mechanical chest compression devices, 38% responded that such devices were available to them; when used, 28% declared always or frequently experiencing problems with ventilation such as frequent alarms. During bag-mask ventilation in intubated patients, 18% declared stopping chest compression during insufflation, and 39% applied > 10 breaths/min, which conflicts with international CPR guidelines. When a ventilator was used, the volume controlled mode was the most common strategy cited, but there was heterogeneity regarding ventilator settings for PEEP, trigger, FIO2, and breathing frequency. SpO2 and end-tidal CO2 were the 2 most monitored variables cited. CONCLUSIONS: Physicians indicated heterogeneous practices that often differ significantly from international CPR guidelines. This may reflect the low level of evidence and a lack of detailed recommendations concerning ventilation during CPR.