François-Xavier Duchateau

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.

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial

Importance Bag-mask ventilation (BMV) is a less complex technique than endotracheal intubation (ETI) for airway management during the advanced cardiac life support phase of cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest. It has been reported as superior in terms of survival. Objectives To assess noninferiority of BMV vs ETI for advanced airway management with regard to survival with favorable neurological function at day 28. Design, Settings, and Participants Multicenter randomized clinical trial comparing BMV with ETI in 2043 patients with out-of-hospital cardiorespiratory arrest in France and Belgium. Enrollment occurred from March 9, 2015, to January 2, 2017, and follow-up ended January 26, 2017. Intervention Participants were randomized to initial airway management with BMV (n = 1020) or ETI (n = 1023). Main Outcomes and Measures The primary outcome was favorable neurological outcome at 28 days defined as cerebral performance category 1 or 2. A noninferiority margin of 1% was chosen. Secondary end points included rate of survival to hospital admission, rate of survival at day 28, rate of return of spontaneous circulation, and ETI and BMV difficulty or failure. Results Among 2043 patients who were randomized (mean age, 64.7 years; 665 women [32%]), 2040 (99.8%) completed the trial. In the intention-to-treat population, favorable functional survival at day 28 was 44 of 1018 patients (4.3%) in the BMV group and 43 of 1022 patients (4.2%) in the ETI group (difference, 0.11% [1-sided 97.5% CI, −1.64% to infinity]; P for noninferiority = .11). Survival to hospital admission (294/1018 [28.9%] in the BMV group vs 333/1022 [32.6%] in the ETI group; difference, −3.7% [95% CI, −7.7% to 0.3%]) and global survival at day 28 (55/1018 [5.4%] in the BMV group vs 54/1022 [5.3%] in the ETI group; difference, 0.1% [95% CI, −1.8% to 2.1%]) were not significantly different. Complications included difficult airway management (186/1027 [18.1%] in the BMV group vs 134/996 [13.4%] in the ETI group; difference, 4.7% [95% CI, 1.5% to 7.9%]; P = .004), failure (69/1028 [6.7%] in the BMV group vs 21/996 [2.1%] in the ETI group; difference, 4.6% [95% CI, 2.8% to 6.4%]; P < .001), and regurgitation of gastric content (156/1027 [15.2%] in the BMV group vs 75/999 [7.5%] in the ETI group; difference, 7.7% [95% CI, 4.9% to 10.4%]; P < .001). Conclusions and Relevance Among patients with out-of-hospital cardiorespiratory arrest, the use of BMV compared with ETI failed to demonstrate noninferiority or inferiority for survival with favorable 28-day neurological function, an inconclusive result. A determination of equivalence or superiority between these techniques requires further research. Trial Registration clinicaltrials.gov Identifier: NCT02327026

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.

Commercial Air Travel After Pneumothorax: A Review of the Literature

Because of the physiological stresses of commercial air travel, the presence of a pneumothorax has long been felt to be an absolute contraindication to flight. Additionally, most medical societies recommend that patients wait at least 2 weeks after radiographic resolution of the pneumothorax before they attempt to travel in a nonurgent fashion via commercial air transport. This review sought to survey the current body of literature on this topic to determine if a medical consensus exists; furthermore, this review considered the scientific support, if any, supporting these recommendations. In this review, we found a paucity of data on the issue and noted only a handful of prospective and retrospective studies; thus, true evidence-based recommendations are difficult to develop at this time. We have made recommendations, when possible, addressing the nonurgent commercial air travel for the patient with a recent pneumothorax. However, more scientific research is necessary in order to reach an evidence-based conclusion on pneumothoraces and flying.

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.

Factors associated with difficult intubation in prehospital emergency medicine.

Objectives When managing airways in a prehospital setting, emergency physicians have to deal with difficult intubation (DI), which increases morbidity and mortality. The primary goal of this study was to determine predictors of DI in the out-of-hospital field faced by the French physician-staffed Emergency Medical Service. Methods The study was a prospective, observational study, including all consecutive patients intubated during a 30-month period. Patients having experienced standard intubation (two attempts or less) or DI (more than two attempts) were compared. Results Six hundred and ninety-four patients were included: 70 (11%) were classified as DI and 583 as standard intubations. Logistic regression showed that airways obstruction [odds ratio (OR), 4.1; 95% confidence interval (CI), 1.71–14.4], intubation on the floor (OR, 2.6; 95% CI, 1.04–6.6), and a hyoid-mental distance less than three fingers (OR, 2.3; 95% CI, 1.2–4.7) were independent predictors of DI. Immediate complications occurred in 89 patients (16%): 66 (11%) in the standard intubation group and 23 (31%) in the DI group (P<0.01). Conclusion For prehospital orotracheal intubation, independent risk factors of DI are a mental-thyroid distance less than three fingers, a patient on the floor, and a superior airways obstruction. Anticipation of DI could result in fewer attempts, and fewer complications, as the rate of complication increases with the difficulty of intubation.

Out-of-hospital interventions by the French Emergency Medical Service are associated with a high survival in patients aged 80 year or over

Aging represents a major issue for the healthcare system in Western countries. While age alone is an inaccurate criterion for allocation of health resources, it plays a major role in mortality of patients with organ failures [1]. Situations in which elderly patients present with an acute life-threatening pathology represent an increasing number of calls for the French Emergency Medical Service (EMS) system. In such cases both a physician and paramedics are available on scene within minutes following the call. Recent data suggest that adding advanced life support capabilities to existing EMS systems can have a positive impact on outcomes in certain patient popu-

Long-term prognosis after out-of-hospital resuscitation of cardiac arrest in trauma patients: prehospital trauma-associated cardiac arrest

Background Although prehospital cardiac arrest (CA) remains associated with poor long-term outcome, recent studies show an improvement in the survival rate after prehospital trauma associated CA (TCA). However, data on the long-term neurological outcome of TCA, particularly from physician-staffed Emergency Medical Service (EMS), are scarce, and results reported have been inconsistent. The objective of this pilot study was to evaluate the long-term outcome of patients admitted to several trauma centres after a TCA. Methods This study is a retrospective database review of all patients from a multicentre prospective registry that experienced a TCA and had undergone successful cardiopulmonary resuscitation (CPR) prior their admission at the trauma centre. The primary end point was neurological outcome at 6 months among patients who survived to hospital discharge. Results 88 victims of TCA underwent successful CPR and were admitted to the hospital, 90% of whom were victims of blunt trauma. Of these 88 patients, 10 patients (11%; CI 95% 6% to 19%) survived to discharge: on discharge, 9 patients displayed a GCS of 15 and Cerebral Performance Categories (CPC) 1–2 and one patient had a GCS 7 and CPC of 3. Hypoxia was the most frequent cause of CA among survivors. 6-month follow-up was achieved for 9 patients of the 10 surviving patients. The 9 patients with a good outcome on hospital discharge had a CPC of 1 or 2 6 months post discharge. All returned to their premorbid family and social settings. Conclusions Among patients admitted to hospital after successful CPR from TCA, hypoxia as the likely aetiology of arrest carried a more favourable prognosis. Most of the patients successfully resuscitated from TCA and surviving to hospital discharge had a good neurological outcome, suggesting that prehospital resuscitation may not be futile.

Tracheal intubation related complications in the prehospital setting

Background Prehospital tracheal intubation (TI) is associated with morbidity and mortality, particularly in cases of difficult intubation. The goal of the present study was to describe factors associated with TI related complications in the prehospital setting. Methods This was a prospective cohort study including all patients intubated on scene in a prehospital emergency medical service over a 4 year period. TI related complications included oxygen desaturation, aspiration, vomiting, bronchospasm and/or laryngospasm, and mechanical complications (mainstem intubation, oesophageal intubation and airway lesion— that is, dental or laryngeal trauma caused by the laryngoscope). Difficult intubation was defined as >2 failed laryngoscopic attempts, or the need for any alternative TI method. A multivariate logistic regression was used to identify the risk factors for TI related complications. Results 1251 patients were included; 208 complications occurred in 165 patients (13.1%). Among the 208 complications, the most frequent were oesophageal intubation (n=69, 29.7%), desaturation (n=58, 25.0%) and mainstem intubation (n=37, 15.9%). In multivariate analysis, difficult intubation (OR=6.13, 3.93 to 9.54), Cormack and Lehane grades 3 and 4 (OR=2.23, 1.26 to 3.96 for Cormack and Lehane grade 3 and OR=2.61, 1.28 to 5.33 for Cormack and Lehane grade 4 compared with Cormack and Lehane grade 1) and a body mass index >30 kg/m2 (OR=2.22, 1.38 to 3.56) were significantly associated with TI related complications. Conclusions Despite specific guidelines, TI related complications are more frequent in the prehospital setting when intubation is deemed difficult, the Cormack and Lehane grade is greater than grade 1 and the patient is overweight. In such situations, particular attention is needed to avoid complications.

Self-perception of knowledge and confidence in performing basic life support among medical students.

Aim Before implementing new workshops and teaching in our faculty for performing basic life support (BLS), we aimed to determine the level of self-confidence of medical students with regard to the management of cardiac arrest (CA). Methods We conducted a preinterventional study. A questionnaire was sent to third-year to sixth-year medical students. We recorded sex, year of training, and personal witnessing of CA. We asked them about their theoretical knowledge on 10 main items of BLS and their self-perception of qualification to conduct a CA situation. We tested the respective influence of sex, year of training, and personal witnessing of CA. Results In total, 592 (37%) students completed the questionnaire, 42% of them were men. Less than a third of the students (30%) thought of themselves as being sufficiently qualified to conduct BLS. After the third year, the level of study did not influence their theoretical knowledge or their self-perception of qualification. Male sex and the number of CAs witnessed were the only factors positively associated with better self-confidence regarding qualification. Conclusion Self-perception of qualification in BLS is poor in our faculty. In our study, personal witnessing of CA greatly influenced confidence, whereas level of study did not.