Jean-Louis Ducassé

Peritraumatic dissociation, acute stress, and early posttraumatic stress disorder in victims of general crime.

Objective: To compare the relation between peritraumatic dissociation and acute stress and the early development of posttraumatic stress disorder (PTSD) in victims of general crime. Method: A total of 48 subjects were assessed within 24 hours of the trauma, using the Peritraumatic Dissociative Experiences Questionnaire Self-Report Version (PDEQ-SRV). They were followed longitudinally to assess acute stress (2 weeks after the assault,) using the Standford Acute Stress Reaction Questionnaire (SASRQ), and posttraumatic stress (at 5 weeks), using the Clinician-Administered PTSD Scale (CAPS) and the Impact of Event Scale (IES). Results: Among PTSD subjects mean PDEQ scores were significantly higher (mean 3, SD 0.9) than in those without PTSD (mean 2.3, SD 0.7) (t = 2.78, df 46, P = 0.007). Among PTSD subjects, mean SASRQ scores were significantly higher (mean 97.9, SD 29.2) than in those without PTSD (mean 54.8, SD 28.2) (t = 4.9, df 46, P = 0.00007). Conclusions: High levels of peritraumatic dissociation and acute stress following violent assault are risk factors for early PTSD. Identifying acute reexperiencing can help the clinician identify subjects at highest risk.

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.

Determinants and prognostic impact of compliance with guidelines in reperfusion therapy for ST-segment elevation myocardial infarction: Results from the ESTIM Midi-Pyrénées Area ☆

BACKGROUND Early reperfusion therapy has proven benefit in reducing mortality in patients with ST-segment elevation myocardial infarction (STEMI). Expert guideline committees have defined recommendations to improve the management of patients with STEMI and decrease their mortality rates. AIMS To identify predictors of compliance with American College of Cardiology/American Heart Association guidelines for reperfusion therapy in STEMI and to determine the prognostic impact of compliance. METHODS ESTIM Midi-Pyrénées was a multidisciplinary, prospective registry in patients with STEMI, conducted between June 2001 and June 2003 in French hospitals. Data were analysed from 1277 patients managed by emergency physicians in the prehospital system or emergency room and/or cardiologists in interventional or non-interventional cardiology departments. RESULTS A revascularization strategy was performed in 89.4% of patients; treatment complied with the guidelines in 61.1% of patients. After multivariable analysis, factors associated with compliance were age less or equal than 75years (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.18-2.08), symptom onset during the day (OR 1.43, 95% CI 1.12-1.82), typical electrocardiographic symptoms of STEMI (OR 3.2, 95% CI 2.19-4.5), and initial medical contact. After adjustment for confounders, 1-month mortality was significantly lower in patients managed according to guideline recommendations (OR 0.60, 95% CI 0.40-0.92). CONCLUSION A number of factors can be used to identify STEMI patients who are less likely to be managed according to guidelines. Training focused on these factors should improve management and clinical outcomes of STEMI.

Diagnostic accuracy of quantitative heart-fatty acid binding protein assays compared with Cardiodetect® in the early detection of acute coronary syndrome

BACKGROUND Heart-fatty acid binding protein (h-FABP) has been proposed as a cardiac marker for the early detection of acute coronary syndrome (ACS). In a study of 677 patients admitted to the emergency department (ED) for chest pain, we found that a semiquantitative point-of-care test that detects h-FABP (Cardiodetect(®)) had low sensitivity for the prediction of ACS. OBJECTIVE The aim of this ancillary study was to analyze and compare the performance of h-FABP for early ACS diagnosis in this large cohort of unselected patients, using a quantitative immunoassay and Cardiodetect(®). METHODS h-FABP was measured with a ready-to-use, solid-phase, enzyme-linked immunosorbent assay (ELISA) in 677 patients admitted to the ED with chest pain and suspected non-ST-segment elevation ACS. Two physicians, blinded to the results of the marker, categorized patients as having or not having non-ST-segment elevation ACS. RESULTS Non-ST-segment elevation ACS was diagnosed in 185 patients (27.3%). The median h-FABP level was higher in patients with ACS (1.36μg/L, interquartile range [IQR] 0.59-3.55) than in those without ACS (0.58μg/L, IQR 0.24-1.34; P<0.01). The area under the curve was 0.68 (95% confidence interval [CI] 0.63-0.73). h-FABP did not improve the performance of a model that included the usual diagnostic tools for ACS management (odds ratio 0.92, 95% CI 0.32-2.70). The classification agreement between the ELISA and Cardiodetect(®) was 92.1% (kappa 0.39). CONCLUSION In this study, we confirmed that measurement of h-FABP was insufficient to be used as a marker of ACS and NSTEMI in ED, whatever the analytical technique used.

Compliance with guidelines in patients with ST-segment elevation myocardial infarction after implementation of specific guidelines for emergency care: Results of RESCA+31 registry

BACKGROUND Guidelines emphasize the implementation of local networks with prehospital emergency medical systems to improve the management of patients with ST-segment elevation myocardial infarction (STEMI); they also define the choice of reperfusion strategies and adjunctive treatments. AIM To assess the compliance of STEMI emergency care with current French guidelines in a large area of France and to identify predictors of compliance with guidelines. METHOD The RESCA+31 registry was a 2-year, multicentre, prospective, multidisciplinary study, including 512 consecutive patients with STEMI evolving within 12 hours managed by emergency physicians in the prehospital system or emergency department. Data were recorded during the emergency phase and after admission to cardiology. RESULTS First medical contact (FMC) was prehospital emergency care for 80% of patients; 97% received reperfusion treatment and 98% were admitted to a cardiology intensive care unit (CICU) with a catheterization laboratory. The mortality rate was 5%. Guidelines were complied with in 41% of patients for reperfusion strategies, in 47% for adjunctive treatments and in 23% for both. The only factor independently associated with guideline compliance was FMC by prehospital emergency system. In 52% of cases, emergency physicians underestimated the delay between FMC and admission to a CICU. CONCLUSION Despite the implementation of a network, compliance with guidelines for reperfusion strategies and adjunctive treatments was insufficient in our area. However, very few patients did not receive reperfusion therapy and the mortality rate was low. Efforts should be made to improve the estimation of delay before primary percutaneous coronary intervention.

Prehospital mechanical ventilation of a critical cardiac tamponade

Mechanical ventilation of a critical cardiac tamponade is a high-risk situation that can lead to asystolic cardiac arrest. We report a prehospital mechanical ventilation of a penetrating cardiac injury complicated with tamponade. Onset diagnosis of the circulatory arrest allowed by prehospital continuous ultrasonography led to earlier initiation of the resuscitation and might have favored successful outcome. Electrocardiographic signs are too late to diagnose circulatory arrest.

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.