Michel Galinski

Randomized Study Comparing the "Sniffing Position" with Simple Head Extension for Laryngoscopic View in Elective Surgery Patients

BackgroundThe “sniffing position” is recommended for optimization of glottic visualization under direct laryngoscopy. However, no study to date has confirmed its superiority over simple head extension. In a prospective, randomized study, the authors compared the sniffing position with simple head extension in orotracheal intubation. MethodsThe study included 456 consecutive patients. The sniffing position was obtained by placement of a 7-cm cushion under the head of the patient. The extension position was obtained by simple head extension. The anesthetic procedure included two laryngoscopies without paralysis: the first was used for topical glottic anesthesia. During the second direct laryngoscopy, intubation of the trachea was performed. The head position was randomized as follows: group A was in the sniffing position during the first laryngoscopy and the extension position during the second; group B was in the extension position during the first laryngoscopy and the sniffing position during the second. Glottic exposure was assessed by the Cormack scale. ResultsThe sniffing position improved glottic exposure (decreased the Cormack grade) in 18% of patients and worsened it (increased the Cormack grade) in 11% of patients, in comparison with simple extension. The Cormack grade distribution was not significantly modified between the two groups. Multivariate analysis showed that reduced neck mobility and obesity were independently related to improvement in laryngoscopic view with application of the sniffing position. ConclusionsRoutine use of the sniffing position appears to provide no significant advantage over simple head extension for tracheal intubation in this setting. The sniffing position appears to be advantageous in obese and head extension–limited patients.

Prevalence and Management of Acute Pain in Prehospital Emergency Medicine

Abstract Background. Less is known about the prevalence of pain in prehospital emergency medicine than about pain in the emergency department. Objectives. To estimate the prehospital prevalence of pain and to identify the factors associated with oligoanalgesia. Methods. The mobile intensive care units of the emergency services of a Paris suburb conducted this prospective study. All consecutive patients aged 16 years or older who were able to self-assess pain were included around the clock over a period of 11 months in 2007. Results. Among the 2,279 included patients, 947 had acute pain (42% [95% confidence interval (CI) 40–44]). Pain was intense to severe in 64% of patients. Factors associated with acute pain were trauma (odds ratio [OR] = 2.9 [1.9–4.3]) and age under 75 years (OR = 2.2 [1.7–2.8]). Intense pain was significantly associated with pain of cardiac or traumatic origin. Among the 1,364 patients transported by the mobile units, 48% experienced acute pain (71% had intense to severe pain). An analgesic agent was administered to 73%. According to multivariate analysis, only gynecologic/obstetric emergencies were associated with inadequate treatment (OR = 0.2 [95% CI 0.1–0.6]). Overall, 51% of patients [46–56] experienced pain relief. The rate of pain relief was lowest in patients suffering from trauma or a gynecologic/obstetric disorder. Conclusion. In our studied population, pain in prehospital emergency medicine affects 42% of patients. However, the rate varies widely according to the origin of the pain. Pain management is inadequate, as only one in two patients experiences relief.

Risk factors for onset of hypothermia in trauma victims: The HypoTraum study

IntroductionHypothermia is common in trauma victims and is associated with an increase in mortality. Its causes are not well understood. Our objective was to identify the factors influencing the onset of hypothermia during pre-hospital care of trauma victims.MethodsThis was a multicenter, prospective, open, observational study in a pre-hospital setting.The subjects were trauma victims, over 18 years old, receiving care from emergency medical services (EMS) and transported to hospital in a medically staffed mobile unit.Study variables included: demographics and morphological traits, nature and circumstances of the accident, victims presentation (trapped, seated or lying down, on the ground, unclothed, wet or covered by a blanket), environmental conditions (wind, rain, ground temperature and air temperature on site and in the mobile unit), clinical factors, Revised Trauma Score (RTS), tympanic temperature, care provided (including warming, drugs administered, infusion fluid temperature and volume), and EMS and hospital arrival times.ResultsA total of 448 patients were included. Hypothermia (<35°C) on hospital arrival was present in 64/448 patients (14%). Significant factors associated with the absence of hypothermia in a multivariate analysis were no intubation: Odds Ratio: 4.23 (95% confidence interval 1.62 to 1.02); RTS: 1.68 (1.29 to 2.20); mobile unit temperature: 1.20 (1.04 to 1.38); infusion fluid temperature: 1.17 (1.05 to 1.30); patient not unclothed: 0.40 (0.18 to 0.90); and no head injury: 0.36 (0.16 to 0.83).ConclusionsThe key risk factor for the onset of hypothermia was the severity of injury but environmental conditions and the medical care provided by EMS were also significant factors. Changes in practice could help reduce the impact of factors such as infusion fluid temperature and mobile unit temperature.

Out-of-hospital emergency medicine in pediatric patients: prevalence and management of pain.

INTRODUCTION Much less is known about pain prevalence in pediatric patients in an out-of-hospital than emergency department setting. The purpose of this study was to determine pain prevalence in children in a prehospital emergency setting and to identify the factors associated with pain relief. MATERIALS AND METHODS This prospective cohort study in consecutive patients 15 years or younger was conducted by 5 mobile intensive care units working 24/7 (January-December 2005). The presence of pain, its intensity, and alleviation by the administration of analgesics were recorded. RESULTS A total of 258 of 433 pediatric patients were included, of whom 96 were suffering from acute pain (37%; 95% confidence interval [CI], 31-43) that was intense to severe in 67% of cases. Trauma was the only factor significantly associated with acute pain (odds ratio, 818; 95% CI, 153-4376). Overall, 92% of the children in pain received at least one analgesic drug; 41% received a combination of drugs. Opioid administration was significantly associated with intense to severe pain (odds ratio, 7; 95% CI, 2-25). On arrival at hospital, 67% of the children were still in pain; but 84% had experienced some pain relief regardless of their sex, age, or disorder. CONCLUSION In a prehospital emergency setting, more than a third of children experience acute pain with a high prevalence of intense to severe pain. Scoring pain in children, and especially in the newborn, is beleaguered by a lack of suitable scales. Despite this, it was possible to treat 90% of children in pain and provide relief in 80% of cases.

Gender as a risk factor for pulmonary embolism after air travel

It was the objective of this study to confirm the hypothesis that women experience an increased risk of pulmonary embolism (PE) and/or thromboembolic events after long-distance air travel. We systematically reviewed the records of all patients with confirmed pulmonary embolism after arrival at Roissy-Charles-de-Gaulle (CDG) Airport (Paris, France) during a 13-year period. The incidence of PE was calculated as a function of distance travelled and gender using Bayesian conditional probabilities obtained in part from a control population of long-distance travellers arriving in French Polynesia (Tahiti). A total of 287.6 million passengers landed at CDG airport during the study period. The proportion of male to female long-distance travellers was estimated to be 50.5% to 49.5%. Overall, 116 patients experienced PE after landing [90 females (78%), 26 males (22%)]. The estimated incidence of PE was 0.61 (0.61-0.61) cases per million passengers in females and 0.2 (0.20-0.20) in males, and reached 7.24 (7.17-7.31) and 2.35 (2.33-2.38) cases, respectively, in passengers travelling over 10,000 km. Our study strongly suggests that there is a relationship between risk of PE after air travel and gender. This relationship needs to be confirmed in order to develop the best strategy for prophylaxis.

Reduction of Paracetamol Metabolism after Hepatic Resection

Introduction: Paracetamol is often used as an analgesic following hepatic resection. During liver resection, vascular clamping is carried out to reduce blood loss. Previous studies have described transient postoperative rises in serum aminotransferase levels and decreases in prothrombin time and factor V levels. We have examined paracetamol metabolism after liver resection. Methods: A prospective observational study was performed. All patients undergoing liver resection were included. Propacetamol was given every 6 h. Blood samples for plasma paracetamol concentrations were collected before, 1 h after the end of the first injection (T1), just before the second injection (6 h: T6), and just before the fifth injection (24 h: T24). Results: 37 patients were recruited. 13 had hepatic vascular exclusion (HVE group), 13 had portal triad clamping (PTC group) and 11 had abdominal surgery with no liver resection (NLR group: control group). At T6, the plasma paracetamol concentration in the HVE group was significantly higher than in the NLR groups; at T24, this concentration was significantly higher in the HVE group than in the NLR and PTC groups, and was higher in the PTC group than in the NLR group. Prothrombin time and factor V was significantly lower in the HVE group than in the PTC group on the first postoperative day. Discussion: This study showed a reduction of paracetamol metabolism in the liver resection group with significantly increased paracetamol levels. However, the maximum mean plasma concentration reached was not clinically or toxicologically significant. For these reasons, we cannot suggest that paracetamol should or should not be avoided in patients undergoing liver resection.

Laryngoscope plastic blades in scheduled general anesthesia patients: a comparative randomized study

STUDY OBJECTIVE To compare two brands of disposable plastic laryngoscope blades, Vital View plastic blades and Heine XP plastic blades, with the reusable Heine Classic+ Macintosh metal blades. DESIGN Prospective randomized, controlled, single-blinded study. SETTING Operating room of a university-affiliated hospital. PATIENTS 519 patients without criteria for predicted difficult intubation, undergoing scheduled surgery during general anesthesia. INTERVENTIONS Patients were randomized to three groups according to laryngoscope blade brand. MEASUREMENTS Difficult tracheal intubation was evaluated by the Intubation Difficulty Scale (IDS) (IDS > 5 = procedure involving moderate to major difficulty). MAIN RESULTS The percentage of intubations with an IDS > 5 was 3.1% in Group M (metal blade group), 5.1% in Group V (Vital View plastic blade group), and 10.0% in Group H (Heine plastic blade group). A significant difference was noted between Groups M and H (P = 0.02) but not between Groups M and V. CONCLUSIONS Intubation may be more challenging when using Heine XP plastic blades but no significant difference exists between Vital-View plastic blades and Heine Classic+ metal blades.

Out-of-hospital use of an automated chest compression device: facilitating access to extracorporeal life support or non–heart-beating organ procurement

OBJECTIVE The aim of the study was to assess the ease-of-use, safety, and usefulness of an automated external chest compression device for cardiopulmonary resuscitation. METHODS Adults with out-of-hospital cardiac arrest (OHCA) were included prospectively. The emergency medical services (EMS) in a large suburb northeast of Paris (France) recorded data for standard criteria for EMS care for CA and specific criteria on device use-application time, ease of application and use (visual analog scale score: 0, impossible; 5, very easy), technical incidents, and clinical complications. RESULTS We attended 4868 OHCA patients (January 2005 to April 2010) and used the device in 285 patients (6%) (212 males [74%], 73 females [26%]; median age, 56 [43-70] years). Results (medians with 25-75 percentiles) were as follows: time to apply device, 30 seconds (20-60); ease of application and activation, 5 (4-5) and 5 (5-5), respectively; duration of use, 30 (20-41) minutes; return to spontaneous circulation (ROSC), 76 patients (27%); and time to ROSC, 19 (12-32) minutes after placement. Twenty-seven patients (9%) with refractory CA benefited from extracorporeal life support. Overall, 32 patients were alive after 24 hours, 11 at 7 days, and 3 at 1 month. An additional 23 patients (8%) with refractory CA were selected for non-heart-beating kidney procurement. Ten patients were used to harvest kidneys and 15 were transplanted. There were 21 technical incidents (7%) and 19 clinical complications (7%). CONCLUSION The device was easy to use in routine emergency practice and of particular value in facilitating access to extracorporeal life support or non-heart-beating organ procurement. These uses should be itemized in all OHCA studies.

Information médicale : de l’hôpital à la ville. Que perçoit le médecin traitant ?

BACKGROUND The communication and circulation of medical information between hospitals and GPs play a central role in the quality of care. Numerous statutes, regulations, and clinical practice guidelines stress the need for such communication. We assessed how it really works. METHODS We conducted face-to-face interviews based on a standardized questionnaire with 50 GPs in the districts of Paris and Seine-Saint-Denis, to explore different aspects of their communication with hospitals: the communication channels, and the amount, content, and quality of the information received. RESULTS It appears that the overall quantity of communication is satisfactory but its quality and content vary according to the reasons for which the GP sent the patient to the hospital. GPs have a deep feeling that hospital staff physicians do not collaborate with them. CONCLUSION The proposed personal medical file may help resolve logistic obstacles to the circulation of medical information but it will not bridge the cultural gap that exists between the two pillars of the system of care: the hospital and the GP.

Chest Pain in an Out‐of‐Hospital Emergency Setting: No Relationship Between Pain Severity and Diagnosis of Acute Myocardial Infarction

Chest pain frequently prompts emergency medical services (EMS) call‐outs. Early management of acute coronary syndrome (ACS) cases is crucial, but there is still controversy over the relevance of pain severity as a diagnostic criterion.