Paul-Georges Reuter

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

Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials

BACKGROUND A routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined. Individual clinical trials were underpowered to detect a mortality benefit; we therefore did a meta-analysis to assess the effect of timing on mortality. METHODS We identified randomised controlled trials comparing an early versus a delayed invasive strategy in patients presenting with NSTE-ACS by searching MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. We included trials that reported all-cause mortality at least 30 days after in-hospital randomisation and for which the trial investigators agreed to collaborate (ie, providing individual patient data or standardised tabulated data). We pooled hazard ratios (HRs) using random-effects models. This meta-analysis is registered at PROSPERO (CRD42015018988). FINDINGS We included eight trials (n=5324 patients) with a median follow-up of 180 days (IQR 180-360). Overall, there was no significant mortality reduction in the early invasive group compared with the delayed invasive group HR 0·81, 95% CI 0·64-1·03; p=0·0879). In pre-specified analyses of high-risk patients, we found lower mortality with an early invasive strategy in patients with elevated cardiac biomarkers at baseline (HR 0·761, 95% CI 0·581-0·996), diabetes (0·67, 0·45-0·99), a GRACE risk score more than 140 (0·70, 0·52-0·95), and aged 75 years older (0·65, 0·46-0·93), although tests for interaction were inconclusive. INTERPRETATION An early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients. FUNDING None.

Family Presence during Resuscitation: A Qualitative Analysis from a National Multicenter Randomized Clinical Trial

Background The themes of qualitative assessments that characterize the experience of family members offered the choice of observing cardiopulmonary resuscitation (CPR) of a loved one have not been formally identified. Methods and Findings In the context of a multicenter randomized clinical trial offering family members the choice of observing CPR of a patient with sudden cardiac arrest, a qualitative analysis, with a sequential explanatory design, was conducted. The aim of the study was to understand family members’ experience during CPR. All participants were interviewed by phone at home three months after cardiac arrest. Saturation was reached after analysis of 30 interviews of a randomly selected sample of 75 family members included in the trial. Four themes were identified: 1- choosing to be actively involved in the resuscitation; 2- communication between the relative and the emergency care team; 3- perception of the reality of the death, promoting acceptance of the loss; 4- experience and reactions of the relatives who did or did not witness the CPR, describing their feelings. Twelve sub-themes further defining these four themes were identified. Transferability of our findings should take into account the country-specific medical system. Conclusions Family presence can help to ameliorate the pain of the death, through the feeling of having helped to support the patient during the passage from life to death and of having participated in this important moment. Our results showed the central role of communication between the family and the emergency care team in facilitating the acceptance of the reality of death.

Early invasive strategy in high-risk acute coronary syndrome without ST-segment elevation. The Sisca randomized trial.

BACKGROUND The optimal therapeutic strategy for patients with high-risk acute coronary syndrome without ST-segment elevation (NSTE-ACS) remains unclear. OBJECTIVE Our aim was to compare the effectiveness of an early invasive strategy and a delayed invasive strategy in the management of high-risk NSTE-ACS patients. METHODS This randomized clinical trial in a primarily pre-hospital setting enrolled patients with chest pain, electrocardiographic criteria for an NSTE-ACS, and at least one criterion of severity (ESC criterion or TIMI score >5). Patients were randomized to either an early invasive strategy (tirofiban infusion and coronary angiography within 6h) or delayed invasive strategy (as per guidelines and physician discretion; coronary angiography within 6h was not advised). The primary endpoint was the cumulative incidence of deaths, myocardial infarctions, or urgent revascularizations at 30days of follow-up. Secondary endpoints were failure of delayed management, length of hospital stay and long-term mortality. RESULTS Between January 2007 and February 2010, 170 patients were enrolled. The cumulative incidence of adverse outcomes was significantly lower for early invasive than delayed management (2% [95% CI 0-9] vs. 24% [95% CI 16-35], p<10(-4)). Delayed management failed in 24% of cases. The length of hospital stay was significantly shorter in patients undergoing angioplasty or treated with tirofiban within 6h (p=0.0003). Long-term mortality was 16% in both arms after a median follow-up of 4.1years. CONCLUSION An early invasive strategy reduced major adverse cardiac events in patients with high-risk NSTE-ACS. Early angiography or tirofiban (GP IIb/IIIa inhibitor) infusion proved necessary in a quarter of patients assigned to delayed management.

Cardiopulmonary resuscitation duration and survival in out-of-hospital cardiac arrest patients.

AIM Relationship between cardiopulmonary arrest and resuscitation (CPR) durations and survival after out-of-hospital cardiac arrest (OHCA) remain unclear. Our primary aim was to determine the association between survival without neurologic sequelae and cardiac arrest intervals in the setting of witnessed OHCA. METHODS We analyzed 27,301 non-traumatic, witnessed OHCA patients in France included in the national registry from June 1, 2011 through December 1, 2015. We analyzed cardiac arrest intervals, designated as no-flow (NF; from collapse to start of CPR) and low-flow (LF; from start of CPR to cessation of resuscitation) in relation to 30-day survival without sequelae. We determined the influence of recognized prognostic factors (age, gender, initial rhythm, location of cardiac arrest) on this relation. RESULTS For the entire cohort, the area delimited by a value of NF greater than 12min (95% confidence interval: 11-13min) and LF greater than 33min (95% confidence interval: 29-45min), yielded a probability of 30-day survival of less than 1%. These sets of values were greatly influenced by initial cardiac arrest rhythm, age, sex and location of cardiac arrest. Extended CPR duration (greater than 40min) in the setting of initial shockable cardiac rhythm is associated with greater than 1% survival with NF less than 18min. The NF interval was highly influential on the LF interval regardless of outcome, whether return of spontaneous circulation (p<0.001) or death (p<0.001). CONCLUSION NF duration must be considered in determining CPR duration in OHCA patients. The knowledge of (NF, LF) curves as function of age, initial rhythm, location of cardiac arrest or gender may aid in decision-making vis-à-vis the termination of CPR or employment of advanced techniques.

Relative adrenal insufficiency in critically ill patient after rapid sequence intubation: KETASED ancillary study

PURPOSE Relative adrenal insufficiency (RAI) has been reported as a predictor of mortality in septic patient; however, its effects on mortality and outcomes for critically ill patients remain debatable. The objective of this study was to assess the effect of RAI on prognostic outcomes in patients after out-of-hospital rapid sequence intubation (RSI) and factors associated with the onset of RAI. PATIENTS AND METHODS A prespecified ancillary study of KETASED, a randomized prospective multicenter trial, was conducted. Three hundred ten patients who underwent RSI in an out-of-hospital setting had baseline cortisol and adrenocorticotropic hormone response test measurements within 24 hours of intensive care unit admission and were included. RESULTS The mean (SD) age was 55 (19) years, with a mean (SD) Sequential Organ Failure Assessment score of 9 (4). Two hundred forty-seven (69%) patients presented with RAI. Baseline characteristics were similar between patients with and without RAI, except for the use of etomidate as a sedative agent (63% of patients with RAI vs 21%, P<.001), and history of chronic kidney disease. There was no difference in terms of 28-day mortality between the 2 groups (21% vs 19%, P=.65) and in terms of other 28-day prognosis end points. CONCLUSION In critically ill patients who require RSI, RAI is common and is not associated with worsened outcomes in our cohort.

Prevalence of advance directives and impact on advanced life support in out-of-hospital cardiac arrest victims

AIM To evaluate the prevalence of advance directives and their impact on the management of out-of-hospital cardiac arrest (OHCA) victims. METHODS We analyzed data extracted from the French national registry of adult OHCA patients (RéAC). The data concerned the emergency medical services (EMS) of a Paris suburb over the period 01/01/2013 to 30/11/2015. The primary endpoint was the prevalence of advance directives. Secondary endpoints were the characteristics of the population, of cardiac arrest, and of basic life support as well as outcomes in patients with or without advance directives. RESULTS Advance directives were available for 148/1985 (7.5%) of OHCA patients. Advanced life support was given to 35 patients with directives and 941 patients without (24% vs. 51%, p <0.0001) with no significant difference in the characteristics of the support provided. Spontaneous recovery of cardiac activity was observed in 5 patients with directives and in 217 patients without (14% vs. 23%, p=0.3). Among patients with advance directives, only one was admitted to hospital. He/she died within 24h of admission. CONCLUSION Advance directives were accessed by EMS for 7.5% OHCA patients. Despite their availability, advanced life support was provided to 24% of patients.

Impact of onsite or dispatched automated external defibrillator use on early survival after sudden cardiac arrest occurring in international airports

Out-of-hospital cardiac arrest (OHCA) is a major public health challenge. Use of automated external defibrillators (AED) by laypersons improves survival of patients victim of OHCA. The aim of our study was to compare onsite AED vs. dispatched AED management of cardiac arrest occurring in international airports. We conducted a retrospective, observational, comparative, study on data collected from three international airports: Paris-Charles-de-Gaulle (CDG), Chicago and Madrid-Barajas. We included patients with OHCA occurring inside the airport between 2009 and 2013. Group public access (PUB) included airports where AED were available to laypersons and group dispatched (SEC) was represented by Paris-CDG airport where AED was provided by paramedic teams. The primary endpoint was successful resuscitation defined as survival at time of hospital admission. We included 150 consecutive patients victim of OHCA in the three airports. The time between collapse and AED setting was significantly shorter in the PUB vs. SEC group (4±3minutes vs. 11±11, P=0.0006). The total duration of resuscitation was shorter in the PUB group (10±10minutes vs. 36±25minutes, P<0.0001). Survival at time of hospital admission was higher in the PUB group (62% vs. 38%, P=0.01). The availability of public access AEDs in international airports seems to allow a quicker defibrillation and an increased success rate of resuscitation.INTRODUCTION Out-of-hospital cardiac arrest (OHCA) is a major public health challenge. Use of automated external defibrillators (AED) by laypersons improves survival of patients victim of OHCA. The aim of our study was to compare onsite AED vs. dispatched AED management of cardiac arrest occurring in international airports. METHODS We conducted a retrospective, observational, comparative, study on data collected from three international airports: Paris-Charles-de-Gaulle (CDG), Chicago and Madrid-Barajas. We included patients with OHCA occurring inside the airport between 2009 and 2013. Group public access (PUB) included airports where AED were available to laypersons and group dispatched (SEC) was represented by Paris-CDG airport where AED was provided by paramedic teams. The primary endpoint was successful resuscitation defined as survival at time of hospital admission. RESULTS We included 150 consecutive patients victim of OHCA in the three airports. The time between collapse and AED setting was significantly shorter in the PUB vs. SEC group (4±3minutes vs. 11±11, P=0.0006). The total duration of resuscitation was shorter in the PUB group (10±10minutes vs. 36±25minutes, P<0.0001). Survival at time of hospital admission was higher in the PUB group (62% vs. 38%, P=0.01). CONCLUSION The availability of public access AEDs in international airports seems to allow a quicker defibrillation and an increased success rate of resuscitation.

Research in prehospital emergency medicine: comparison by geographic origin of publications.

Evaluation of the geographic origin of publication is highly complex. A publication can, with the same legitimacy, be attributed according to the origin of the first or the last author, the source of funding or the location or the number of patients included. This leads to further issues for multicentre studies. To compare a paper or a project’s origin by country, other parameters should be considered such as the ratio of publications to the number of researchers/physicians in that field or the geographic organization of emergency care and its network in that country. For example, the presence of prehospital physicians should explain ‘the interest of European teams in the specific field of prehospital emergency medicine’ and influence the number and type of research projects in this area. This is also the case with acute coronary syndromes in France, where emergency physicians are involved in prehospital teams [2].

Hereditary angioedema: Clinical presentation and socioeconomic cost of 200 French patients

Hereditary angioedema: Clinical presentation and socioeconomic cost of 200 French patients Nicolas Javaud, MD, PhD, Laurence Bouillet, MD, PhD, Hasina Rabetrano, MS, Alexandre Bitoun, MD, David Launay, MD, PhD, Frederic Lapostolle, MD, PhD, Paul-Georges Reuter, MD, MS, Ludovic Martin, MD, PhD, Eric Vicaut, MD, PhD, Olivier Fain, MD, Frederic Adnet, MD, PhD, and Isabelle Durand-zaleski, MD, PhD; on behalf of the SOS-HAE Collaborative Study Group