Vincent Bounes

Is there an ideal morphine dose for prehospital treatment of severe acute pain? A randomized, double-blind comparison of 2 doses.

STUDY OBJECTIVE We aimed to determine the best intravenous morphine titration protocol by comparing 2 protocols for prehospital treatment of patients with severe acute pain. METHODS Eligible patients with a numerical rating scale (NRS) score of 60/100 or higher were randomly allocated to receive either 0.05 mg/kg morphine then 0.025 mg/kg every 5 minutes (group A) or 0.1 mg/kg morphine then 0.05 mg/kg every 5 minutes (group B) intravenously. The protocol-defined primary outcome measure was the percentage of patients with pain relief (with a NRS score of 30/100 or lower) 30 minutes after the first injection. RESULTS A total of 106 consecutive patients were randomized. Thirty minutes after the injection, 66% of the patients in group A had an NRS of 30 or lower vs 76% of those in group B (P = .25). Ten minutes after the injection, 17% of the patients in group A had an NRS score of 30 or lower vs 40% of those in group B, (odds ratio, 3.4; 95% confidence interval, 1.3-8.8; P < .01). Patients in group B were significantly more satisfied with their analgesia. In addition, there were no serious complications in either group. However, patients in group B did experience almost twice the incidence of adverse effects overall and in particular 4 times the level of emesis, although neither of these observations were statistically significant. Using univariate and multivariate analysis, only an initial NRS score of 100 was an independent predictive factor for failure of analgesia (odds ratio, 0.125; 95% confidence interval, 0.02-0.68; P < .05). CONCLUSION The high-dose morphine regimen showed a similar analgesic response pattern to the low-dose one in severe acute pain in a prehospital setting. Patients in the high-dose group were more likely to experience pain relief 10 minutes after the injection. In the interests of achieving rapid pain relief, an initial dose of 0.05 mg/kg should no longer be recommended for treating severe acute pain in a prehospital setting. Another important message arising from our study is that a regimented dose of morphine, with an initial dose and strictly administered lower doses at regular intervals, is safe in the prehospital setting.

Disruption of posteromedial large-scale neural communication predicts recovery from coma

Objective: We hypothesize that the major consciousness deficit observed in coma is due to the breakdown of long-range neuronal communication supported by precuneus and posterior cingulate cortex (PCC), and that prognosis depends on a specific connectivity pattern in these networks. Methods: We compared 27 prospectively recruited comatose patients who had severe brain injury (Glasgow Coma Scale score <8; 14 traumatic and 13 anoxic cases) with 14 age-matched healthy participants. Standardized clinical assessment and fMRI were performed on average 4 ± 2 days after withdrawal of sedation. Analysis of resting-state fMRI connectivity involved a hypothesis-driven, region of interest–based strategy. We assessed patient outcome after 3 months using the Coma Recovery Scale–Revised (CRS-R). Results: Patients who were comatose showed a significant disruption of functional connectivity of brain areas spontaneously synchronized with PCC, globally notwithstanding etiology. The functional connectivity strength between PCC and medial prefrontal cortex (mPFC) was significantly different between comatose patients who went on to recover and those who eventually scored an unfavorable outcome 3 months after brain injury (Kruskal-Wallis test, p < 0.001; linear regression between CRS-R and PCC-mPFC activity coupling at rest, Spearman ρ = 0.93, p < 0.003). Conclusion: In both etiology groups (traumatic and anoxic), changes in the connectivity of PCC-centered, spontaneously synchronized, large-scale networks account for the loss of external and internal self-centered awareness observed during coma. Sparing of functional connectivity between PCC and mPFC may predict patient outcome, and further studies are needed to substantiate this potential prognosis biomarker.

Postoperative analgesia after total hip arthroplasty: patient-controlled analgesia versus transdermal fentanyl patch

STUDY OBJECTIVE To determine whether a new transdermal fentanyl patch (TFP) is a good choice for the postoperative pain management of patients undergoing primary total hip arthroplasty compared with patient-controlled analgesia (PCA). DESIGN Randomized, prospective study. SETTING University hospital. PATIENTS 30 patients undergoing primary total hip arthroplasty. INTERVENTIONS Patients received either a TFP (group T; Duragesic 50 microg/h, matrix fentanyl patch, Janssen-Cilag) applied approximately 10 hours before induction of general anesthesia and PCA programmed in the postanesthesia care unit (PACU), or PCA programmed in the PACU (group P). MEASUREMENTS Intraoperative sufentanil and additional postoperative morphine administration were recorded, as well as visual analog scores and routine vital signs at predetermined intervals during the first 48 hours. MAIN RESULTS Morphine consumption on arrival in the PACU was 3.5+/-3 mg in group T versus 13+/-5 mg in group P (P<0.0001). Visual analog scores on arrival in the PACU were 37+/-22 mm in group T versus 73+/-13 mm in group P (P<0.0001). Cumulative morphine consumption at the 24th hour was 43+/-16 mg in group P and 4+/-3 mg in group T (P<0.0001). Cumulative morphine consumption at the 48th hour was 54+/-26 mg in group P and 5+/-4 mg in group T (P<0.0001). Intraoperative sufentanil consumption was 38+/-15 microg in group T versus 30+/-5 microg in group P (not significant). The sedation score was 0 in both groups during the first 48 postoperative hours. CONCLUSIONS Preoperative TFP application decreases pain scores and morphine consumption in the PACU and appears to have prolonged effects spanning the first 48 postoperative hours.

Sédation et analgésie en structure d’urgence. Réactualisation 2010 de la Conférence d’experts de la Sfar de 1999

Sedation and analgesia in emergency structure. Reactualization 2010 of the Conference of Experts of Sfar of 1999 B. Vivien *, F. Adnet , V. Bounes , G. Chéron , X. Combes , J.-S. David , J.-F. Diependaele , J.-J. Eledjam , B. Eon , J.-P. Fontaine , M. Freysz , P. Michelet , G. Orliaguet , A. Puidupin , A. Ricard-Hibon , B. Riou , E. Wiel , J.-E. de La Coussaye o,4,** a Samu de Paris, département d’anesthésie-réanimation, hôpital Necker–Enfants-Malades, université Paris Descartes–Paris-5, 149, rue de Sèvres, 75730 Paris cedex 15, France b EA 3409, Samu 93, hôpital Avicenne, université Paris-13, 125, rue de Stalingrad, 93009 Bobigny, France c Samu 31, pôle de médecine d’urgences, hôpitaux universitaires, université de Toulouse, 1, avenue Jean-Poulhès, place du Dr.Baylac, 31059 Toulouse cedex 9, France d Département des urgences pédiatriques, hôpital Necker–Enfants-Malades, université Paris Descartes–Paris-5, 149, rue de Sèvres, 75730 Paris cedex 15, France e Département d’anesthésie-réanimation-urgences, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69493 Pierre-Bénite, France f Smur pédiatrique régional de Lille, centre hospitalier régional universitaire de Lille, université Lille-2, Nord-de-France, 5, avenue Oscar-Lambret, 59037 Lille cedex, France g Structure des urgences, hôpital Lapeyronie, université 1, 191, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France h Pôle réanimation urgence, service d’aide médicale urgente hyperbarie (RUSH), réanimation des urgences, CHU de SainteMarguerite, 270, boulevard Sainte-Marguerite, 13009 Marseille, France i Service d’accueil des urgences, hôpital Saint-Louis, université Paris-7, 1, avenue Claude-Vellefaux, 75010 Paris, France j Samu 21, département d’anesthésie-réanimation, centre hospitalier universitaire de Dijon, faculté de médecine, 3, rue du Faubourg-Raines, BP 1519, 21033 Dijon cedex, France Annales Françaises d’Anesthésie et de Réanimation 31 (2012) 391–404

Continuous positive airway pressure for cardiogenic pulmonary edema: a randomized study.

STUDY OBJECTIVE The purpose of this randomized controlled trial was to determine the immediate and delayed effects of noninvasive ventilation for patients in acute cardiogenic pulmonary edema (ACPE) in addition to aggressive usual care in a medical prehospital setting. METHODS Out-of-hospital patients in severe ACPE were eligible for the study. Patients were randomized to receive either usual care, including conventional optimal treatment with furosemide, oxygen, and high-dose boluses of isosorbide dinitrate plus oxygen, or conventional medications plus out-of-hospital continuous positive airway pressure (CPAP). The primary outcome was the treatment success defined as all of respiratory rate less than 25 breaths per minute and oxygen saturation of greater than 90% at the end of 1-hour study. Secondary end points included death during 30 days after inclusion. Lengths of intensive care unit and hospital stays were also recorded. RESULTS In total, 124 patients were enrolled into the study. The 2 groups had similar baseline characteristics. For the primary outcome analysis, 22 (35.5%) of 62 patients were considered as experiencing a treatment success in the usual care group vs 19 (31.7%) of 60 in the CPAP group (P = .65). Seven patients died within 30 days in the usual care group vs 6 in the CPAP group (P = .52). There were no statistically significant differences between the treatment groups for length of stay either in hospital or in the intensive care unit. CONCLUSION In the prehospital setting, in spite of its potential advantages for patients in ACPE, CPAP may not be preferred to a strict optimal intravenous treatment.

Sufentanil Is Not Superior to Morphine for the Treatment of Acute Traumatic Pain in an Emergency Setting: A Randomized, Double-Blind, Out-of-Hospital Trial

STUDY OBJECTIVE We determine the best intravenous opioid titration protocol by comparing morphine and sufentanil for adult patients with severe traumatic acute pain in an out-of-hospital setting, with a physician providing care. METHODS In this double-blind randomized clinical trial, patients were eligible for inclusion if aged 18 years or older, with acute severe pain (defined as a numeric rating scale score ≥ 6/10) caused by trauma. They were assigned to receive either intravenous 0.15 μg/kg sufentanil, followed by 0.075 μg/kg every 3 minutes or intravenous 0.15 mg/kg morphine and then 0.075 mg/kg. The primary endpoint of the study was pain relief at 15 minutes, defined as a numeric rating scale less than or equal to 3 of 10. Secondary endpoints were time to analgesia, adverse events, and duration of analgesia during the first 6 hours. RESULTS A total of 108 patients were included, 54 in each group. At 15 minutes, 74% of the patients in the sufentanil group had a numeric rating scale score of 3 or lower versus 70% of those in the morphine group (Δ4%; 95% confidence interval -13% to 21%). At 9 minutes, 65% of the patients in the sufentanil group experienced pain relief versus 46% of those in the morphine group (Δ18%; 95% confidence interval 0.1% to 35%). The duration of analgesia was in favor of the morphine group. Nineteen percent of patients experienced an adverse event in both groups, all mild to moderate. CONCLUSION Intravenous morphine titration using a loading dose of morphine followed by strictly administered lower doses at regular intervals remains the criterion standard. Moreover, this study supports the idea that the doses studied should be considered for routine administration in severe pain protocols.

A Comparison Between Double-injection Axillary Brachial Plexus Block and Midhumeral Block for Emergency Upper Limb Surgery

In this prospective and randomized study, we compared a double-injection axillary (median and radial nerves) block with a midhumeral block in 90 patients undergoing emergency upper limb surgery. Time to perform the block, success rate, and patient tolerance were evaluated. The time to perform the block was 5 min longer in the midhumeral group. The success rate was similar in both groups (80% and 91% in groups axillary and midhumeral respectively), except for the musculocutaneous nerve. Patient tolerance was better in the axillary group. Double-injection axillary brachial plexus block is superior to midhumeral block for emergency hand surgery.

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.

Rupture of splenic artery aneurysm during early pregnancy: a rare and catastrophic event.

Spontaneous rupture of splenic artery aneurysm during pregnancy is a rare, life-threatening event with a catastrophic prognosis. Splenic artery aneurysm, known to be more frequent in women, especially among multiparous ones, is generally asymptomatic until rupture. Because of increased blood flow and hormonal modifications, this rupture occurs frequently during pregnancy, most often at the end of the third trimester. We present the case of a second parous woman in early pregnancy with a rupture of splenic artery aneurysm initially diagnosed as a complicated ectopic pregnancy, which profoundly modifies surgical treatment. Through this case report, we want to draw attention to the fact that even if complicated ectopic pregnancy is much more frequent, ruptured splenic artery aneurysm (SAA) needs to be considered as a part of differential diagnosis of hemoperitoneum during the first trimester as well.