Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

Resilience strategy in emergency medicine during the Covid-19 pandemic in Paris

Objectives

SARS-Cov-2 is a respiratory virus of the coronavirus family. It is responsible for viral pneumonia. The Covid-19 pandemic started in China in December 2019 before spreading to the rest of the world. Managing this pandemic has significantly changed the way our emergency services work. The main objective of this study was to describe the organizational impact of the Covid-19 pandemic in Emergency Medicine.

Methods

Descriptive observational study of the “adaptation strategy” of two Parisian emergency services, during the first wave of the Covid-19 pandemic from March 01, 2020 until the end of lockdown on May 11, 2020.

Results

As the infectious reason is the main reason for consultation during a pandemic, prevention measures have been reinforced. In order to limit the risk of viral transmission, a segmentation of the emergency services and the entire hospital was carried out. So we were able to distinguish between Red zones (High viral density) and Green zones (Low viral density). The hospital's infectious medicine and resuscitation capacity has been increased to manage the massive influx of patients consulting the emergency room.

Conclusion

Our resilience strategy reinforced by the implementation of the containment system has made it possible to overcome this pandemic. It would be appropriate to assess the impact of this strategy on the occurrence of nosocomial infections later.

Évaluation des éléments perturbateurs lors de réanimation cardiopulmonaire aux urgences

Introduction : La simulation est un outil d’enseignement en médecine qui a montré un bénéfice entre autres pour l’apprentissage de la réanimation cardiopulmonaire (RCP). Cependant, la RCP simulée peut différer grandement de la RCP en conditions réelles. Le but de cette étude exploratoire était d’identifier des éléments perturbateurs susceptibles d’intervenir lors d’une RCP.

Méthodes : Il s’agit d’une étude transversale anonyme par questionnaire distribué par courrier électronique aux urgentistes de cinq services d’urgences à Paris. Le questionnaire comprenait des questions sur les éléments perturbateurs lors d’une RCP. D’autres questions ont exploré les différences perçues entre la RCP simulée et la RCP réelle. Les résultats sont exprimés sous forme de pourcentages et moyennes (± écart-type).

Résultats : Sur 100 médecins interrogés, 43 (43 %) réponses ont été analysées. Cinquante-trois pour cent étaient des femmes âgées en moyenne de 32 ± 3 ans. Les éléments perturbateurs de la RCP dans la vie réelle étaient principalement les interruptions de tâches provenant du personnel non médical (n = 16 ; 37 %), de la famille du patient (n = 5 ; 12 %), des autres spécialistes (n = 5 ; 12 %) et des appels téléphoniques (n = 2 ; 5 %). La saturation du flux patient des urgences (n = 12 ; 28 %) a également été mentionnée comme perturbateur. Les médecins ont aussi déclaré que certaines compétences techniques et non techniques étaient plus difficiles à réaliser dans la vie réelle que lors de simulations.

Conclusion : Cette étude exploratoire a permis d’identifier des éléments perturbateurs rencontrés dans des cas réels de RCP qui pourront être intégrés aux sessions de simulation afin d’en augmenter le réalisme.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

Trends in death attributed to myocardial infarction, heart failure and pulmonary embolism in Europe and Canada over the last decade

BACKGROUND

Worldwide, cardiovascular diseases and cancer account for ∼40% of deaths. Certain reports have shown a progressive decrease in mortality. Our main objective was to assess mortality trends related to myocardial infarction (MI), heart failure (HF) and pulmonary embolism (PE).

METHODS

MI, HF and PE were studied as cause of death based on the analysis of death certificates in Canada (C), England and Wales (E), France (F) and Sweden (S). We also used a multiple cause approach. Age-standardized death rates (SDR) were calculated.

RESULTS

The SDR for MI, HF or PE as the underlying cause of death, all decreased during the last decade. The decrease in SDR secondary to MI exceeded that for HF or PE. Concerning multiple cause of death, a greater decrease was also found for MI, compared with HF or PE.

CONCLUSIONS

We confirm the beneficial trends in SDR with MI, HF or PE both as underlying or multiple causes in the studied countries. For HF and PE, multiple cause approach seems more accurate to describe the burden of these two pathologies. Our study also suggests that more efforts should be dedicated to HF and PE in order to achieve similar trends than in MI.

[Improving vital organs perfusion by the respiratory pump: physiology and clinical use]

OBJECTIVE

In this article, we review the effects of the respiratory pump to improve vital organ perfusion by the use of an inspiratory threshold device.

DATA SOURCES

Medline and MeSH database.

STUDY SELECTION

All papers with a level of proof of I to III have been used.

DATA EXTRACTION

The analysis of the papers has focused on the physiological modifications induced by intrathoracic pressure regulation.

DATA SYNTHESIS

Primary function of breathing is to provide gas exchange. Studies of the mechanisms involved in animals and humans provide the physiological underpinnings for "the other side of breathing": to increase circulation to the heart and brain. We describe studies that focus on the fundamental relationship between the generation of negative intrathoracic pressure during inspiration through a low-level of resistance created by an impedance threshold device and the physiologic effects of a respiratory pump. A decrease in intrathoracic pressure during inspiration through a fixed resistance resulting in an intrathoracic pressure of -7 cmH2O has multiple physiological benefits including: enhanced venous return, cardiac stroke volume and aortic blood pressure; lower intracranial pressure; resetting of the cardiac baroreflex; elevated cerebral blood flow oscillations and increased tissue blood flow/pressure gradient.

CONCLUSION

The clinical and animal studies support the use of the intrathoracic pump to treat different clinical conditions: hemorrhagic shock, orthostatic hypotension, septic shock, and cardiac arrest.

Migraine diagnosis and management in general emergency departments in France

Background

We conducted a prospective study of patients admitted to 22 general emergency departments in France over 1 week.

Patients and methods

Of 15,835 adult patients, 483 (3.1%) had headache and 98 (0.6%) had migraine.

Results

Compared with the migraine population in France, our migraine patients were similar in terms of proportion of female patients (75%) and mean age (37.6 ± 13.8 years) but presented earlier in their disease course. Patients sought emergency treatment because of a severe attack (49%) or because of ineffective treatment (20%). Non-opioid analgesics excluding non-steroidal anti-inflammatory drugs (NSAIDs), and NSAIDs, were most commonly prescribed as acute treatment, yet it took more than 48 h for symptom resolution in 36% of 92 follow-up patients.

Conclusions

Results suggest there is room for improvement in choice of agents prescribed. We propose additional education and training of clinicians to improve adherence to clinical practice guidelines.

A randomized study of out-of-hospital continuous positive airway pressure for acute cardiogenic pulmonary oedema: physiological and clinical effects

AIMS

In acute cardiogenic pulmonary oedema (ACPE), continuous positive airway pressure (CPAP) added to medical treatment improves outcome. The present study was designed to assess the benefit of CPAP as a first line treatment of ACPE in the out-of-hospital environment.

METHODS AND RESULTS

The protocol lasted 45 min, divided into three periods of 15 min. Patients with ACPE were randomly assigned in two groups: 1/Early CPAP (n = 63): CPAP alone (T0-T15); CPAP + medical treatment (T15-T30); medical treatment alone (T30-T45) and 2/Late CPAP (n = 61): medical treatment alone (T0-T15); medical treatment + CPAP (T15-T30); medical treatment alone (T30-T45). Primary endpoint: effect of early CPAP on a dyspnoea clinical score and on arterial blood gases. Secondary endpoints: incidence of tracheal intubation, inotropic support, and in-hospital mortality. T0-T15: CPAP alone had a greater effect than medical treatment on the clinical score (P = 0.0003) and on PaO(2) (P = 0.0003). T15-T30: adding CPAP to medical treatment (late CPAP group) improved clinical score and blood gases and the two groups were no longer different at T30. T30-T45: in both groups, CPAP withdrawal worsened clinical score. Six patients in 'early CPAP' group vs. 16 in 'late CPAP' group were intubated [P = 0.01, odds-ratio: OR = 0.30 (0.09-0.89)]. Dobutamine was used only in the 'late CPAP' group (n = 5), (P = 0.02). Hospital death was higher in 'late CPAP' group (n = 8) than in 'early CPAP' group (n = 2) [P = 0.05, OR = 0.22 (0.04-1.0)].

CONCLUSION

When compared to usual medical care, immediate application of CPAP alone in out-of-hospital treatment of ACPO is significantly better improving physiological variables and symptoms and significantly reduces tracheal intubation incidence and in-hospital mortality.

[Management of severe acute asthma in adults]

Any life-threatening episode of asthma requires early pre-hospital specialized medical management by emergency medical crews. Gravity depends on both clinical criteria and a peak expiratory flow rate (PEFR) more than 30% below either the level predicted by the reference graph or the patient's reference value. Initial treatment combines continuous nebulizations containing a beta2-agonist and ipratropium bromide, with oxygen administration and intravenous corticosteroid bolus. Recommended as second-line treatment in the absence of adequate response are: intravenous magnesium sulphate and continuous-perfusion beta2-agonists (electric syringe), or, in the case of shock, epinephrine. If mechanical ventilation is required, its settings should aim for low tidal volumes, low frequency, and increased expiratory time.

Mechanical advances in cardiopulmonary resuscitation

Challenged by the continued high mortality rates for patients in cardiac arrest, the American Heart Association and the European Resuscitation Council developed a new set of guidelines in 2000 to help advance several new and promising cardiopulmonary resuscitation (CPR) techniques and devices. This is the first time these organizations have taken such a bold move, in part because of the poor results with standard closed-chest cardiac massage. The new techniques, interposed abdominal counterpulsation and active compression decompression CPR, each provide greater blood flow to the vital organs in animal models of CPR and lead to higher blood pressures in patients in cardiac arrest. In some clinical studies, both techniques have resulted in a significant increase in survival after cardiac arrest in comparison with standard CPR. Three of the four new CPR devices that were recommended in the new guidelines also provide superior vital organ blood flow and increased blood pressures in comparison with standard CPR. The three devices that improve the efficiency of CPR are the circumferential vest, an active compression decompression CPR device, and an inspiratory impedance valve used in combination with the active compression decompression CPR device. The fourth device type, one that compresses the thorax using an automated mechanical piston compression mechanism, was recommended to reduce the number of personnel required to perform CPR. However, no studies on the automated mechanical compression devices have showed an improvement in hemodynamic variables or survival in comparison with standard CPR. Taken together, these new technologies represent an important step forward in the evolution of CPR from a pair of hands to devices designed to enhance CPR efficiency. Each of these advances is described, and the recent literature about each of them is reviewed.

The effects of positive end-expiratory pressure during active compression decompression cardiopulmonary resuscitation with the inspiratory threshold valve

The use of an inspiratory impedance threshold valve (ITV) during active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) improves perfusion pressures, and vital organ blood flow. We evaluated the effects of positive end-expiratory pressure (PEEP) on gas exchange, and coronary perfusion pressure gradients during ACD + ITV CPR in a porcine cardiac arrest model. All animals received pure oxygen intermittent positive pressure ventilation (IPPV) at a 5:1 compression-ventilation ratio during ACD + ITV CPR. After 8 min, pigs were randomized to further IPPV alone (n = 8), or IPPV with increasing levels of PEEP (n = 8) of 2.5, 5.0, 7.5, and 10 cm H(2)O for 4 consecutive min each, respectively. Mean +/- SEM arterial oxygen partial pressure decreased in the IPPV group from 150 +/- 30 at baseline after 8 min of CPR to 110 +/- 25 torr at 24 min, but increased in the PEEP group from 115 +/- 15 to 170 +/- 25 torr with increasing levels of PEEP (P <0.02 for comparisons within groups). Mean +/- SEM diastolic aortic minus diastolic left ventricular pressure gradient was significantly (P < 0.001) higher after the administration of PEEP (24 +/- 0 vs 17 +/- 1 mm Hg with 5 cm H(2)O of PEEP, and 26 +/- 0 vs 17 +/- 1 mm Hg with 10 cm H(2)O of PEEP), whereas the diastolic aortic minus right atrial pressure gradient (coronary perfusion pressure) was comparable between groups. Furthermore, systolic aortic pressures were significantly (P < 0.05) higher with 10 cm H(2)O of PEEP when compared with IPPV alone (68 +/- 0 vs 59 +/- 2 mm Hg). In conclusion, when CPR was performed with devices designed to improve venous return to the chest, increasing PEEP levels improved oxygenation. Moreover, PEEP significantly increased the diastolic aortic minus left ventricular gradient and did not affect the decompression phase aortic minus right atrial pressure gradient. These data suggest that PEEP reduces alveolar collapse during ACD + ITV CPR, thus leading to an increase in indirect myocardial compression.

IMPLICATIONS

Inspiratory impedance during active compression-decompression cardiopulmonary resuscitation improves perfusion pressures, and vital organ blood flow during cardiac arrest. Increasing levels of positive end-expiratory pressure during performance of active compression-decompression cardiopulmonary resuscitation with an inspiratory impedance valve improves oxygenation, and increases the diastolic aortic-left ventricular pressure gradient and systolic arterial blood pressure.

In-hospital and long-term prognosis of elderly patients requiring endotracheal intubation for life-threatening presentation of cardiogenic pulmonary edema

OBJECTIVE

We studied the in-hospital course, long-term prognosis, and functional status of elderly patients with life-threatening cardiogenic pulmonary edema requiring mechanical ventilation.

DESIGN

Semiprospective evaluation.

SETTING

Twelve intensive care units and one emergency prehospital medical department in university hospitals.

PATIENTS

Patients, aged >75 yrs, with life-threatening cardiogenic pulmonary edema requiring invasive airway management during the prehospital phase between January 1994 and January 1999 were included.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

A total of 79 patients were studied, of which 55 were included in the prospective phase and 24 during the retrospective phase. The age range was 75-99 yrs, with a mean age of 82.4 +/- 5.9. The male/female ratio was 35:44. The in-hospital mortality was 26.6%. The mean follow-up time for all 58 survivors was 23 months (range, 2-56 months). Among those discharged, survival at 1 yr was 69%. At 3 months after hospital discharge, 49 (87%) patients lived at home, 46 (82%) were able to bathe themselves, 35 (62%) could walk at least one block, and 34 (61%) could climb one flight of stairs.

CONCLUSIONS

Mortality after severe pulmonary edema requiring endotracheal intubation in a very elderly cohort has a predictably high mortality, although not related directly to the degree of presenting respiratory compromise. However, approximately 50% of the overall cohort returned to relatively good functional status, despite advanced age and a severely compromised presentation. Aggressive airway management appears, therefore, justified in this select group of patients.

Use of an inspiratory impedance threshold valve during cardiopulmonary resuscitation: a progress report

Building upon studies on the mechanism of active compression-decompression (ACD) cardiopulmonary resuscitation, a new inspiratory impedance threshold valve has been developed to enhance the return of blood to the thorax during the decompression phase of CPR. Use of this device results in a greater negative intrathoracic pressure during chest wall decompression. This leads to improved vital organ perfusion during both standard and ACD CPR. Animal and human studies suggest that this simple device increases cardiopulmonary circulation by harnessing more efficiently the kinetic energy of the outward movement of the chest wall during standard CPR or active chest wall decompression. When used in conjunction with ACD CPR during clinical evaluation, addition of the impedance valve resulted in sustained systolic pressures of greater than 100 mmHg and diastolic pressures of greater than 55 mmHg. The new valve may be beneficial in patients in asystole or shock refractory ventricular fibrillation, when enhanced return of blood flow to the chest is needed to 'prime the pump'. The potential long-term benefits of this new valve remain under investigation.

Inspiratory impedance during active compression-decompression cardiopulmonary resuscitation: a randomized evaluation in patients in cardiac arrest

BACKGROUND

Blood pressure is severely reduced in patients in cardiac arrest receiving standard cardiopulmonary resuscitation (CPR). Although active compression-decompression (ACD) CPR improves acute hemodynamic parameters, arterial pressures remain suboptimal with this technique. We performed ACD CPR in patients with a new inspiratory threshold valve (ITV) to determine whether lowering intrathoracic pressures during the "relaxation" phase of ACD CPR would enhance venous blood return and overall CPR efficiency.

METHODS AND RESULTS

This prospective, randomized, blinded trial was performed in prehospital mobile intensive care units in Paris, France. Patients in nontraumatic cardiac arrest received ACD CPR plus the ITV or ACD CPR alone for 30 minutes during advanced cardiac life support. End tidal CO(2) (ETCO(2)), diastolic blood pressure (DAP) and coronary perfusion pressure, and time to return of spontaneous circulation (ROSC) were measured. Groups were similar with respect to age, gender, and initial rhythm. Mean maximal ETCO(2), coronary perfusion pressure, and DAP values, respectively (in mm Hg), were 13.1+/-0.9, 25.0+/-1.4, and 36.5+/-1.5 with ACD CPR alone versus 19.1+/-1.0, 43.3+/-1.6, and 56.4+/-1.7 with ACD plus valve (P<0.001 between groups). ROSC was observed in 2 of 10 patients with ACD CPR alone after 26.5+/-0.7 minutes versus 4 of 11 patients with ACD CPR plus ITV after 19.8+/-2.8 minutes (P<0.05 for time from intubation to ROSC). Conclusions-Use of an inspiratory resistance valve in patients in cardiac arrest receiving ACD CPR increases the efficiency of CPR, leading to diastolic arterial pressures of >50 mm Hg. The long-term benefits of this new CPR technology are under investigation.

A comparison of standard cardiopulmonary resuscitation and active compression-decompression resuscitation for out-of-hospital cardiac arrest. French Active Compression-Decompression Cardiopulmonary Resuscitation Study Group

BACKGROUND

We previously observed that short-term survival after out-of-hospital cardiac arrest was greater with active compression-decompression cardiopulmonary resuscitation (CPR) than with standard CPR. In the current study, we assessed the effects of the active compression-decompression method on one-year survival.

METHODS

Patients who had cardiac arrest in the Paris metropolitan area or in Thionville, France, more than 80 percent of whom had asystole, were assigned to receive either standard CPR (377 patients) or active compression-decompression CPR (373 patients) according to whether their arrest occurred on an even or odd day of the month, respectively. The primary end point was survival at one year. The rate of survival to hospital discharge without neurologic impairment and the neurologic outcome were secondary end points.

RESULTS

Both the rate of hospital discharge without neurologic impairment (6 percent vs. 2 percent, P=0.01) and the one-year survival rate (5 percent vs. 2 percent, P=0.03) were significantly higher among patients who received active compression-decompression CPR than among those who received standard CPR. All patients who survived to one year had cardiac arrests that were witnessed. Nine of 17 one-year survivors in the active compression-decompression group and 2 of 7 in the standard group, respectively, initially had asystole or pulseless electrical activity. In 12 of the 17 survivors who had received active compression-decompression CPR, neurologic status returned to base line, as compared with 3 of 7 survivors who had received standard CPR (P=0.34).

CONCLUSIONS

Active compression-decompression CPR performed during advanced life support significantly improved long-term survival rates among patients who had cardiac arrest outside the hospital.

Effect of active compression-decompression resuscitation (ACD-CPR) on survival: a combined analysis using individual patient data

Active compression decompression resuscitation (ACD-CPR) has been developed as an alternative to standard cardiopulmonary resuscitation (S-CPR). To determine the effect of ACD-CPR on survival and neurologic outcome in patients with out-of-hospital cardiac arrest, this combined analysis involved individual patient data from 2866 patients from seven separate randomized prospective prehospital studies who had received ACD-CPR or S-CPR after out-of-hospital cardiac arrest in seven international sites. Significant improvement in 1-h survival (odds ratio (OR) = 0.83; confidence interval (CI): 0.695-0.99; P < 0.05) was found with ACD-CPR (n = 1410) versus S-CPR (n = 1456). The odds ratio for hospital discharge after ACD-CPR was similar (OR = 0.82; CI: 0.609-1.107, P = NS), but this finding was not statistically significant. Using the chi2-test for trend, there was a significant improvement in overall survival with ACD-CPR (P < 0.05) versus S-CPR. This improvement was largely due to the influence of results from one study site. Neurological outcome and complication rates were comparable between groups. Further study is needed to determine which emergency medical services systems may benefit from out-of-hospital use of ACD-CPR.

[Routes of administration of drugs for severe acute asthma]

Beta2-mimetics represent the primary treatment for acute severe asthma. Their route of administration are nebulizer inhalation and inhalation chamber, or direct intratracheal route in patients receiving artificial ventilation. The subcutaneous route remains useful while awaiting implementation of nebulizer routine. The intravenous route is indicated in cases of non-rapid improvement in patients' receiving inhaled treatment.

Prolonged severe hypercapnia complicating near fatal asthma in a 35-year-old woman

OBJECTIVE

We describe a patient with a prolonged and severe hypercapnia occurring during an episode of status asthmaticus induced by ophthalmic instillation of carteolol.

SETTING

Prehospital Emergency Medical Service and Pulmonary Intensive Care Unit in a university hospital.

PATIENT

A 35-year-old female developed an acute asthma attack while at home, which required advanced life support.

INTERVENTION

On hospital admission, arterial blood gases revealed a PaCO2 of 208 mmHg. Hypercapnia persisted with a PaCO2 of more than 190 mmHg for 10 h, with pH always less than 7.00. The patient was finally discharged after 26 days without sequelae.

CONCLUSION

This case illustrates the cerebral and cardiovascular tolerance of severe and prolonged hypercapnia associated with major acidosis.

The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation

BACKGROUND

A quantitative scale of intubation difficulty would be useful for objectively comparing the complexity of endotracheal intubations. The authors have developed a quantitative score that can be used to evaluate intubating conditions and techniques with the aim of determining the relative values of predictive factors of intubation difficulty and of the techniques used to decrease such difficulties.

METHODS

An Intubation Difficulty Scale (IDS) was developed, based on parameters known to be associated with difficult intubation. It was then evaluated prospectively in a group of 311 consecutive prehospital intubations and 315 intubations in an operating room. In the operating room, the IDS was compared with two other parameters: the time to completion of intubation and the visual analog scale (VAS). Time was measured by an independent observer. Operators in both groups completed a checklist regarding the conditions of intubation.

RESULTS

There is a good correlation between the IDS scale and the VAS assessment of difficulty and time to completion of intubation. VAS and time to completion have a significant but lesser correlation to each other. Comparison of IDS with operator-assessed subjective categorical impression of difficulty by Kruskall-Wallis was statistically significant.

CONCLUSIONS

The IDS correlates with but is less subjective than the VAS and categorical classification. IDS correlates with time to intubation, but it offers details regarding the difficulty encountered that time alone does not. This score may not only aid in evaluation of factors linked to difficult intubations, but it may provide a uniform approach to comparing studies related to this subject.

Benefit of active compression-decompression cardiopulmonary resuscitation as a prehospital advanced cardiac life support. A randomized multicenter study

BACKGROUND

We compared short-term prognosis of active compression-decompression (ACD) and standard (STD) cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrests.

METHODS AND RESULTS

We randomized advanced cardiac life support (ACLS) with ACD ACLS CPR on odd days and STD ACLS CPR on even days. We measured the rates of return of spontaneous circulation (ROSC), survival at 1 hour (H1), at 24 hours (H24), and at 1 month (D30): hospital discharge (HD); neurological outcome; and complications. Mean times from collapse to basic cardiac life support CPR was 9 minutes and from collapse to ACLS CPR was 21 minutes. Compared with the STD ACLS patients (n = 258), ACD ACLS patients (n = 254) had higher survival rates (ROSC, 44.9% versus 29.8%, P = .0004; H1, 36.6% versus 24.8%, P = .003; H24, 26% versus 13.6%, P = .002; HD without neurological impairment, 5.5% versus 1.9%, P = .03) and a trend for improvement in neurological outcome at D30 (Glasgow-Pittsburgh Outcome Categories = 1.6 +/- 0.8 versus 2.3 +/- 1.1. P = .09). Sternal dislodgements (2.9% versus 0.4%, P = .03) and hemoptysis (5.4% versus 1.3%, P = .01) were more frequent in the ACD ACLS group.

CONCLUSIONS

Despite long time intervals, ACD significantly improved short-term survival rates in out-of-hospital cardiac arrests compared with STD CPR.

Active compression-decompression cardiopulmonary resuscitation--instructor and student manual for teaching and training. Part I: The workshop

In an attempt to standardize the teaching and training of active compression-decompression cardiopulmonary resuscitation (ACD-CPR), a group of leading emergency physicians, cardiologists, anesthesiologists, paramedics and nurses with practical, theoretical, educational, and scientific experience in the subject met in June 1995. The group was called The International Working Group of Teaching and Training Active Compression-Decompression CPR. The group was 'born' as a result of the first International Conference of Active Compression-Decompression CPR held in Copenhagen in March 1995. The following paper describes the background, development and text of and ACD-CPR course manual for both students and instructors.

Head injury: clonidine decreases plasma catecholamines

Seven patients who had suffered head injury 3 to 5 days before the study was undertaken received clonidine (2.5 micrograms/kg iv over 10 min). This resulted in a reduction of plasma norepinephrine (p less than .05) and in normalization of plasma epinephrine (p less than .05). Neither common carotid blood flow nor diastolic blood flow as index of global cerebral perfusion as measured by pulsed Doppler changed. The reduction of sympathetic overactivity, probably due to the specific action of clonidine on alpha 2-adrenoceptors within the rostral ventrolateral medulla, may be of interest in the management of head injury because of the maintenance of cephalic hemodynamics.