Development and validation of a clinico-biological score to predict outcomes in patients with drowning-associated cardiac arrest

BACKGROUND

While several scoring systems have been developed to predict short-term outcome in out-of-hospital cardiac arrest patients, there is currently no dedicated prognostic tool for drowning-associated cardiac arrest (DACA) patients.

METHODS

Patients experiencing DACA from two retrospective multicenter cohorts of drowning patients were included in the present study. Among the patients from the development cohort, risk-factors for day-28 mortality were assessed by logistic regression. A prediction score was conceived and assessed in patients from the validation cohort.

RESULTS

Among the 103 included patients from the development cohort, the day-28 mortality rate reached 51% (53/103). Identified independent early risk-factors for day-28 mortality included cardiopulmonary resuscitation duration longer than 20 min (OR 6.40 [95% CI 1.88-23.32]; p = 0.003), temperature at Intensive Care Unit admission <34 °C (OR 8.84 [95% CI 2.66-32.92]; p < 0.001), need for invasive mechanical ventilation (OR 6.83 [95% CI 1.47-40.87]; p = 0.02) and lactate concentration > 7 mmol/L (OR 3.56 [95% CI 1.01-13.07]; p = 0.04). The Area Under the ROC Curve (AUC) of the developed score based on those variables reached 0.91 (95% CI, 0.86-0.97). The optimal cut-off for predicting poor outcomes was 4 points with a sensitivity of 92% (95% CI, 82-98%), a specificity of 82% (95% CI, 67-91%), a positive predictive value (PPV) of 84% (95% CI, 72-95%) and a negative predictive value (NPV) of 91% (95% CI, 79-96%). The assessment of this score on the validation cohort of 81 patients exhibited an AUC of 0.82. Using the same 4 points threshold, sensitivity, specificity, PPV and NPV values of the validation cohort were: 81%, 67%, 72% and 77%, respectively.

CONCLUSION

In patients suffering from drowning induced initial cardiac arrest admitted to ICU with a DACA score ≥ 4, the likelihood of survival at day-28 is significantly lower. Prospective validation of the DACA score and assessment of its usefulness are warranted in the future.

Can the use of whole-body CT be reduced in cases of kinetic-based polytrauma patients without a clinical severity criterion? A bi-center retrospective study

OBJECTIVE

To identify clinical and biological criteria predictive of significant traumatic injury in only kinetic-based polytrauma patients without clinical severity criteria. To propose a decisional algorithm to assist the emergency doctor in deciding whether or not to perform a WBCT in the above population.

METHODS

Retrospective bi-center study. 1270 patients with high velocity trauma without clinical severity criteria, for whom a WBCT was performed in 2017, were included. Patients with hemodynamic, respiratory or neurological severity criterion or those requiring pre-hospital resuscitation measures were excluded. Our primary endpoint was the identification of a significant lesion, i.e. any lesion that led to hospitalization > 24 h for monitoring or medico-surgical treatment. Data collected were age, sex, mechanism of injury, Glasgow Coma Scale score, number of symptomatic body regions, blood alcohol level, and neutrophil count.

RESULTS

Multivariate analysis found independent predictors of significant injury: fall > 5 m (OR: 14.36; CI: 2.3-283.4; p = 0.017), Glasgow score = 13 or 14 (OR: 4.40; CI:1.30-18.52; p = 0.027), presence of 2 symptomatic body regions (OR: 10.21; CI: 4.66-23.72; p = 0.05), positive blood alcohol level (OR: 2.81; CI: 1.13-7.33; p = 0.029) and neutrophilic leukocytosis (OR: 8.76; CI: 3.94-21.27; p = 0.01). A composite clinico-biological endpoint predictive of the absence of significant lesion was identified using a Classification and Regression Tree: number of symptomatic regions < 2, absence of Neutrophilic leukocytosis and negative blood alcohol concentration.

CONCLUSION

A simple triage algorithm was created with the objective of identifying, in high velocity trauma without clinical severity criteria, those without significant traumatic injury.

Acute mesenteric ischemia: which predictive factors of delayed diagnosis at emergency unit?

PURPOSE

Acute mesenteric ischemia (AMI) is frequently diagnosed late, leading to a poor prognosis. Our aims were to identify predictive factors of delayed diagnosis and to analyze the outcomes of patients with AMI admitted in emergency units.

METHODS

All the patients with AMI (2015-2020), in two Emergency units, were retrospectively included. Two groups were defined according to the time of diagnosis between the arrival at emergency unit and the CT scan: ≤ 6 h (early), > 6 h (delayed).

RESULTS

119 patients (mean age = 71 ± 7 years) were included. The patients with a delayed diagnosis (n = 33, 28%) were significantly associated with atypical presentation, including lower rates of abdominal pain (73 vs 89%, p = 0.003), abdominal tenderness (33 vs 43%, p = 0.03), and plasma lactate (4 ± 2 vs 6 ± 7 mmol/l, p = 0.03) when compared with early diagnosis. After multivariate analysis, the absence of abdominal pain was the only independent predictive factor of delayed diagnosis (Odd Ratio = 0.17; 95% CI = 0.03-0.88, p = 0.03). Patients with delayed diagnosis tended to be associated to lower rates of revascularization (9 vs 17%, p = 0.4), higher rates of major surgical morbidity (90 vs 57%, p = 0.1), longer length of stay (16 ± 23 vs 13 ± 15 days, p = 0.4) and, at the end of follow-up, higher rate of short small bowel syndrome (18 vs 7%, p = 0.095).

CONCLUSION

AMI is a challenge for emergency physicians. History of patient, physical exam, biological data are not sufficient to diagnose AMI. New biomarkers, and awareness of emergency physicians should improve and accelerate the diagnosis of AMI.

Adenosinergic System and Neuroendocrine Syncope: What Is the Link?

Although very common, the precise mechanisms that explain the symptomatology of neuroendocrine syncope (NES) remain poorly understood. This disease, which can be very incapacitating, manifests itself as a drop in blood pressure secondary to vasodilation and/or extreme slowing of heart rate. As studies continue, the involvement of the adenosinergic system is becoming increasingly evident. Adenosine, which is an ATP derivative, may be involved in a large number of cases. Adenosine acts on G protein-coupled receptors with seven transmembrane domains. A1 and A2A adenosine receptor dysfunction seem to be particularly implicated since the activation leads to severe bradycardia or vasodilation, respectively, two cardinal symptoms of NES. This mini-review aims to shed light on the links between dysfunction of the adenosinergic system and NHS. In particular, signal transduction pathways through the modulation of cAMP production and ion channels in relation to effects on the cardiovascular system are addressed. A better understanding of these mechanisms could guide the pharmacological development of new therapeutic approaches.

Impact of the implementation of a trauma system on compliance with evidence-based clinical management guidelines in penetrating thoracic trauma

PURPOSE

Since 2014, a trauma system (TS) for the Provence-Alpes-Cote-d'Azur (PACA) region has been set up with protocols based on the European guidelines for the management of bleeding trauma patients. The present study aims to assess compliance with protocols in penetrating thoracic trauma on admission to a level I trauma centre and to determine whether compliance impacts morbidity and mortality.

METHODS

This multicentric pre-post study included all penetrating thoracic trauma patients referred to Marseille area level I centres between January 2009 and December 2019. On the basis of the European guidelines, eight objectively measurable recommendations concerning the in-hospital trauma care for the first 24 h were analysed. Per-patient and per-criterion compliance rates and their impact on morbidity and mortality were evaluated before and after TS implementation.

RESULTS

A total of 426 patients were included. No differences between the two groups (before and after 2014) were reported for demographics or injury severity. The median (interquartile range) per-patient compliance rate increased from 67% [0.50; 0.75] to 75% [0.67; 1.0] (p < 0.01) after implementation of a TS. The 30-day morbidity-mortality was, respectively, of 17% (30/173) and 13% (32/253) (p = 0.18) before and after TS implementation. A low per-patient compliance rate was associated with an increase in the 30-day morbidity-mortality rate (p < 0.01). Severity score-adjusted per-patient compliance rates were associated with decreased 30-day morbidity-mortality (odds ratio [IC 95%] = 0.98 [0.97; 0.99] p = 0.01).

CONCLUSION

Implementation of a TS was associated with better compliance to European recommendations and better outcomes for severe trauma patients. These findings should encourage strict adherence to European trauma protocols to ensure the best patient outcomes.

Safety, Pharmacokinetic, and Pharmacodynamic Study of a Sublingual Formula for the Treatment of Vasovagal Syncope

Background

Vasovagal syncope is a common cause of syncope which, if recurrent, can have multiple negative consequences such as injury and occupational disability. Various medications can be used to decrease the recurrence of vasovagal syncope but there are no drugs that can be used by patients to interrupt a perceived vasovagal episode.

Methods

A phase I study was performed to evaluate the tolerability and safety of a gel formulation containing capsaicin (1 mg), phenylephrine HCL (PE) and caffeine citrate (200 mg) (CPC) in normal adult volunteers. Secondary objectives were to characterize the pharmacokinetics (PK) of the CPC formulation and the highest dose of PE needed to achieve a target increase in systolic BP of at least 40 mmHg. After receiving the first dose, a second dose of the CPC mixture was administered at 2 h. Suboptimal changes in systolic blood pressure (SBP) were noted at PE doses of 0.6, 1.2, and 1.8 mg, therefore a second cohort was studied at PE doses of 10, 20, and 30 mg. Blood samples were collected in rapid sequence and were assayed for all three drugs.

Results

A total of 17 subjects received the drug with no serious adverse effects reported. All doses were well tolerated, although the capsaicin content usually caused expected temporary oral and gastric discomfort. One subject did not complete the study because of a vasovagal reaction that was associated with the frequent blood sampling. There was a 5–25 min lag in the appearance of measurable blood concentrations of capsaicin and phenylephrine. Most subjects had baseline caffeine concentrations from dietary use, with a gradual increase noted after 15 min consistent with GI absorption. Although the intended criterion of a 40 mmHg increase in SBP was not reached, a clinically significant increase in BP for at least 15 min was noted in the six subjects who received the highest dose of PE (30 mg), with a gradual decline over the next 2 h.

Conclusion

The ternary mixture of capsaicin, phenylephrine, and caffeine was well tolerated when administered as two sublingual/oral doses over a 2-h period.

Early assessment of patients with COVID-19 and dyspnea using lung ultrasound scoring

OBJECTIVES

The main objective was to evaluate the precision of the Modified Lung Ultrasound (MLUS score) for predicting the need for respiratory support in the first 48 hours in patients with dyspnea due to the coronavirus disease 2019 (COVID-19). The secondary objectives were 1) to compare the MLUS and National Early Warning Score 2 (NEWS2), as well as the combination of both scores, as predictors of severity according to the World Health Organization (WHO) Ordinal Scale for Clinical Improvement; and 2) to compare severity assessed by ultrasound scoring to severity assessed by lung computed tomography (CT).

MATERIAL AND METHODS

Multicenter prospective observational cohort study conducted from March 30 to April 30, 2020, in 2 university hospitals. Adult patients with dyspnea due to COVID-19 were included. An initial lung ultrasound was performed, and the results of MLUS, NEW2, and lung CT evaluations were recorded. Patients were classified by risk according to the WHO scale at 48 hours, as follows: low risk (score less than 5) or high risk (score of 5 or more).

RESULTS

A total of 100 patients were included: 35 (35%) were classified as low risk and 65 (65%) as high risk. The correlation between the MLUS and WHO assessments was positive and very high (Spearman rank correlation 􀁕 = 0.832; P .001). The area under the receiver operating characteristic curves of the MLUS, NEW2 and combined ultrasound scores, in relation to prediction of risk classification were, respectively, 0.96 (0.93-0.99), 0.89 (0.82-0.95) and 0.98 (0.96-1.0). The MLUS and lung CT assessments were correlated.

CONCLUSION

An early lung ultrasound score can predict clinical severity in patients with dyspnea due to COVID-19.

Cell Analysis from Dried Blood Spots: New Opportunities in Immunology, Hematology, and Infectious Diseases

Blood cell analysis is a major pillar of biomedical research and healthcare. These analyses are performed in central laboratories. Rapid shipment from collection site to the central laboratories is currently needed because cells and biomarkers degrade rapidly. The dried blood spot from a fingerstick allows the preservation of cellular molecules for months but entire cells are never recovered. Here leucocyte elution is optimized from dried blood spots. Flow cytometry and mRNA expression profiling are used to analyze the recovered cells. 50-70% of the leucocytes that are dried on a polyester solid support via elution after shaking the support with buffer are recovered. While red blood cells lyse upon drying, it is found that the majority of leucocytes are preserved. Leucocytes have an altered structure that is improved by adding fixative in the elution buffer. Leucocytes are permeabilized, allowing an easy staining of all cellular compartments. Common immunophenotyping and mRNAs are preserved. The ability of a new biomarker (CD169) to discriminate between patients with and without Severe Acute Respiratory Syndrome induced by Coronavirus 2 (SARS-CoV-2) infections is also preserved. Leucocytes from blood can be dried, shipped, and/or stored for at least 1 month, then recovered for a wide variety of analyses, potentially facilitating biomedical applications worldwide.

CD169 and CD64 could help differentiate bacterial from CoVID-19 or other viral infections in the Emergency Department

The identification of a bacterial, viral, or even noninfectious cause is essential in the management of febrile syndrome in the emergency department (ED), especially in epidemic contexts such as flu or CoVID-19. The aim was to assess discriminative performances of two biomarkers, CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), using a new flow cytometry procedure, in patients presenting with fever to the ED during epidemics. Eighty five adult patients presenting with potential infection were included during the 2019 flu season in the ED of La Timone Hospital. They were divided into four diagnostic outcomes according to their clinical records: no-infection, bacterial infection, viral infection and co-infection. Seventy six patients with confirmed SARS-CoV-2 infection were also compared to 48 healthy volunteers. For the first cohort, 38 (45%) patients were diagnosed with bacterial infections, 11 (13%) with viral infections and 29 (34%) with co-infections. mCD169 was elevated in patients with viral infections, with a majority of Flu A virus or Respiratory Syncytial Virus, while nCD64 was elevated in subjects with bacterial infections, with a majority of Streptococcus pneumoniae and Escherichia coli. nCD64 and mCD169 showed 90% and 80% sensitivity, and 78% and 91% specificity, respectively, for identifying patients with bacterial or viral infections. When studied in a second cohort, mCD169 was elevated in 95% of patients with SARS-CoV-2 infections and remained at normal level in 100% of healthy volunteers. nCD64 and mCD169 have potential for accurately distinguishing bacterial and acute viral infections. Combined in an easy and rapid flow cytometry procedure, they constitute a potential improvement for infection management in the ED, and could even help for triage of patients during emerging epidemics.

Outbreak of pneumococcal pneumonia among shipyard workers in Marseille, France, January to February 2020

We report the third outbreak of pneumococcal pneumonia within one year among workers in European shipyards. During January and February 2020, 37 cases of pneumonia were identified in a shipyard in Marseille, south-eastern France. Outbreak control measures were implemented, including a mass vaccination campaign with 23-valent pneumococcal polysaccharide vaccine targeting all shipyard workers. Given the high mobility of shipyard workers, coordinated responses between European public health institutes are necessary to avoid further outbreaks.

Hemodynamic Profiles of Cardiogenic Shock Depending on Their Etiology

The pathophysiology of cardiogenic shock (CS) varies depending on its etiology, which may lead to different hemodynamic profiles (HP) and may help tailor therapy. We aimed to assess the HP of CS patients according to their etiologies of acute myocardial infarction (AMI) and acute decompensated chronic heart failure (ADCHF). We included patients admitted for CS secondary to ADCHF and AMI. HP were measured before the administration of any inotrope or vasopressor. Systemic Vascular Resistances index (SVRi), Cardiac Index (CI), and Cardiac Power Index (CPI) were measured by trans-thoracic Doppler echocardiography on admission. Among 37 CS patients, 28 had CS secondary to ADCHF or AMI and were prospectively included. The two groups were similar in terms of demographic data and shock severity criteria. AMI CS was associated with lower SVRi compared to CS related to ADCHF: 2010 (interquartile range (IQR): 1895-2277) vs. 2622 (2264-2993) dynes-s·cm^-5·m^-2 (p = 0.002). A trend toward a higher CI was observed: respectively 2.13 (1.88-2.18) vs. 1.78 (1.65-1.96) L·min^-1·m^-2 (p = 0.067) in AMICS compared to ADCHF. CS patients had different HP according to their etiologies. AMICS had lower SVR and tended to have a higher CI compared to ADHF CS. These differences should be taken into account for patient selection in future research.

Comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed COVID-19 pneumonia

Purpose

The relationship between lung ultrasound (LUS) and chest computed tomography (CT) scans in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is not clearly defined. The primary objective of our study was to assess the performance of LUS in determining severity of SARS-CoV-2 pneumonia compared with chest CT scan. Secondary objectives were to test the association between LUS score and location of the patient, use of mechanical ventilation, and the pulse oximetry (SpO₂)/fractional inspired oxygen (FiO₂) ratio.

Methods

A multicentre observational study was performed between 15 March and 20 April 2020. Patients in the Emergency Department (ED) or Intensive Care Unit (ICU) with acute dyspnoea who were PCR positive for SARS-CoV-2, and who had LUS and chest CT performed within a 24-h period, were included.

Results

One hundred patients were included. LUS score was significantly associated with pneumonia severity assessed by chest CT and clinical features. The AUC of the ROC curve of the relationship of LUS versus chest CT for the assessment of severe SARS-CoV-2 pneumonia was 0.78 (CI 95% 0.68–0.87; p < 0.0001). A high LUS score was associated with the use of mechanical ventilation, and with a SpO₂/FiO₂ ratio below 357.

Conclusion

In known SARS-CoV-2 pneumonia patients, the LUS score was predictive of pneumonia severity as assessed by a chest CT scan and clinical features. Within the limitations inherent to our study design, LUS can be used to assess SARS-CoV-2 pneumonia severity.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-06186-0) contains supplementary material, which is available to authorized users.

Cannabinoid hyperemesis syndrome in two French emergency departments: a prospective cohort

Chronic cannabis use can be associated with uncontrollable vomiting and abdominal pain. Diagnostic criteria for cannabinoid hyperemesis syndrome (CHS) were defined in 2012 by Simonetto et al. The objectives of this study were to describe the prevalence of CHS, the patients' epidemiological characteristics, and to show the difficulties encountered in caring for these patients in emergency departments, the extent of health care and an unsuitable follow-up in general practices. A prospective cohort of patients with CHS was recruited among a target population of patients leaving the adult emergency services of the Marseille hospitals Nord and La Timone between October 2017 and July 2018, with abdominal pain syndrome of unidentified etiology. Inclusion criteria for the CHS cohort were chronic cannabis use associated with nausea and vomiting. There were 48 patients included in the CHS cohort who took cannabis daily, in a target population of 2 848 patients (i.e. 1.6%). A hot shower was the most effective symptomatic treatment in 54.2% of cases. Patients suffering from CHS spent significantly more hours in emergency departments (11 vs. 6.5), and, on average, visits were more frequent (4.9 vs. 3). 20.3% of them were hospitalized to continue pain medication. Once out of hospital, follow-up was limited, and weaning off cannabis, the only etiological treatment, was difficult to set up. Informing patients about CHS is essential, and a hot shower could be systematically proposed, thus limiting an unnecessary extent of health care. CHS is genuine, medical staff should be made aware of it in occupational training, and it should be seriously considered in health policies.

Flow cytometry evaluation of infection-related biomarkers in febrile subjects in the emergency department

Aim: In an Emergency Department (ED), the etiological identification of infected subjects is essential. 13 infection-related biomarkers were assessed using a new flow cytometry procedure. Materials & methods: If subjects presented with febrile symptoms at the ED, 13 biomarkers' levels, including CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), were tested and compared with clinical records. Results: Among 50 subjects, 78% had bacterial infections and 8% had viral infections. nCD64 showed 82% sensitivity and 91% specificity for identifying subjects with bacterial infections. mCD169, HLA-ABC ratio and HLA-DR on monocytes had high values in subjects with viral infections. Conclusion: Biomarkers showed promising performances to improve the ED's infectious stratification.

Drowning Classification: A Reappraisal of Clinical Presentation and Prognosis for Severe Cases

BACKGROUND

Drowning is still a major cause of accidental death worldwide. In 1997, Szpilman proposed a classification of drowning that has become the reference. As considerable efforts have been made to improve prevention and care, it seemed appropriate to reassess the prognosis and clinical presentation of drowning patients more than 20 years after this first publication. The aim of this study is to provide a reappraisal of patients who need advanced health care and a precise description of their respective neurologic, respiratory, and hemodynamic profiles.

METHODS

This retrospective study was conducted over four consecutive summer periods between 2014 and 2017 in ICUs located in France, French Polynesia, and the French Antilles. Patients were classified according to the drowning classification system proposed by Szpilman.

RESULTS

During the study period, 312 drowning patients were admitted with severe clinical presentation (grades 2-6). All patients benefited from rapid extraction from the water (< 10 min for all) and specialized care (emergency medical services), starting from the prehospital period. Although the global hospital mortality was similar to that previously reported (18.5%), great differences existed among the severity grades. Respective grade mortalities were low for grades 2 through 5 (grade 2, 0%; grade 3, 3%; grade 4, 0%; grade 5, 2%), and the mortality for grade 6 remained similar to that previously reported (54%). These results confirmed that the occurrence of cardiac arrest after drowning is still bad prognosis. Conversely, for other grades, this study strengthens the importance of specialized intervention to interrupt the drowning process.

CONCLUSIONS

On the basis of these results, drowning-related cardiac arrest is still the prognosis cornerstone. For other victims, the prognosis was better than previously expected, which strengthens the importance of specialized intervention to interrupt the drowning process.

Complications of peripheral venous catheters: The need to propose an alternative route of administration

Use of peripheral venous catheters (PVCs) is very common in hospitals. According to the literature, after a visit to the emergency department >75% of hospitalised patients carry a PVC, among which almost 50% are useless. In this study, the presence and complications of PVCs in an infectious diseases (ID) unit of a French tertiary-care university hospital were monitored. A total of 614 patients were prospectively included over a 6-month period. Among the 614 patients, 509 (82.9%) arrived in the ID unit with a PVC, of which 260 (51.1%) were judged unnecessary and were removed as soon as the patients were examined by the ID team. More than one-half of PVCs were removed within 24 h in the unit (308/509; 60.5%). PVCs were complicated for 65 (12.8%) of the 509 patients, with complications including extravasation, cutaneous necrosis, lymphangitis, phlebitis, tearing off the patient, superficial venous thrombosis and arthritis. We must therefore continue to search for unjustified PVC insertion. Alternatives to the intravenous administration route must be proposed, such as subcutaneous infusion or oral antibiotic therapy.

Contribution of Capillary Refilling Time and Skin Mottling Score to Predict ICU Admission of Patients with Septic or haemorrhagic Shock Admitted to the Emergency Department: A TRCMARBSAU Study

Objective

In the emergency department (ED), the severity assessment of shock is a fundamental step prior to the admission in the intensive care unit (ICU). As biomarkers are time consuming to evaluate the severity of micro- and macro-circulation alteration, capillary refill time and skin mottling score are two simple, available clinical criteria validated to predict mortality in the ICU. The aim of the present study is to provide clinical evidence that capillary refill time and skin mottling score assessed in the ED also predict ICU admission of patients with septic or haemorrhagic shock.

Methods

This trial is an observational, non-randomised controlled study. A total of 1500 patients admitted to the ED for septic or haemorrhagic shock will be enrolled into the study. The primary outcome is the admission to the ICU.

Results

The study will not impact the treatments provided to each patient. Capillary refill time and skin mottling score will not be taken into account to decide patient's treatments and/or ICU admission. Patients will be followed up during their hospital stay to determine their precise destination after the ED (home, ICU or ward) and the 28- and 90-day mortality after hospital admission.

Conclusion

The results from the present study will provide clinical evidence on the correlation between the ICU admission and the capillary refill time and the skin mottling score in septic or haemorrhagic shock admitted to the ED. The aim of the present study is to provide two simple, reliable and non-invasive tools for the triage and early orientation of these patients.

Clinical research assessment by flow cytometry of biomarkers for infectious stratification in an Emergency Department

Aim: Management of patients with infections within the Emergency Department (ED) is challenging for practitioners, as the identification of infectious causes remains difficult with current techniques. A new combination of two biomarkers was tested with a new rapid flow cytometry technique. Materials & methods: Subjects from the ED were tested for their CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169) levels and results were compared to their clinical records. Results: Among 139 patients, 29% had confirmed bacterial infections and 5% viral infections. nCD64 and mCD169 respectively showed 88 and 86% sensitivity and 90 and 100% specificity for identifying subjects in bacterial or viral conditions. Conclusion: This point-of-care technique could allow better management of patients in the ED.

[Evaluation of an "Emergency Thrombosis" care system in a university-hospital department of general emergencies]

GOAL

Describe the use of diagnostic, prognostic and therapeutic algorithms for venous thromboembolism (VTE), derived from the 2014 European guidelines, in a teaching hospital's emergencies department and compare two groups: the 2015 group "without a care path" and the 2017 group "with a care path".

METHOD

Comparative and retrospective study of the characteristics of emergencies department patients admitted for VTE from January to June 2015 for the 2015 group and from January to June 2017 for the 2017 group.

RESULTS

Seventy-nine patients were included in the 2015 group and 62 patients in the 2017 group. In 24% of cases a clinical probability rule was calculated in the 2017 group (vs. no score in 2015, P<0.05). In the 2015 group, 10% of patients did not have a D-Dimer measurement in case of low clinical probability (vs. 0% in 2017, P<0.05). For both groups, the severity score sPESI was not noted in the medical record. All patients with pulmonary embolism were hospitalized in both groups. A total of 36% of patients with deep vein thrombosis (DVT) were hospitalized in the 2015 group (vs. none in 2017, P<0.05). A total of 52.5% of patients were treated with direct oral anticoagulants (DOAS) in the 2017 group vs. 32.5% in the 2015 group (P<0.05). In 18% of cases DOAS were prescribed by emergency physicians in the 2017 group vs. 2.5% in the 2015 group (P<0.05). Mean hospital stay was 7.4 days in the 2017 group and 9.4 days in the 2015 group (P<0.05).

CONCLUSION

We observed a change in clinical practices and prescriptions after the establishment of an "Emergency Thrombosis" care system. Indeed, improvement in the calculation of the clinical probability score, increase in the outpatient management of DVT, increase in prescribing DOAS and reducing the length of hospital stay were the main revisions. The implementation of standardized digitally calculated clinical and prognostic probability scores would optimize this care path, as well as allow a better distribution of the post-emergency consultations created for outpatients.

From Expert Protocols to Standardized Management of Infectious Diseases

We report here 4 examples of management of infectious diseases (IDs) at the University Hospital Institute Méditerranée Infection in Marseille, France, to illustrate the value of expert protocols feeding standardized management of IDs. First, we describe our experience on Q fever and Tropheryma whipplei infection management based on in vitro data and clinical outcome. Second, we describe our management-based approach for the treatment of infective endocarditis, leading to a strong reduction of mortality rate. Third, we report our use of fecal microbiota transplantation to face severe Clostridium difficile infections and to perform decolonization of patients colonized by emerging highly resistant bacteria. Finally, we present the standardized management of the main acute infections in patients admitted in the emergency department, promoting antibiotics by oral route, checking compliance with the protocol, and avoiding the unnecessary use of intravenous and urinary tract catheters. Overall, the standardization of the management is the keystone to reduce both mortality and morbidity related to IDs.

Unmanned aerial vehicles (drones) to prevent drowning

BACKGROUND

Drowning literature have highlighted the submersion time as the most powerful predictor in assessing the prognosis. Reducing the time taken to provide a flotation device and prevent submersion appears of paramount importance. Unmanned aerial vehicles (UAVs) can provide the location of the swimmer and a flotation device.

OBJECTIVE

The objective of this simulation study was to evaluate the efficiency of a UAV in providing a flotation device in different sea conditions, and to compare the times taken by rescue operations with and without a UAV (standard vs UAV intervention). Several comparisons were made using professional lifeguards acting as simulated victims. A specifically-shaped UAV was used to allow us to drop an inflatable life buoy into the water.

RESULTS

During the summer of 2017, 28 tests were performed. UAV use was associated with a reduction of time it took to provide a flotation device to the simulated victim compared with standard rescue operations (p < 0.001 for all measurements) and the time was reduced even further in moderate (81 ± 39 vs 179 ± 78 s; p < 0.001) and rough sea conditions (99 ± 34 vs 198 ± 130 s; p < 0.001). The times taken for UAV to locate the simulated victim, identify them and drop the life buoy were not altered by the weather conditions.

CONCLUSION

UAV can deliver a flotation device to a swimmer safely and quickly. The addition of a UAV in rescue operations could improve the quality and speed of first aid while keeping lifeguards away from dangerous sea conditions.

Patterns of invasive mechanical ventilation in patients with severe blunt chest trauma and lung contusion: A French multicentric evaluation of practices

Introduction

This study investigated invasive mechanical ventilation modalities used in severe blunt chest trauma patients with pulmonary contusion. Occurrence, risk factors, and outcomes of early onset acute respiratory distress syndrome were also evaluated.

Methods

We performed a retrospective multicenter observational study including 115 adult patients hospitalized in six level 1 trauma intensive care units between April and September of 2014. Independent predictors of early onset acute respiratory distress syndrome were determined by multiple logistic regression analysis based on clinical characteristics and initial management.

Results

Protective ventilation principles were highly implemented, even prophylactically before acute respiratory distress syndrome occurrence. Early onset acute respiratory distress syndrome appeared to be associated with lung contusion of >20% of total lung volume and early onset pneumonia.

Conclusions

Predictors of early onset acute respiratory distress syndrome could help with identifying high-risk populations, potentially improving case management through specific protocol development for these patients.

Early versus delayed invasive strategy for intermediate- and high-risk acute coronary syndromes managed without P2Y12 receptor inhibitor pretreatment: Design and rationale of the EARLY randomized trial

According to recent literature, pretreatment with a P2Y₁₂ ADP receptor antagonist before coronary angiography appears no longer suitable in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) due to an unfavorable risk-benefit ratio. Optimal delay of the invasive strategy in this specific context is unknown. We hypothesize that without P2Y₁₂ ADP receptor antagonist pretreatment, a very early invasive strategy may be beneficial. The EARLY trial (Early or Delayed Revascularization for Intermediate- and High-Risk Non-ST-Segment Elevation Acute Coronary Syndromes?) is a prospective, multicenter, randomized, controlled, open-label, 2-parallel-group study that plans to enroll 740 patients. Patients are eligible if the diagnosis of intermediate- or high-risk NSTE-ACS is made and an invasive strategy intended. Patients are randomized in a 1:1 ratio. In the control group, a delayed strategy is adopted, with the coronary angiography taking place between 12 and 72 hours after randomization. In the experimental group, a very early invasive strategy is performed within 2 hours. A loading dose of a P2Y₁₂ ADP receptor antagonist is given at the time of intervention in both groups. Recruitment began in September 2016 (n = 558 patients as of October 2017). The primary endpoint is the composite of cardiovascular death and recurrent ischemic events at 1 month. The EARLY trial aims to demonstrate the superiority of a very early invasive strategy compared with a delayed strategy in intermediate- and high-risk NSTE-ACS patients managed without P2Y₁₂ ADP receptor antagonist pretreatment.

Hospital and out-of-hospital mortality in 670 hypertensive emergencies and urgencies

Long-term mortality in patients with acute severe hypertension is unclear. The authors aimed to compare short-term (hospital) and long-term (12 months) mortality in these patients. A total of 670 adults presenting for acute severe hypertension between January 1, 2015, and December 31, 2015, were included. A total of 57.5% were hypertensive emergencies and 66.1% were hospitalized: 98% and 23.2% of those with hypertensive emergencies and urgencies, respectively (P = .001). Hospital mortality was 7.9% and was significantly higher for hypertensive emergencies (12.5% vs 1.8%, P = .001). At 12 months, 106 patients died (29.4%), mainly from hypertensive emergencies (38.9% vs 8.9%, P = .001). Median survival was 14 days for neurovascular emergencies and 50 days for cardiovascular emergencies. Patients with hypertensive emergencies or urgencies had bad long-term prognosis. Short-term mortality is mainly caused by neurovascular emergencies, but cardiovascular emergencies are severe, with high mortality at 12 months. These results justify better follow-up and treatment for these patients.

WITHDRAWN: Chest Trauma: First 48 hours management

The Publisher regrets that this article is an accidental duplication of an article that has already been published in , http://dx.doi.org/10.1016/j.accpm.2017.01.003 . The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Chest trauma: First 48hours management

Chest trauma remains an issue for health services for both severe and apparently mild trauma management. Severe chest trauma is associated with high mortality and is considered liable for 25% of mortality in multiple traumas. Moreover, mild trauma is also associated with significant morbidity especially in patients with preexisting conditions. Thus, whatever the severity, a fast-acting strategy must be organized. At this time, there are no guidelines available from scientific societies. These expert recommendations aim to establish guidelines for chest trauma management in both prehospital an in hospital settings, for the first 48hours. The "Société française d'anesthésie réanimation" and the "Société française de médecine d'urgence" worked together on the 7 following questions: (1) criteria defining severity and for appropriate hospital referral; (2) diagnosis strategy in both pre- and in-hospital settings; (3) indications and guidelines for ventilatory support; (4) management of analgesia; (5) indications and guidelines for chest tube placement; (6) surgical and endovascular repair indications in blunt chest trauma; (7) definition, medical and surgical specificity of penetrating chest trauma. For each question, prespecified "crucial" (and sometimes also "important") outcomes were identified by the panel of experts because it mattered for patients. We rated evidence across studies for these specific clinical outcomes. After a systematic Grade^® approach, we defined 60 recommendations. Each recommendation has been evaluated by all the experts according to the DELPHI method.

Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry

RATIONALE, AIMS AND OBJECTIVES

The aim of this study was to describe the cohort of persons having experiences fatal and non-fatal drowning events, registered in the French cardiac arrest registry and to identify termination of resuscitation criteria.

METHODS

We performed a prospective multicenter study based on data from French cardiac arrest registry database. All patients with cardiac arrest after drowning (CAD) recorded between July 2011 and November 2014 were included. The population description was carried out by medians [interquartile ranges (IQR)] or frequencies. The characteristics were compared in terms of the primary endpoint (alive vs dead at hospital admission) using chi-square or Fisher's exact and the Mann-Whitney U test. The predictive model was carried out using the multivariate logistic regression.

RESULTS

The analysis included 234 CAD. The majority of patients were adults (83.6%) and males (64.5%). Most of the submersions occurred out of home (75.6%). We recorded 66.7% of incidents in fresh water. About a third of CAD was witnessed of which 33.8% had an immediate basic life support. Most of CAD patients received an advanced cardiac life support (87.2%). The median Mobile Medical Team response time was 22 [15-30] minutes. At hospital, 40.6% of patients were alive. Twenty one patients (9.0%) were discharged alive. Among them, 17 had a good neurological outcome. Faster interventions generally resulted in higher survival chances (Mobile Medical Team response time OR: 0.960[0.925; 0.996]; P = 0.0.031; no flow duration OR: 0.535[0.313; 0.913]; P = 0.022) if associated with ventilation (OR: 6.742[2.043; 22.250]; P = 0.002). Age (OR: 0.971[0.955; 0.988]; P = 0.001) and location outside (OR: 0.203[0.064; 0.625]; P = 0.007) are the other criteria of our model.

CONCLUSIONS

The model is helpful to highlight explanative variables concerning CAD patients' outcome. The next step is the validation of these five factors by a larger study. Prevention and public training to lifesaving behaviours must be considered as priorities in French public health programmes.

Prehospital and in-hospital course of care for patients with acute heart failure: Features and impact on prognosis in "real life"

BACKGROUND

Acute heart failure (AHF) is a life-threatening medical emergency for which no new effective therapies have emerged in recent decades. No previous study has exhaustively described the entire course of care of AHF patients from first medical contact to hospital discharge or assessed its impact on prognosis.

AIM

To fully describe the course of care and analyze its influence on outcomes in patients hospitalized with an AHF syndrome in an academic university center.

METHODS

One hundred and nineteen adults with AHF from three public academic university hospitals were consecutively enrolled in a multicenter prospective observational cohort study. All of the emergency departments, intensive care units, coronary care units, cardiology wards and other medical wards participated in the study.

RESULTS

The composite primary outcome (6-month rate of cardiovascular death, readmission for acute heart failure, acute coronary syndrome or stroke) occurred in 59% of patients. This rate was high and similar regardless of first medical contact, type of transport, first medical department of admission and number of medical departments involved in the course of care. A cardiologist was involved in management in 80% of cases. The global median hospital stay was shorter with cardiology vs non-cardiology management (7 days [interquartile range 4-11] vs 10 days [interquartile range 7-18]; P=0.003). History of hypertension (P=0.004), need for non-invasive ventilation (P=0.023) and Lee prognostic score (P=0.028) were independently associated with the primary outcome.

CONCLUSIONS

Morbimortality and readmissions were high regardless of the course of care in patients admitted for AHF in real life. The reduction in hospital stay when cardiologists were involved in management encourages the creation of "mobile AHF cardiology teams".

Pathophysiological and diagnostic implications of cardiac biomarkers and antidiuretic hormone release in distinguishing immersion pulmonary edema from decompression sickness

Immersion pulmonary edema (IPE) is a misdiagnosed environmental illness caused by water immersion, cold, and exertion. IPE occurs typically during SCUBA diving, snorkeling, and swimming. IPE is sometimes associated with myocardial injury and/or loss of consciousness in water, which may be fatal. IPE is thought to involve hemodynamic and cardiovascular disturbances, but its pathophysiology remains largely unclear, which makes IPE prevention difficult. This observational study aimed to document IPE pathogenesis and improve diagnostic reliability, including distinguishing in some conditions IPE from decompression sickness (DCS), another diving-related disorder.Thirty-one patients (19 IPE, 12 DCS) treated at the Hyperbaric Medicine Department (Ste-Anne hospital, Toulon, France; July 2013-June 2014) were recruited into the study. Ten healthy divers were recruited as controls. We tested: (i) copeptin, a surrogate marker for antidiuretic hormone and a stress marker; (ii) ischemia-modified albumin, an ischemia/hypoxia marker; (iii) brain-natriuretic peptide (BNP), a marker of heart failure, and (iv) ultrasensitive-cardiac troponin-I (cTnI), a marker of myocardial ischemia.We found that copeptin and cardiac biomarkers were higher in IPE versus DCS and controls: (i) copeptin: 68% of IPE patients had a high level versus 25% of DCS patients (P < 0.05) (mean ± standard-deviation: IPE: 53 ± 61 pmol/L; DCS: 15 ± 17; controls: 6 ± 3; IPE versus DCS or controls: P < 0.05); (ii) ischemia-modified albumin: 68% of IPE patients had a high level versus 16% of DCS patients (P < 0.05) (IPE: 123 ± 25 arbitrary-units; DCS: 84 ± 25; controls: 94 ± 7; IPE versus DCS or controls: P < 0.05); (iii) BNP: 53% of IPE patients had a high level, DCS patients having normal values (P < 0.05) (IPE: 383 ± 394 ng/L; DCS: 37 ± 28; controls: 19 ± 15; IPE versus DCS or controls: P < 0.01); (iv) cTnI: 63% of IPE patients had a high level, DCS patients having normal values (P < 0.05) (IPE: 0.66 ± 1.50 μg/L; DCS: 0.0061 ± 0.0040; controls: 0.0090 ± 0.01; IPE versus DCS or controls: P < 0.01). The combined "BNP-cTnI" levels provided most discrimination: all IPE patients, but none of the DCS patients, had elevated levels of either/both of these markers.We propose that antidiuretic hormone acts together with a myocardial ischemic process to promote IPE. Thus, monitoring of antidiuretic hormone and cardiac biomarkers can help to make a quick and reliable diagnosis of IPE.

[Prevalence and severity of hypertensive emergencies and outbreaks in the hospital emergency department of CHU Timone at Marseille: Follow-up in three months of hospitalized patients]

GOAL

Evaluation of the prevalence and severity of hypertensive emergencies and crisis in an Emergency Service of Timone hospital in Marseille and follow-up of 3 months of hospitalized emergencies.

METHODS

This study was conducted in the Emergency Department between April 1 and June 30, 2015. All patients with BP>180 and/or 110mmHg was recorded and classified in true emergencies (presence of visceral pain) and hypertensive isolated crisis. A phone follow-up patients was organized.

RESULTS

During this period, 170 patients were identified: 95 (56%) hypertensive crisis and 75 (44%) hypertensive emergencies: 25 OAP (33%), 18 ischemic stroke (24%), 15 hemorrhagic stroke (20%), 9 angina (12%) and 8 different. The clinical characteristics of hypertensive emergencies are preferentially dyspnea (27%) motor deficit (36%), and chest pain (16%). The BP of hypertensive emergencies at their admission (3 measurements, oscillometric automatic device) is close to the hypertensive crisis (198.17±19.3 to 96.4±21.2mmHg versus 191±31.6 to 96.12±21). The BP controlled after 15minutes of rest is lower for crisis compared to real emergencies (152±47 to 79±28 vs. 174±31 to 86±26). Age emergency is larger (77±14 vs. 67±17), the number of slightly larger drug (1.79 versus 1.67±1±1). Telephone follow-up was performed after an average period of three months. Ninety-nine patients were contacted by telephone: 46 patients who were admitted for hypertensive emergency patients and 53 for a push. Eighteen deaths have been recorded, including 15 among hypertensive emergencies (9 in hemorrhagic stroke, 5 for ischemic stroke, and 1 for OAP) with 5-hospital deaths within 48hours after admission and 10 within 3 months in patients hospitalized with hypertensive emergency or 33%. Seventy-seven patients out of 99 had been reviewed by their attending physicians. A questionnaire was sent by mail to patients who have not answered the phone contacts, and responses are pending.

CONCLUSION

Hypertensive emergencies hospitalized in Timone Hospital represent 44% of patients hospitalized for emergency HTA. Their gravity is 1/3 since most patients die within three months warranting closer management of these fragile patients by creating a specialized consulting postemergency.

Epidemiology of unintentional drowning in a metropolis of the French Mediterranean coast: a retrospective analysis (2000-2011)

Drowning affects more than 500,000 people worldwide and is responsible for at least 350,000 deaths each year. In France, 1235 drowning resulting in 496 deaths were recorded in the summer 2012. This retrospective study has investigated the epidemiology of drowning in the city of Marseille (South of France) between 2000 and 2011. We identified 449 cases of unintentional drowning. The highest incidence was found among males with a median age of 36 years. The incidence was 5.3 victims per 10,000 inhabitants with a mortality rate of 1.2 per 10,000. These accidents occurred mainly at sea (89%) and during the summer season. A majority of drowning victims (69%) were admitted in a hospital. This is the only study in France to analyse data on drowning throughout the year and over a long period. Drowning is a serious condition burdened by 22% of victims who die.

Undercorrection of hypernatremia is frequent and associated with mortality

Background

About 1% of patients admitted to the Emergency Department (ED) have hypernatremia, a condition associated with a mortality rate of 20 to 60%. Management recommendations originate from intensive care unit studies, in which patients and medical diseases differ from those in ED.

Methods

We retrospectively studied clinical characteristics, treatments, and outcomes of severely hypernatremic patients in the ED and risk factors associated with death occurrence during hospitalization.

Results

During 2010, 85 cases of severe hypernatremia ≥150 mmol/l were admitted to ED. Hypernatremia occurred in frail patients: mean age 79.7 years, 55% institutionalized, 28% with dementia.

Twenty four percent of patients died during hospitalization. Male gender and low mean blood pressure (MBP) were independently associated with death, as well as slow natremia correction speed, but not the severity of hyperosmolarity at admission. Infusion solute was inappropriate for 45% of patients with MBP <70 mmHg who received hypotonic solutes and 22% of patients with MBP ≥70 mmHg who received isotonic solutes or were not perfused.

Conclusions

This is the first study assessing outcome of hypernatremic patients in the ED according to the treatment provided. It appears that not only a too quick, but also a too slow correction speed is associated with an increased risk of death regardless of initial natremia. Medical management of hypernatremic patients must be improved regarding evaluation and treatment.

Ticagrelor versus prasugrel in diabetic patients with an acute coronary syndrome. A pharmacodynamic randomised study

Optimal P2Y12 receptor blockade is critical to prevent ischaemic recurrence in patients undergoing percutaneous coronary intervention (PCI). We aimed to compare the level of platelet reactivity (PR) inhibition achieved by prasugrel and ticagrelor loading dose (LD) in diabetic acute coronary syndrome (ACS) patients undergoing PCI. We performed a single-center prospective open-label randomised trial. Patients with diabetes mellitus undergoing PCI for an ACS were randomised to receive prasugrel 60 mg or ticagrelor 180 mg. The primary endpoint of the study was the level of platelet reactivity (PR) assessed between 6 and 18 hours post-LD using the VASP index. We randomised 100 diabetic patients undergoing PCI for an ACS. No difference was observed in baseline characteristics between the two groups. In particular, the rate of patient receiving insulin therapy was identical (25 vs 28.6%; p =0.7). Ticagrelor achieved a significantly lower PR compared to prasugrel loading dose (17.3 ± 14.2 vs 27.7 ± 23.3%; p=0.009). In addition the rate of high on-treatment platelet reactivity, defined by a VASP ≥50%, tend to be lower in the ticagrelor group although the difference did not reach statistical significance (6 vs 16%; p=0.2). The rate of low on treatment PR was identical (60 vs 54%; p=0.8). The present study demonstrates that ticagrelor LD is superior to prasugrel LD to reduce PR in ACS patients with diabetes mellitus. Whether the higher potency of ticagrelor could translate into a clinical benefit should be investigated.

Assessing post-treatment platelet reactivity: a focus on patient selection and setting

Dual antiplatelet therapy is critical to inhibit platelet reactivity in order to prevent ischemic recurrences in stented patients. However, studies have observed a variable blockade of the P2Y12 adenosine diphosphate receptor between patients following clopidogrel intake. This interindividual variability in the biological response is not uncommon with clopidogrel (about 50%) and even prasugrel (20%). High on-treatment platelet reactivity (HTPR) is correlated with thrombotic events following percutaneous coronary intervention. Several studies suggested that tailoring of antiplatelet therapy based on platelet reactivity (PR) monitoring could safely reduce the rate of major adverse cardiovascular events in HTPR patients. In addition, low on-treatment PR was recently associated with bleeding events both in patients treated with prasugrel and clopidogrel. Of importance, bleedings are associated with a poor prognosis in stented patients. Overall, the potential of PR monitoring to individualize antiplatelet therapy might benefit stented patients by reducing both ischemic and bleeding risks. However, such strategies remain to be evaluated in adequately designed large-scale randomized clinical trials.