Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial

Rationale: Management of first episodes of primary spontaneous pneumothorax remains the subject of debate. Objectives: To determine whether first-line simple aspiration is noninferior to first-line chest tube drainage for lung expansion in patients with complete primary spontaneous pneumothorax. Methods: We conducted a prospective, open-label, randomized noninferiority trial. Adults aged 18-50 years with complete primary spontaneous pneumothorax (total separation of the lung from the chest wall), recruited at 31 French hospitals from 2009 to 2015, received simple aspiration (n = 200) or chest tube drainage (n = 202) as first-line treatment. The primary outcome was pulmonary expansion 24 hours after the procedure. Secondary outcomes were tolerance of treatment, occurrence of adverse events, and recurrence of pneumothorax within 1 year. Substantial discordance in the numerical inputs used for trial planning and the actual trial rates of the primary outcome resulted in a reevaluation of the trial analysis plan. Measurement and Main Results: Treatment failure occurred in 29% in the aspiration group and 18% in the chest tube drainage group (difference in failure rate, 0.113; 95% confidence interval [CI], 0.026-0.200). The aspiration group experienced less pain overall (mean difference, -1.4; 95% CI, -1.89, -0.91), less pain limiting breathing (frequency difference, -0.18; 95% CI, -0.27, -0.09), and less kinking of the device (frequency difference, -0.05; 95% CI, -0.09, -0.01). Recurrence of pneumothorax was 20% in this group versus 27% in the drainage group (frequency difference, -0.07; 95% CI, -0.16, +0.02). Conclusions: First-line management of complete primary spontaneous pneumothorax with simple aspiration had a higher failure rate than chest tube drainage but was better tolerated with fewer adverse events. Clinical trial registered with www.clinicaltrials.gov (NCT01008228).

S100B serum level: A relevant biomarker for the management of non-traumatic headaches in emergency care?

BACKGROUND

The diagnostic of primary or secondary headaches in emergency units is mostly based on brain imaging, which is expensive and sometimes hardly accessible. An increase in serum S100B protein has already been found in several neurological conditions inducing brain damage. The objective of this study was to assess the diagnostic performance of S100B serum assay to distinguish primary and secondary headaches among patients with non-traumatic headaches in the emergency department.

METHODS

This was a phase 2, prospective, monocentric diagnostic study. Eighty-one adult patients with non-traumatic headaches in the emergency department were included. In addition to the usual management, a blood assay of the S100B protein was performed in the emergency department, as well as a brain MRI between 48 and 96 h if not performed during the initial management. The primary or secondary headache diagnosis was made at one month by an expert committee, blindly of the results of the S100B assay. The primary outcome was the blood assay of the S100B protein.

RESULTS

There was 63 patients for analysis in the primary headache group and 17 in the secondary headache group. The S100B protein assay was significantly higher in secondary headaches than primary headaches, with an AUC of the ROC curve of 0.67. The optimal threshold of 0.06 μg.L^-1 allowed to obtain those diagnostic characteristics: sensitivity 75% [48; 93], specificity 62% [48; 74], PPV 35% [20; 54] and NPV 90% [76; 97]. The association between the S100B protein level and the onset of pain was significantly higher for patients with headaches <3 h.

CONCLUSION

The assay of the S100B protein could be useful in the management of this pathology in emergencies. Future studies taking into account dosing time and etiologies could be conducted in order to refine its use in practice.

Magnetic needle-tracking device for ultrasound guidance of radial artery puncture: A randomized study on a simulation model

INTRODUCTION

Ultrasound-guidance of radial artery catheter insertion improves the first attempt success and reduces the occurrence of hematomas. Needle-tracking devices optimize needle-ultrasound beam alignment by displaying in real-time the needle tip position. We compared the median time need by experienced physicians to achieve radial artery puncture using either a conventional ultrasonography device (CUD) or a magnetic needle-tracking ultrasound device (MUD) in a simulation training arm model.

METHODS

Fifty experienced residents and physicians performed two punctures in randomized order with the CUD and the MUD. The primary outcome was puncture duration; the secondary outcomes were puncture success, rate of accidental vein puncture, and practitioner's comfort (subjective scale 0-10).

RESULTS

The median [lower-upper quartile] puncture time was 10 [6-14] seconds when using CUD and 4 [3-7] seconds when using MUD (P < .01). In the multivariate analysis, MUD use was associated with decreased puncture duration whatever the puncture order (OR 1.13 [1.07-1.20], P < .01). The participants performed 99 (99%) successful punctures: 50 with the MUD (100%) and 49 with the CUD (98%). There was no accidental venous puncture. The practitioner's comfort level was 6.5 [6, 7] with the CUD and 8 [7-9] with the MUD (P < .01).

CONCLUSION

MUD reduced radial artery puncture time and improved physician comfort in a simulation training arm model.

Ultrasound guidance in difficult radial artery puncture for blood gas analysis: A prospective, randomized controlled trial

Background

Ultrasound (US) guidance has yet to prove its applicability in radial arterial blood gas analysis (ABGA) punctures. The main objective of our study was to compare the number of first-attempt successes (NFAS) for radial arterial puncture in difficult patients with or without US guidance. The Secondary aims were to compare the number of punctures (NOP), puncture time, and patient pain.

Methods

In this single-center, randomized controlled trial, patients who required a radial ABGA and in whom the arterial puncture was assessed as difficult (because of non-palpable radial arteries or two previous puncture failures by a nurse) were assigned to the US group or no-US (NUS) group (procedure performed by a trained physician).

Results

Thirty-six patients were included in the US group and 37 in the NUS groups. The NFAS was 7 (19%) in the NUS group and 19 (53%) in the US group. The relative risk of success in the US group was 2.79 (95% CI,1.34 to 5.82), p = 0.01. In the NUS and US groups, respectively, the median NOP was 3 [2; 6] vs. 1 [1; 2], estimated difference −2.0 (95%CI, −3.4 to −0.6), p < 0.01; the respective puncture time was 3.1 [1.6; 5.4] vs. 1.4 [0.6; 3.1] min, estimated difference −1.45 (95%CI, −2.57 to −0.39), p = 0.01; the respective median patient pain was 6 [4; 8] vs. 2 [1; 4], estimated difference −4.0 (95%CI, −5.8 to −2.3); p < 0.01.

Conclusion

US guidance by a trained physician significantly improves the rate of success in difficult radial ABGA patients.

Out-of-hospital Times Using Helicopters Versus Ground Services for Emergency Patients

OBJECTIVE

Minimizing out-of-hospital time reduces morbidity and mortality in patients with severe trauma, acute coronary syndrome, or acute stroke. Our objective was to compare out-of-hospital times by helicopter versus ground services when the estimated time of arrival on the scene was over 20 minutes.

METHODS

We proposed a retrospective observational monocentric study following 2 cohorts. The helicopter group and the ground group included patients with severe trauma, acute coronary syndrome, or acute stroke transported by helicopter or ground services.

RESULTS

Two hundred thirty-nine patients were included; 118 were in the ground group, and 121 were in the helicopter group. Distances for the helicopter group were higher (62.1 ± 22.5 km vs. 27.6 ± 10.4 km, P < .001). When distances were over 35 km, the helicopter group was faster. We identified distance, need for surgery, and intensive care hospitalization as 3 predicting factors for choosing helicopters over ground modes of transport.

CONCLUSION

In cases of severe trauma, acute coronary syndrome, or acute stroke, emergency medical helicopter transport can be chosen over ground transport when patients are in a severe state and when the distance is further than 35 km from the hospital.

Concordance and limits between transcutaneous and arterial carbon dioxide pressure in emergency department patients with acute respiratory failure: a single-center prospective observational study

Introduction

Transcutaneous CO ₂ (PtCO ₂) is a continuous and non-invasive measure recommended by scientific societies in the management of respiratory distress. The objective of this study is to evaluate the correlation between PtCO ₂ and blood pressure of CO ₂ (PaCO ₂) by blood gas analysis in emergency patients with dyspnoea and to determine the factors that interfere in this correlation.

Methods

From January to June 2014, all patients admitted to resuscitation room of the emergency department targeted for arterial blood gases were included prospectively. A sensor measuring the PtCO ₂ was attached to the ear lobe of the patient before the gas analysis. Anamnesis, clinical and laboratory parameters were identified.

Results

90 patients with dyspnoea were included (with 104 pairs of measurements), the median age was 79 years [69-85]. The correlation between PtCO ₂ and PaCO ₂ was R ²= 0.83 (p <0.001) but became lower for values of PaCO ₂>60 mm Hg. The mean bias (±SD) between the two methods of measurement (Bland-Altman analysis) was -1.4 mm Hg (±7.7) with limits of agreement of -16.4 to 13.7 mm Hg. In univariate analysis, PaO ₂ interfered in this correlation. After multivariate analysis, the temperature (OR = 3.01, 95% CI = 1.16-7.09) and the PaO ₂ (OR = 1.22, 95% CI = 1.02-1.47) were found to be significant.

Conclusions

In patients admitted in emergency unit for acute respiratory failure, there is a significant correlation between PaCO ₂ and PtCO ₂, mainly for values below 60 mm Hg. The two limiting factors of use are hyperthermia and users training.

Hospital out-lying through lack of beds and its impact on care and patient outcome

Background

When medical wards become saturated, the common practice is to resort to outlying patients in another ward until a bed becomes free.

Objectives

Compare the quality of care provided for inpatients who are outlying (O) in inappropriate wards because of lack of vacant beds in appropriate specialty wards to the care given to non outlying (NO) patients.

Methods

We propose a matched-pair cluster study. The exposed group consisted of inpatients that were outliers in inappropriate wards because of lack of available beds. Non-exposed subjects (the control group) were those patients who were hospitalized in the ward that corresponded to the reason for their admission. Each patient of the exposed group was matched to a specific control subject. The principal objective was to prospectively measure differences in the length of hospital stays, the secondary objectives were to assess mortality, rate of re-admission at 28 days, and rate of transfer into intensive care.

Results

238 were included in the NO group, 245 in the O group. More patients in the O group (86% vs 76%) were transferred into a ward with prescription completed. O patients remained in hospital for 8 days [4-15] vs 7 days [4-13] for NO patients (p = 0.04). 124 (52%) of the NO patients received heparin-based thromboembolic prevention during their stay in hospital vs 104 (42%) of the O patient group (p = 0.03). 66 (27%) O patients were re-admitted to hospital within 28 days vs 40 (17%) NO patients (p = 0.008).

Conclusion

O patients had a worse prognosis than NO patients.