Incidence, Complications, and Factors Associated with Out-of-Hospital First Attempt Intubation Failure in Adult Patients: A Secondary Analysis of the CURASMUR Trial Data.

Objectives: The objectives of this study were to evaluate first attempt intubation failure rate, its associated factors, and its related complications in out-of-hospital emergency setting, when emergency physicians perform standardized airway management using rapid sequence intubation in adult patients. Material and methods: The present study was a substudy of the Succinylcholine versus Rocuronium for out-of-hospital Emergency Intubation (CURASMUR) Trial, which compared Succinylcholine and Rocuronium used for Rapid sequence intubation. First attempt Intubation failure rate and early intubation related complications were recorded. We used multivariable logistic regression analysis to determine first intubation failure associated factors. Results: A total of 1230 patients were included with mean age of 55.9 +/- 19 years. First attempt intubation failure was recorded in 285 (23.2%) patients. The occurrence of a first attempt intubation failure was independently associated with history of ear, nose, and throat neoplasia (OR 2.20, CI 95% 1.06-4.60). Early intubation related complications were more frequent in case of first attempt intubation failure: 80 of 285 (28.4%) in patients with first attempt intubation failure and 185 of 945 (19.6%) in patients with successful first attempt intubation [OR 1.44; CI 95%, 1.11-1.87]. Conclusion: Based on a large multicenter study on out-of-hospital tracheal intubation of adult patients, we found that first attempt intubation failure rate was high and that history of ear, nose, and throat (ENT) neoplasia was an independent associated factor. Failure in first intubation attempt was associated with significantly more intubation related complications.

Assessment of the SpO2/FiO2 ratio as a tool for hypoxemia screening in the emergency department.

OBJECTIVE: We assessed the performance of the ratio of peripheral arterial oxygen saturation to the inspired fraction of oxygen (SpO2/FiO2) to predict the ratio of partial pressure arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) among patients admitted to our emergency department (ED) during the SARS-CoV-2 outbreak. METHODS: We retrospectively studied patients admitted to an academic-level ED in France who were undergoing a joint measurement of SpO2 and arterial blood gas. We compared SpO2 with SaO2 and evaluated performance of the SpO2/FiO2 ratio for the prediction of 300 and 400 mmHg PaO2/FiO2 cut-off values in COVID-19 positive and negative subgroups using receiver-operating characteristic (ROC) curves. RESULTS: During the study period from February to April 2020, a total of 430 arterial samples were analyzed and collected from 395 patients. The area under the ROC curves of the SpO2/FiO2 ratio was 0.918 (CI 95% 0.885-0.950) and 0.901 (CI 95% 0.872-0.930) for PaO2/FiO2 thresholds of 300 and 400 mmHg, respectively. The positive predictive value (PPV) of an SpO2/FiO2 threshold of 350 for PaO2/FiO2 inferior to 300 mmHg was 0.88 (CI95% 0.84-0.91), whereas the negative predictive value (NPV) of the SpO2/FiO2 threshold of 470 for PaO2/FiO2 inferior to 400 mmHg was 0.89 (CI95% 0.75-0.96). No significant differences were found between the subgroups. CONCLUSIONS: The SpO2/FiO2 ratio may be a reliable tool for hypoxemia screening among patients admitted to the ED, particularly during the SARS-CoV-2 outbreak.

Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial.

Importance: Rocuronium and succinylcholine are often used for rapid sequence intubation, although the comparative efficacy of these paralytic agents for achieving successful intubation in an emergency setting has not been evaluated in clinical trials. Succinylcholine use has been associated with several adverse events not reported with rocuronium. Objective: To assess the noninferiority of rocuronium vs succinylcholine for tracheal intubation in out-of-hospital emergency situations. Design, Setting and Participants: Multicenter, single-blind, noninferiority randomized clinical trial comparing rocuronium (1.2 mg/kg) with succinylcholine (1 mg/kg) for rapid sequence intubation in 1248 adult patients needing out-of-hospital tracheal intubation. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. The date of final follow-up was August 31, 2016. Interventions: Patients were randomly assigned to undergo tracheal intubation facilitated by rocuronium (n = 624) or succinylcholine (n = 624). Main Outcomes and Measures: The primary outcome was the intubation success rate on first attempt. A noninferiority margin of 7% was chosen. A per-protocol analysis was prespecified as the primary analysis. Results: Among 1248 patients who were randomized (mean age, 56 years; 501 [40.1%] women), 1230 (98.6%) completed the trial and 1226 (98.2%) were included in the per-protocol analysis. The number of patients with successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, with a between-group difference of -4.8% (1-sided 97.5% CI, -9% to ∞), which did not meet criteria for noninferiority. The most common intubation-related adverse events were hypoxemia (55 of 610 patients [9.0%]) and hypotension (39 of 610 patients [6.4%]) in the rocuronium group and hypoxemia (61 of 616 [9.9%]) and hypotension (62 of 616 patients [10.1%]) in the succinylcholine group. Conclusions and Relevance: Among patients undergoing endotracheal intubation in an out-of-hospital emergency setting, rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate. Trial Registration: ClinicalTrials.gov Identifier: NCT02000674.

Appropriateness and Complications of Peripheral Venous Catheters Placed in an Emergency Department.

BACKGROUND: The insertion of peripheral venous catheters (PVCs) is the invasive procedure most frequently performed in hospitals, and it could be associated with complications. The appropriateness of PVC placement, however, has not been carefully analyzed. OBJECTIVES: We conducted a study to assess the rate of PVC placement in our Emergency Department (ED), their use, their immediate or potential usefulness, and their complications. METHODS: In this descriptive prospective study, we recorded every PVC placed in our ED during 1 week and assessed its appropriateness in terms of its use and potential usefulness. We then followed the patients transferred to medical wards to determine the duration of PVC maintenance and any complications. RESULTS: PVCs (n = 210) were placed for 34% (n = 207) of the 605 patients admitted to the ED during the study period. Of these PVCs, 27% (n = 52) were not used and 43% (n = 91) were considered ineffective. Follow-up covered 92 patients with PVCs transferred to medical wards. We recorded seven episodes of phlebitis (8%) and no infections, local or systemic. The mean duration of PVS maintenance in the medical wards was 40 h from insertion. Of the PVCs with complications, 43% were ineffective. The mean duration of maintenance of the PVCs that led to complications was 80 h, compared with 35 h for those without complications (p < 0.02). CONCLUSION: In accordance with the literature, half of the PVCs inserted in our ED were ineffective; half the PVCs causing complications were avoidable.

Emergency department syndromic surveillance to investigate the health impact and factors associated with alcohol intoxication in Reunion Island.

In Reunion Island, alcohol is the most tried out psychoactive substance. To our knowledge, few indicators measuring the health burden of alcohol use exist on the island. In this context, an exploratory analysis based on syndromic surveillance data was implemented in order to describe the emergency department (ED) visits for alcohol intoxication (AI) and factors associated with their variations.An analysis of anonymized records routinely collected by the syndromic surveillance system was carried out. A daily indicator of ED visits for AI was built from a selection of ICD-10 codes between 2010 and 2012. Health impact of AI was first described comparing this indicator to all causes ED visits. Then, AI visits were analyzed with time-series methods using generalized additive Poisson regression models allowing for overdispersion. The following variables were included in the model: long-term trend, seasonality, day of the week, public and school holidays, days of festival and minimum social benefits payday.During the study period, 16 652 visits for AI were recorded in EDs of Reunion Island. AI visits were the second reason for ED visits (i.e. 4%) after traumatism. AI visits mainly concerned men (87%) and the age group of 25-54 years (69%). There was a significant increase in ED visits for AI during days of benefits payday, weekends and publics holidays.This study demonstrated the interest of syndromic surveillance to monitor non-infectious diseases. Time-series models showed a robust association between ED visits for AI and several factors.

Health impact assessment of cyclone Bejisa in Reunion Island (France) using syndromic surveillance.

INTRODUCTION: On January 2, 2014, Cyclone Bejisa struck Reunion Island (France). This storm led to major material damages, such as power outages, disturbance of drinking water systems, road closures, and the evacuation of residents. In this context, the Regional Office of French Institute for Public Health Surveillance in Indian Ocean (Cire OI) set up an epidemiological surveillance in order to describe short-term health effects of the cyclone. METHODS: The assessment of the health impact was based mainly on a syndromic surveillance system, including the activity of all emergency departments (EDs) and the Emergency Medical Service (EMS) of the island. From these data, several health indicators were collected and analyzed daily and weekly. To complete this assessment, all medical charts recorded in the EDs of Reunion Island from January 2, 2014 through January 5, 2014 were reviewed in order to identify visits directly and indirectly related to the cyclone, and to determine mechanisms of injuries. RESULTS: The number of calls to the EMS peaked the day of the cyclone, and the number of ED visits increased markedly over the next two days. At the same time, a significant increase in visits for trauma, burns, and carbon monoxide poisoning was detected in all EDs. Among 1,748 medical records reviewed, eight visits were directly related to the cyclone and 208 were indirectly related. For trauma, the main mechanisms of injury were falls and injuries by machinery or tools during the clean-up and repair works. Due to prolonged power outages, several patients were hospitalized: some to assure continuity of care, others to take care of an exacerbation of a chronic disease. An increase in leptospirosis cases linked to post-cyclone clean-up was observed two weeks after the cyclone. CONCLUSION: Information based on the syndromic surveillance system allowed the authors to assess rapidly the health impact of Cyclone Bejisa in Reunion Island; however, an underestimation of this impact was still possible. In the near future, several lines of work will be planned by the authors in order to improve the assessment.

Deep Learning Transformer Models for Building a Comprehensive and Real-time Trauma Observatory: Development and Validation Study.

BACKGROUND: Public health surveillance relies on the collection of data, often in near-real time. Recent advances in natural language processing make it possible to envisage an automated system for extracting information from electronic health records. OBJECTIVE: To study the feasibility of setting up a national trauma observatory in France, we compared the performance of several automatic language processing methods in a multiclass classification task of unstructured clinical notes. METHODS: A total of 69,110 free-text clinical notes related to visits to the emergency departments of the University Hospital of Bordeaux, France, between 2012 and 2019 were manually annotated. Among these clinical notes, 32.5% (22,481/69,110) were traumas. We trained 4 transformer models (deep learning models that encompass attention mechanism) and compared them with the term frequency-inverse document frequency associated with the support vector machine method. RESULTS: The transformer models consistently performed better than the term frequency-inverse document frequency and a support vector machine. Among the transformers, the GPTanam model pretrained with a French corpus with an additional autosupervised learning step on 306,368 unlabeled clinical notes showed the best performance with a micro F1-score of 0.969. CONCLUSIONS: The transformers proved efficient at the multiclass classification of narrative and medical data. Further steps for improvement should focus on the expansion of abbreviations and multioutput multiclass classification.

Risk factors for failed first intubation attempt in an out-of-hospital setting: a multicenter prospective study.

This study was performed to identify variables potentially associated with failure of the first intubation attempt in an out-of-hospital emergency setting, considering all aspects of tracheal intubation. This observational prospective multicenter study was performed over 17 months and involved 10 prehospital emergency medical units. After each tracheal intubation, the operator was required to provide information concerning operator and patient characteristics, as well as the environmental conditions during intubation, by completing a data collection form. The primary endpoint was failure of the first intubation attempt. During the study period, 1546 patients were analyzed, of whom 59% were in cardiac arrest; 486 intubations failed on the first attempt (31.4% [95% confidence interval = 30.2-32.6]). Multivariate analysis revealed that the following 7 of 28 factors were associated with an increased risk of a failed first intubation attempt: operator with fewer than 50 prior intubations (odds ratio [OR] = 1.8 [1.4-2.4]), small inter-incisor space (OR = 2.3 [1.7-3.2]), limited extension of the head (OR = 1.6 [1.1-2.1]), macroglossia (OR = 2.3 [1.6-3.2]), ear/nose/throat (ENT) tumor (OR = 4.4 [1.4-13.4]), cardiac arrest (OR = 1.8 [1.3-2.6]), and vomiting (OR = 1.7 [1.3-2.3]). The frequency of adverse events among non-cardiac arrest patients was 17.6%; it increased with each additional intubation attempt. The first intubation attempt failed in more than 30% of cases, and seven variables were associated with increased risk of failure. Most of these factors could not be predicted.

Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial.

BACKGROUND: Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction has traditionally been supported by unfractionated heparin, which has never been directly compared with a new anticoagulant using consistent anticoagulation and similar antiplatelet strategies in both groups. We compared traditional heparin treatment with intravenous enoxaparin in primary PCI. METHODS: In a randomised open-label trial, patients presenting with ST-elevation myocardial infarction were randomly assigned (1:1) to receive an intravenous bolus of 0·5 mg/kg of enoxaparin or unfractionated heparin before primary PCI. Wherever possible, medical teams travelling in mobile intensive care units (ambulances) selected, randomly assigned (using an interactive voice response system at the central randomisation centre), and treated patients. Patients who had received any anticoagulant before randomisation were excluded. Patients and caregivers were not masked to treatment allocation. The primary endpoint was 30-day incidence of death, complication of myocardial infarction, procedure failure, or major bleeding. The main secondary endpoint was the composite of death, recurrent acute coronary syndrome, or urgent revascularisation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00718471. FINDINGS: 910 patients were assigned to treatment with enoxaparin (n=450) or unfractionated heparin (n=460). The primary endpoint occurred in 126 (28%) patients after anticoagulation with enoxaparin versus 155 (34%) patients on unfractionated heparin (relative risk [RR] 0·83, 95% CI 0·68-1·01, p=0·06). The incidence of death (enoxaparin, 17 [4%] vs heparin, 29 [6%] patients; p=0·08), complication of myocardial infarction (20 [4%] vs 29 [6%]; p=0·21), procedure failure (100 [26%] vs 109 [28%]; p=0·61), and major bleeding (20 [5%] vs 22 [5%]; p=0·79) did not differ between groups. Enoxaparin resulted in a significantly reduced rate of the main secondary endpoint (30 [7%] vs 52 [11%] patients; RR 0·59, 95% CI 0·38-0·91, p=0·015). Death, complication of myocardial infarction, or major bleeding (46 [10%] vs 69 [15%] patients; p=0·03), death or complication of myocardial infarction (35 [8%] vs 57 [12%]; p=0·02), and death, recurrent myocardial infarction, or urgent revascularisation (23 [5%] vs 39 [8%]; p=0·04) were all reduced with enoxaparin. INTERPRETATION: Intravenous enoxaparin compared with unfractionated heparin significantly reduced clinical ischaemic outcomes without differences in bleeding and procedural success. Therefore, enoxaparin provided an improvement in net clinical benefit in patients undergoing primary PCI. FUNDING: Direction de la Recherche Clinique, Assistance Publique-Hôpitaux de Paris; Sanofi-Aventis.

Surveillance of COVID-19 using a keyword search for symptoms in reports from emergency medical communication centers in Gironde, France: a 15 year retrospective cross-sectional study.

During periods such as the COVID-19 crisis, there is a need for responsive public health surveillance indicators related to the epidemic. To determine the performance of keyword-search algorithm in call reports to emergency medical communication centers (EMCC) to describe trends in symptoms during the COVID-19 crisis. We retrospectively retrieved all free text call reports from the EMCC of the Gironde department (SAMU 33), France, between 2005 and 2020 and classified them with a simple keyword-based algorithm to identify symptoms relevant to COVID-19. A validation was performed using a sample of manually coded call reports. The six selected symptoms were fever, cough, muscle soreness, dyspnea, ageusia and anosmia. We retrieved 38,08,243 call reports from January 2005 to October 2020. A total of 8539 reports were manually coded for validation and Cohen's kappa statistics ranged from 75 (keyword anosmia) to 59% (keyword dyspnea). There was an unprecedented peak in the number of daily calls mentioning fever, cough, muscle soreness, anosmia, ageusia, and dyspnea during the COVID-19 epidemic, compared to the past 15 years. Calls mentioning cough, fever and muscle soreness began to increase from February 21, 2020. The number of daily calls reporting cough reached 208 on March 3, 2020, a level higher than any in the previous 15 years, and peaked on March 15, 2020, 2 days before lockdown. Calls referring to dyspnea, anosmia and ageusia peaked 12 days later and were concomitant with the daily number of emergency room admissions. Trends in symptoms cited in calls to EMCC during the COVID-19 crisis provide insights into the natural history of COVID-19. The content of calls to EMCC is an efficient epidemiological surveillance data source and should be integrated into the national surveillance system.

Pulmonary embolism after a long-haul flight.

The relation between long-haul flights (LHF) and venous thromboembolic disease is well established. Nonetheless, the incidence of pulmonary embolisms after these flights is probably underestimated because of the difficulties in case ascertainment. Reunion Island appears to present the ideal geographic conditions for accurately assessing this incidence. We aimed to assess the incidence of pulmonary embolisms in people who had recently taken a LHF to Reunion Island. We conducted a retrospective multi-center descriptive study and included all cases of pulmonary embolisms diagnosed between January 1, 2015, and January 30, 2017 (according to the hospitals' discharge summary database) in the island's four public hospitals within 30 days after taking an LHF to Reunion. We took different delays of diagnosis to calculate the incidence. We have considered the time to diagnosis at 1 month as significant according to the time applied in the Geneva score for risk factors. The study included 45 patients landing on Reunion over a 2-year period. The total number of passengers arriving by LHF during this period was 1,223,001. The incidence of pulmonary embolism after an LHF was thus calculated at 36.8 per million travelers at 1 month. The incidence for PE diagnosed, after 15 days was 29.4 per million travelers, and after 7 days, it was 21.9 per million travelers. The male/female ratio was 0.67. The mean interval between the flight and symptom onset was 7 days. In our population, the incidence of pulmonary embolisms after LHFs in our study is clearly higher than that reported in the literature (36.8 vs 4.8). Our exhaustive data collection probably explains this difference. A case-control study appears necessary to analyze the risk factors for pulmonary embolism after a LHF.

Incidence and factors associated with out-of-hospital peri-intubation cardiac arrest: a secondary analysis of the CURASMUR trial.

The Incidence of peri-intubation cardiac arrest (PICA) has been rarely assessed in the out-of-hospital setting. The objectives of this study were to assess the incidence and factors associated with PICA (cardiac arrest occurring within 15 min of intubation) in an out-of-hospital emergency setting, wherein emergency physicians perform standardized airway management using a rapid sequence intubation technique in adult patients. This was a secondary analysis of the "Succinylcholine versus Rocuronium for out-of-hospital emergency intubation" (CURASMUR) trial, which compared the first attempt intubation success rate between succinylcholine and rocuronium in adult patients requiring emergency tracheal intubation for any vital distress except cardiac arrest. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. All operators were emergency physicians. The PICA incidence was recorded and multivariable logistic regression analysis was used to identify the factors associated with its occurrence. A total of 1226 patients were included with a mean age of 55.9 ± 19 years. PICA was recorded in 35 (2.8%) patients. Multivariable analysis indicated that the occurrence of PICA was independently associated with a body mass index (BMI) > 30 kg m2 [adjusted odds ratio (aOR) 4.85; 95% confidence interval (CI) 1.82-12.90, p = 0.02], oxygen saturation (SpO2) before intubation < 90% (aOR 3.4; 95% CI 1.50-7.60, p = 0.003), difficult intubation (defined by an Intubation Difficulty Score [IDS] > 5, [aOR 3.59; 95% CI 1.82-8.08, p = 0.02], the use of rocuronium instead of succinylcholine (aOR 2.47; 95% CI 1.08-5.64, p = 0.03), post intubation hypoxaemia (aOR 2.70; 95% CI 1.05-6.95, p = 0.04), post-intubation hypotension (aOR 4.07; 95% CI 1.62-10.22, p = 0.003), and pulmonary aspiration(aOR 4.78; 95% CI 1.48-15.36, p = 0.009). Early PICA occurred in approximately 3% of cases in the out-of-hospital setting. We identified several independent risk factors for PICA, including obesity, hypoxaemia before intubation and difficult intubation.

Sudden cardiac arrest: ECG repolarization after resuscitation.

INTRODUCTION: Early repolarization (ERep) abnormalities on electrocardiogram (ECG) are common immediately following cardiac arrest. We characterized and correlated electrocardiographic repolarization abnormalities immediately after cardiac arrest with acute coronary angiography. METHODS AND RESULTS: We studied 225 consecutive patients presenting with out-of-hospital cardiac arrest. All these patients had successful cardiopulmonary resuscitation and acute coronary angiography. The first ECG recorded after successful resuscitation was analyzed by two independent cardiologists. Patients were categorized according to their repolarization pattern. Pattern 1: No ST segment elevation or ERep. Pattern 2: ST segment elevation without ERep. Pattern 3: ST segment elevation and ERep. Pattern 4: ERep only. Patterns 1, 2, 3, and 4 were found in 112 (50%), 74 (33%), 19 (8%), and 20 (9%) patients, respectively. Cardiac arrest was due to acute myocardial ischemia in 45%, 82%, 39%, and 15% of patients in groups 1, 2, 3 and 4, respectively (P < 0.0001). Sensitivity and specificity of pattern 2 was 50% and 88%, respectively, for acute coronary lesion, whereas isolated ERep pattern occurred in 9% of cases and was associated with a nonischemic event (80%). Among 65 patients (29%) who survived, 7% of patients with pattern 1, 13% with pattern 2, 60% with pattern 3, and 88% with pattern 4 exhibited ERep on ECG during the follow-up. CONCLUSION: In the context of cardiac resuscitation, an ECG with ST elevation favors acute myocardial infarction, whereas the presence of ERep is a marker of a nonischemic event and future ERep syndrome.

Comparison of the accuracy of noninvasive hemoglobin monitoring by spectrophotometry (SpHb) and HemoCue® with automated laboratory hemoglobin measurement.

BACKGROUND: The reference method for hemoglobin concentration measurement remains automated analysis in the laboratory. Although point-of-care devices such as the HemoCue® 201+ (HemoCue, Ängelholm, Sweden) provide immediate hemoglobin values, a noninvasive, spectrophotometry-based technology (Radical-7®; Masimo Corp., Irvine, CA) that provides continuous online hemoglobin (SpHb) measurements has been introduced. This clinical study aimed to test the hypothesis that SpHb monitoring was equivalent to that of HemoCue® (the automated hemoglobin measurement in the laboratory taken as a reference method) during acute surgical hemorrhage. METHODS: Blood for laboratory analysis was sampled after induction of anesthesia, during surgery according to the requirements of the anesthesiologist, and finally after the transfer of the patient to the recovery room. When each blood sample was taken, capillary samples were obtained for analysis with HemoCue®. SpHb monitoring was performed continuously during surgery. Using the automated hemoglobin measurement in the laboratory as a reference method, the authors tested the hypothesis that SpHb monitoring is equivalent to that of HemoCue®. The agreement between two methods was evaluated by linear regression and Bland and Altman analysis. RESULTS: Eighty-five simultaneous measurements from SpHb, HemoCue®, and the laboratory were obtained from 44 patients. Bland and Altman comparison of SpHb and HemoCue® with the laboratory measurement showed, respectively, bias of -0.02 ± 1.39 g · dl(-1) and -0.17 ± 1.05 g · dl(-1), and a precision of 1.11 ± 0.83 g · dl(-1) and 0.67 ± 0.83 g · dl(-1). Considering an acceptable difference of ± 1.0 g · dl(-1) with the laboratory measurement, the percentage of outliers was significantly higher for SpHb than for HemoCue® (46% vs. 16%, P < 0.05). CONCLUSIONS: Taking automated laboratory hemoglobin measurement as a reference, the study shows that SpHb monitoring with Radical-7® gives lower readings than does the HemoCue® for assessment of hemoglobin concentration during hemorrhagic surgery.

An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrach™): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery.

BACKGROUND: Because algorithms for difficult airway management, including the use of new optical tracheal intubation devices, require prospective evaluation in routine practice, we prospectively assessed an algorithm for difficult airway management that included two new airway devices. METHODS: After 6 months of instruction, training, and clinical testing, 15 senior anesthesiologists were asked to use an established algorithm for difficult airway management in anesthetized and paralyzed patients. Abdominal, gynecologic, and thyroid surgery patients were enrolled. Emergency, obstetric, and patients considered at risk of aspiration were excluded. If tracheal intubation using a Macintosh laryngoscope was impossible, the Airtraq laryngoscope (VYGON, Ecouen, France) was recommended as a first step and the LMA CTrach™ (SEBAC, Pantin, France) as a second. A gum elastic bougie was advocated to facilitate tracheal access with the Macintosh and Airtraq laryngoscopes. If ventilation with a facemask was impossible, the LMA CTrach™ was to be used, followed, if necessary, by transtracheal oxygenation. Patient characteristics, adherence to the algorithm, efficacy, and early complications were recorded. RESULTS: Overall, 12,225 patients were included during 2 yr. Intubation was achieved using the Macintosh laryngoscope in 98% cases. In the remainder of the cases (236), a gum elastic bougie was used with the Macintosh laryngoscope in 207 (84%). The Airtraq laryngoscope success rate was 97% (27 of 28). The LMA CTrach™ allowed rescue ventilation (n = 2) and visually directed tracheal intubation (n = 3). In one patient, ventilation by facemask was impossible, and the LMA CTrach™ was used successfully. CONCLUSIONS: Tracheal intubation can be achieved successfully in a large cohort of patients with a new management algorithm incorporating the use of gum elastic bougie, Airtraq, and LMA CTrach™ devices.

Unanticipated difficult airway management in the prehospital emergency setting: prospective validation of an algorithm.

BACKGROUND: Difficult intubation management algorithms have proven efficacy in operating rooms but have rarely been assessed in a prehospital emergency setting. We undertook a prospective evaluation of a simple prehospital difficult intubation algorithm. METHODS: All of our prehospital emergency physicians and nurse anesthetists were asked to adhere to a simple algorithm in all cases of impossible laryngoscope-assisted tracheal intubation. They received a short refresher course and training in the use of the gum elastic bougie (GEB) and the intubating laryngeal mask airway (ILMA), which were techniques to be used as a first and a second step, respectively. In cases of difficult ventilation with arterial desaturation, IMLA was to be used first. Cricothyroidotomy was the ultimate rescue technique when ventilation through ILMA failed. Patient characteristics, adherence to the algorithm, management efficacy, and early complications were recorded (August 2005-December 2009). RESULTS: An alternative technique to secure the airway was needed in 160 of 2,674 (6%) patients undergoing intubation. Three instances of nonadherence to the algorithm were recorded. GEB was used first in 152 patients and was successful in 115. ILMA was used first in 8 patients and second in the 37 GEB-assisted intubation failures. Forty-five patients were successfully mask-ventilated, and 42 were blindly intubated before reaching the hospital. Cricothyroidotomy was used successfully in a patient with severe upper airway obstruction as a result of pharyngeal neoplasia. Early intubation-related complications occurred in 52% difficult cases. CONCLUSION: Adherence to a simple algorithm using GEB, ILMA, and cricothyroidotomy solved all difficult intubation cases occurring in a prehospital emergency setting.

Out-of-hospital tracheal intubation with single-use versus reusable metal laryngoscope blades: a multicenter randomized controlled trial.

STUDY OBJECTIVE: Emergency tracheal intubation is reported to be more difficult with single-use plastic than with reusable metal laryngoscope blades in both inhospital and out-of-hospital settings. Single-use metal blades have been developed but have not been compared with conventional metal blades. This controlled trial compares the efficacy and safety of single-use metal blades with reusable metal blades in out-of-hospital emergency tracheal intubation. METHODS: This randomized controlled trial was carried out in France with out-of-hospital emergency medical units (Services de Médecine d'Urgence et de Réanimation). This was a multicenter prospective noninferiority randomized controlled trial in adult out-of-hospital patients requiring emergency tracheal intubation. Patients were randomly assigned to either single-use or reusable metal laryngoscope blades and intubated by a senior physician or a nurse anesthetist. The primary outcome was first-pass intubation success. Secondary outcomes were incidence of difficult intubation, need for alternate airway devices, and early intubation-related complications (esophageal intubation, mainstem intubation, vomiting, pulmonary aspiration, dental trauma, bronchospasm or laryngospasm, ventricular tachycardia, arterial desaturation, hypotension, or cardiac arrest). RESULTS: The study included 817 patients, including 409 intubated with single-use blades and 408 with a reusable blade. First-pass intubation success was similar in both groups: 292 (71.4%) for single-use blades, 290 (71.1%) for reusable blades. The 95% confidence interval (CI) for the difference in treatments (0.3%; 95% CI -5.9% to 6.5%) did not include the prespecified inferiority margin of -7%. There was no difference in rate of difficult intubation (difference 3%; 95% CI -7% to 2%), need for alternate airway (difference 4%; 95% CI -8% to 1%), or early complication rate (difference 3%; 95% CI -3% to 8%). CONCLUSION: First-pass out-of-hospital tracheal intubation success with single-use metal laryngoscopy blades was noninferior to first-pass success with reusable metal laryngoscope blades.

Trends in reasons for emergency calls during the COVID-19 crisis in the department of Gironde, France using artificial neural network for natural language classification.

OBJECTIVES: During periods such as the COVID-19 crisis, there is a need for responsive public health surveillance indicators in order to monitor both the epidemic growth and potential public health consequences of preventative measures such as lockdown. We assessed whether the automatic classification of the content of calls to emergency medical communication centers could provide relevant and responsive indicators. METHODS: We retrieved all 796,209 free-text call reports from the emergency medical communication center of the Gironde department, France, between 2018 and 2020. We trained a natural language processing neural network model with a mixed unsupervised/supervised method to classify all reasons for calls in 2020. Validation and parameter adjustment were performed using a sample of 39,907 manually-coded free-text reports. RESULTS: The number of daily calls for flu-like symptoms began to increase from February 21, 2020 and reached an unprecedented level by February 28, 2020 and peaked on March 14, 2020, 3 days before lockdown. It was strongly correlated with daily emergency room admissions, with a delay of 14 days. Calls for chest pain and stress and anxiety, peaked 12 days later. Calls for malaises with loss of consciousness, non-voluntary injuries and alcohol intoxications sharply decreased, starting one month before lockdown. No noticeable trends in relation to lockdown was found for other groups of reasons including gastroenteritis and abdominal pain, stroke, suicide and self-harm, pregnancy and delivery problems. DISCUSSION: The first wave of the COVID-19 crisis came along with increased levels of stress and anxiety but no increase in alcohol intoxication and violence. As expected, call related to road traffic crashes sharply decreased. The sharp decrease in the number of calls for malaise was more surprising. CONCLUSION: The content of calls to emergency medical communication centers is an efficient epidemiological surveillance data source that provides insights into the societal upheavals induced by a health crisis. The use of an automatic classification system using artificial intelligence makes it possible to free itself from the context that could influence a human coder, especially in a crisis situation. The COVID-19 crisis and/or lockdown induced deep modifications in the population health profile.