In-hospital cardiac arrest rhythm analysis by anesthesiologists: a diagnostic performance study.

PURPOSE: In-hospital cardiac arrest is associated with high morbidity and mortality, with an overall survival rate at one year of approximately 13%. The first cardiac rhythm is often analyzed by anesthesiologist-intensivists. We aimed to determine the diagnostic performance of anesthesiologist-intensivists when distinguishing between shockable and nonshockable rhythms. METHODS: We conducted a simulation-based, multicentre, prospective, observational study between May 2019 and March 2020. The responses of the participants were used to calculate individual sensitivity (defined as the proportion of decisions to shock for shockable rhythms) and individual specificity (defined as the proportion of decisions not to shock for nonshockable rhythms). The main outcome measure was the overall diagnostic performance, defined as the overall sensitivity and specificity. Secondary outcome measures were the sensitivity and specificity of participants' decisions for each type of cardiac arrest rhythm and their decision-making times. RESULTS: Among the 267 physicians contacted, 179 (67%) completed the test. The median [interquartile range (IQR)] overall sensitivity was 88 [79-95]% and the median overall specificity was 86 [77-92]%. Among shockable rhythms, the median [IQR] sensitivity was 100 [100-100]% for ventricular tachycardia (VT), 100 [100-100]% for coarse ventricular fibrillation (VF), and 60 [20-100]% for fine VF. The median [IQR] specificities for nonshockable rhythms were 93 [86-100]% for asystole and 83 [72-86]% for pulseless electrical activity. The median decision times ranged from 2.0 to 3.5 sec. CONCLUSION: Anesthesiologist-intensivists were quickly and effectively able to analyze rhythms in this simulation-based study. Participants' sensitivity in deciding to deliver shocks for VT and coarse VF was excellent, while specificity of their decisions for pulseless electrical activity was insufficient.

RéSUMé: OBJECTIF: L'arrêt cardiaque intra-hospitalier est associé à une morbidité et mortalité élevées, associées à un taux de survie global à un an d'environ 13 %. Le premier rythme cardiaque est souvent analysé par des anesthésiologistes-intensivistes. Nous avons cherché à déterminer la performance diagnostique des anesthésiologistes-intensivistes à distinguer un rythme choquable d'un rythme non choquable. MéTHODE: Nous avons effectué une étude observationnelle prospective, multicentrique basée sur la simulation entre mai 2019 et mars 2020. Les réponses des participants ont été utilisées pour calculer la sensibilité individuelle (définie comme étant la proportion de décisions de choquer pour les rythmes choquables) et la spécificité individuelle (définie comme la proportion de décisions de ne pas choquer pour les rythmes non choquables). Le critère d'évaluation principal était la performance diagnostique globale, définie comme étant la sensibilité et la spécificité globales. Les critères d'évaluation secondaires étaient la sensibilité et la spécificité des décisions des participants pour chaque type de rythme d'arrêt cardiaque, ainsi que le temps de prise de décision. RéSULTATS: Parmi les 267 médecins contactés, 179 (67 %) ont complété le test. La sensibilité globale médiane [écart interquartile (ÉIQ)] était de 88 [79-95] % et la spécificité globale médiane était de 86 [77-92] %. Parmi les rythmes choquables, la sensibilité médiane [ÉIQ] était de 100 [100-100] % pour la tachycardie ventriculaire (TV), de 100 [100-100] % pour la fibrillation ventriculaire (FV) large et de 60 [20-100] % pour la FV fine. Les spécificités médianes [ÉIQ] pour les rythmes non choquables étaient de 93 [86-100] % pour l'asystolie et de 83 [72-86] % pour l'activité électrique sans pouls. Les temps de décision médians variaient de 2,0 à 3,5 secondes. CONCLUSION: Les anesthésiologistes-intensivistes ont été rapidement et efficacement en mesure d'analyser les rythmes dans cette étude basée sur la simulation. La sensibilité de prendre la décision d'administrer un choc pour une TV ou une FV était excellente pour les participants, tandis que la spécificité de cette décision pour l'activité électrique sans pouls était insuffisante.

Spontaneous Cervical Spinal Epidural Hematoma Associated with Dabigatran.

BACKGROUND: While spontaneous spinal epidural hematomas are rare, 1 of the identified risk factors is vitamin K antagonist therapy. CASE DESCRIPTION: We present a case of a spontaneous spinal epidural hematoma occurring in a patient under treatment with dabigatran, a non-vitamin K oral anticoagulant. The initial hemiparesis symptom was misleading and was retrospectively identified as Brown-Séquard syndrome. Immediate dabigatran antagonism with idarucizumab followed by posterior cervical laminectomy permitted a complete neurologic recovery at day 4. CONCLUSIONS: This is the first description of a spontaneous spinal epidural hematoma under non-vitamin K antagonist oral anticoagulant therapy that has been successfully antagonized and emphasizes the importance of specific antidote development.

Prehospital Endotracheal Intubation in Warm Climates: Caution is Required.

BACKGROUND: Out-of-hospital endotracheal intubation is a frequent procedure for trauma care. Nevertheless, in warm climates, sunlight and heat can interfere with the flow of the usual procedure. They can affect the equipment and hinder the operator. There are few data on this issue. The presentation of this case highlights three common complications that may occur when intubating under a hot and bright sun. CASE REPORT: A 23-year-old man had a car accident in Djibouti, at 11:00 a.m., in broad sunlight. The heat was scorching. Due to a severe head trauma, with a Glasgow Coma Scale score of 8, it was decided to perform an endotracheal intubation. The operator faced three problems: the difficulty of seeing inside the mouth in the bright sunlight, the softening of the tube under the influence of the heat, and the inefficiency of colorimetric CO2 detectors in the warm atmosphere in confirming the proper endotracheal tube placement. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Solutions are simple, but must be known and planned ahead, prior to beginning the procedure: Putting a jacket over his head while doing the laryngoscopy would solve the problem of dazzle; adjuncts like a stylet or gum elastic bougie have to be used at the outset to fix the softening problem; alternative methods to exhaled CO2 detection, such as the syringe aspiration technique, to confirm the proper tube placement, should be available.

Management of bleeding and transfusion during liver transplantation before and after the introduction of a rotational thromboelastometry-based algorithm.

Orthotopic liver transplantation (OLT) remains a potentially hemorrhagic procedure. Rotational thromboelastometry (ROTEM) is a point-of-care device used to monitor coagulation during OLT. Whether it allows blood loss and transfusions to be reduced during OLT remains controversial. Excellent correlations and predictive values have been found between ROTEM parameters and fibrinogen. We hypothesized that the use of a ROTEM-based transfusion algorithm during OLT would lead to more fibrinogen transfusion and decreased bleeding and blood transfusion. Sixty adult patients were consecutively included in a prospective, without-versus-with study: 30 in the group without ROTEM results and 30 in the group with the ROTEM-based algorithm. A small and nonsignificant increase in median fibrinogen transfusions was found for the with group (6.0 g versus 4.5 g, P = 0.50). It was not associated with a decrease in blood transfusions or in the number of patients exposed to blood products.