Acute care for patients exposed to a chemical attack: protocol for an international multicentric observational study.

INTRODUCTION: The use of weapons of mass destruction against civilian populations is of serious concern to public health authorities. Chemical weapons are of particular concern. A few studies have investigated medical responses in prehospital settings in the immediate aftermath of a chemical attack, and they were limited by the paucity of clinical data. This study aims to describe the acute management of patients exposed to a chemical attack from the incident site until their transfer to a medical facility. METHODS AND ANALYSIS: This international multicentric observational study addresses the period from 1970 to 2036. An online electronic case report form was created to collect data; it will be hosted on the Biomedical Telematics Laboratory Platform of the Quebec Respiratory Health Research Network. Participating medical centres and their clinicians are being asked to provide contextual and clinical information, including the use of protective equipment and decontamination capabilities for the medical evacuation of the patient from the incident site of the chemical attack to the moment of admission at the medical facility. In brief, variables are categorised as follows: (1) chemical exposure (threat); (2) prehospital and hospital/medical facility capabilities (staffing, first aid, protection, decontamination, disaster plans and medical guidelines); (3) clinical interventions before hospital admission, including the use of protection and decontamination and (4) outcomes (survivability vs mortality rates). Judgement criteria focus on decontamination drills applied to any of the patient's conditions. ETHICS AND DISSEMINATION: The Sainte-Justine Research Centre Ethics Committee approved this multicentric study and is acting as the main evaluating centre. Study results will be disseminated through various means, including conferences, indexed publications in medical databases and social media. TRIAL REGISTRATION NUMBER: NCT05026645.

Gaps in Prehospital Care for Patients Exposed to a Chemical Attack - A Systematic Review.

INTRODUCTION: The survivability of mass casualties exposed to a chemical attack is dependent on clinical knowledge, evidence-based practice, as well as protection and decontamination capabilities. The aim of this systematic review was to identify the knowledge gaps that relate to an efficient extraction and care of mass casualties caused by exposure to chemicals. METHODS: This systematic review was conducted from November 2018 through September 2020 in compliance with Cochrane guidelines. Five databases were used (MEDLINE, Web of Science Core Collection, Embase, Cochrane, and CINAHL) to retrieve studies describing interventions performed to treat victims of chemical attacks (protection, decontamination, and treatment). The outcomes were patient's health condition leading to his/her stabilization (primary) and death (secondary) due to interventions applied (medical, protection, and decontamination). RESULTS: Of the 2,301 papers found through the search strategy, only four publications met the eligibility criteria. According to these studies, the confirmed chemical poisoning cases in acute settings resulting from the attacks in Matsumoto (1994), Tokyo (1995), and Damascus (2014) accounted for 1,333 casualties including 11 deaths. No study reported comprehensive prehospital clinical data in acute settings. No mention was made of the integration of specialized capabilities in medical interventions such as personal protective equipment (PPE) and decontamination to prevent a secondary exposure. Unfortunately, it was not possible to perform the planned meta-analysis. CONCLUSIONS: This study demonstrated gaps in clinical knowledge application regarding the medical extraction of casualties exposed during a chemical attack. Further research is required to optimize clinical practice integrating mixed capabilities (protection and decontamination) for the patient and medical staff.

Oxygen Conservation Methods With Automated Titration.

BACKGROUND: Oxygen titration is recommended to avoid hyperoxemia and hypoxemia. Automated titration, as well as the [Formula: see text] target, may have an impact on oxygen utilization, with potential logistical effects in emergency and military transportation. We sought to assess the oxygen flow required for different [Formula: see text] targets in spontaneously breathing subjects, and to evaluate individualized automated oxygen titration to maintain stable oxygenation in subjects with COPD and healthy subjects with induced hypoxemia. METHODS: In the first part of the study, oxygen flow was evaluated in hospitalized subjects for different [Formula: see text] targets from 90% to 98%. Oxygen requirements to reach these targets were determined using a device that automatically adjusts oxygen flow every second on the basis of the [Formula: see text] target. In the second part of the study, the same automated oxygen titration method was used to correct hypoxemia in subjects with COPD and in healthy subjects with induced hypoxemia while the subjects wore a gas mask. Oxygen flow, [Formula: see text], and heart rate were continuously recorded. RESULTS: Thirty-six spontaneously breathing hospitalized subjects were included in the first part of the study. Oxygen flow was reduced more than 6-fold when the [Formula: see text] target was decreased from 98% to 90%. The second part of the study included 15 healthy and 9 subjects with stable COPD. In healthy subjects, heterogeneous oxygen flows were required to correct induced hypoxemia (0.2-2.5 L/min). In subjects with COPD, oxygen flow varied from 0 L/min (in 9 of 18 tested conditions) to 2.9 L/min. CONCLUSIONS: Significant reductions in the amount of oxygen delivered could be obtained with optimized [Formula: see text] targets. Oxygen delivery through a gas mask to correct hypoxemia is feasible, and automated oxygen titration may help individualize oxygen administration and reduce oxygen utilization. (ClinicalTrials.gov registration: NCT02782936, NCT02809807.).