Relationship between cancer status and medical response by an emergency dispatch center: From a French SAMU database.

OBJECTIVE: In many countries, the first line response to an emergency call is decided by the emergency dispatch center EMS clinician. Our main objective was to compare the pre-hospital response to calls received from cancer and non-cancer patients. We also compared the reasons for calling, for each group. METHODS: We conducted a retrospective cohort study of data collected between January 1, 2016 and December 31, 2020, from emergency dispatch center records of the Isère county, France. Statistical tests were conducted after matching one cancer patient with two non-cancer patients, resulting in a cohort of 44,022 patients. We used multivariate logistic regression to determine the impact of patient cancer status on the medical decision taken in response to the emergency call. RESULTS: Overall, data on 849,110 patients were extracted, including 16,451 patients with a diagnosis of cancer and 29,348 non-cancer patients. In the matched cohort, cancer was associated with a higher odd of having a mobile intensive care unit (MICU) [odds ratio (OR)=2.02 (1.81-2.26), p<0.001] or an ambulance being dispatched to the patient's home or other location [OR=2.36 (2.24-2.48), p<0.001]. The two most frequent medical responses were to send an ambulance (58.6%) and giving advice only (36.8%). The five main reasons for the emergency call for the cancer group were cardiovascular disease symptoms (13.5%), respiratory problems (10.6%), digestive disorders (10.4%), infections (8.9%) and neurological disorders (6.0%). CONCLUSION: An MICU or an ambulance was more often dispatched for cancer patients than for others. Considering that cancer is a very frequent comorbidity in Western countries, knowledge of the patient's cancer status should be sought and taken into consideration when a patient seeks emergency help.

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.

Validity of the lever sign test for the clinical diagnosis of anterior cruciate ligament tears: Assessments in ski resorts.

INTRODUCTION: The clinical diagnosis of an anterior cruciate ligament (ACL) tear is based on 3 tests: anterior drawer, pivot shift and Lachman. The latter is the most commonly used test. The "lever sign" is a new clinical test that was first described by Lelli et al. in 2014. The primary objective of this study was to determine the sensitivity of the lever sign test for the clinical diagnosis of ACL tears, in the primary care setting of patients with acute knee injuries. Primary care being the first point of contact between patients and the healthcare system (general practitioners in this study). The secondary objective was to calculate the positive predictive value (PPV) of the lever sign test, by comparing it to the PPV of the Lachman test and its sensitivity. The working hypothesis was that the sensitivity of the lever sign test was equal to or greater than 80%. METHODS: This prospective cohort study included patients with ski-related knee injuries which occurred in French ski resorts between December 1, 2019, and March 15, 2020. The Lachman test and the lever sign test were performed by 36 mountain physicians and were compared to the magnetic resonance imaging (MRI) findings. The lever sign test involved placing a closed fist under the patient's calf in the supine position and applying downward pressure over the quadriceps. Depending on whether the ACL was intact or not, the patient's heel would either rise off the examination table or remain still. This study included 258 patients: 190 women and 68 men. RESULTS: The MRIs found 219 ACL tears and 36 intact ACLs. Three MRIs were deemed uninterpretable. The sensitivity of the lever sign test was 61.2% and the PPV was 83.8%. The sensitivity of the Lachman test was 99.1% and the PPV was 86.5%. CONCLUSION: This study determined the sensitivity of the lever sign test for the clinical diagnosis of ACL tears during real-life situations encountered by mountain physicians. This sensitivity was lower than expected. The Lachman test, on the other hand, showed a very high sensitivity. It remains the test of choice for the clinical diagnosis of ACL tears in patients with knee injuries. Therefore, the lever sign test can complement the Lachman test but is not a substitute for it. LEVEL OF EVIDENCE: II.

Targeted high mean arterial pressure aggravates cerebral hemodynamics after extracorporeal resuscitation in swine.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (E-CPR) is used for the treatment of refractory cardiac arrest. However, the optimal target to reach for mean arterial pressure (MAP) remains to be determined. We hypothesized that MAP levels critically modify cerebral hemodynamics during E-CPR and tested two distinct targets (65-75 vs 80-90 mmHg) in a porcine model. METHODS: Pigs were submitted to 15 min of untreated ventricular fibrillation followed by 30 min of E-CPR. Defibrillations were then delivered until return of spontaneous circulation (ROSC). Extracorporeal circulation was initially set to an average flow of 40 ml/kg/min. The dose of epinephrine was set to reach a standard or a high MAP target level (65-75 vs 80-90 mmHg, respectively). Animals were followed during 120-min after ROSC. RESULTS: Six animals were included in both groups. During E-CPR, high MAP improved carotid blood flow as compared to standard MAP. After ROSC, this was conversely decreased in high versus standard MAP, while intra-cranial pressure was superior. The pressure reactivity index (PRx), which is the correlation coefficient between arterial blood pressure and intracranial pressure, also demonstrated inverted patterns of alteration according to MAP levels during E-CPR and after ROSC. In standard-MAP, PRx was transiently positive during E-CPR before returning to negative values after ROSC, demonstrating a reversible alteration of cerebral autoregulation during E-CPR. In high-MAP, PRx was negative during E-CPR but became sustainably positive after ROSC, demonstrating a prolonged alteration in cerebral autoregulation after ROSC. It was associated with a significant decrease in cerebral oxygen consumption in high- versus standard-MAP after ROSC. CONCLUSIONS: During early E-CPR, MAP target above 80 mmHg is associated with higher carotid blood flow and improved cerebral autoregulation. This pattern is inverted after ROSC with a better hemodynamic status with standard versus high-MAP.

Opioid drug use in emergency and adverse outcomes among patients with chronic obstructive pulmonary disease: a multicenter observational study.

There is still debate as to the safety of non-palliative opioid administration to chronic obstructive pulmonary disease (COPD) patients punctually treated for an acute complaint. All patients over 40 presenting at two university hospital emergency departments (Montréal Qc, Grenoble Fr) from March 2008 to September 2014 with dyspnea, abdominal pain or trauma were retrieved, and COPD patients were selected. Our primary endpoint was a composite criterion including invasive ventilation and death. Comparisons between visits in which opioid drugs were prescribed and those without opioids were performed using an inverse probability of treatment and censoring weight (IPTCW) estimator to adjust for baseline confounders. A survival weighted Cox model was used. 7799 visits by COPD patients were identified, corresponding to 4173 unique patients. Opioid drug prescription was reported in 1317 (16.9%) visits. After applying IPCTW weighting, opioid prescription was found to be associated with the composite criterion of poor clinical outcomes (HR = 4.73 (2.94; 7.61), p < 0.01). When taken separately, this association remained significant for invasive ventilation and death, but not for NIV. All sensitivity analyses confirmed the association, except for patients with trauma or abdominal pain as the main complaint. This excess risk is observed whatever the route of administration.

Sex differences in coronary artery lesions and in-hospital outcomes for patients with ST-segment elevation myocardial infarction under the age of 45.

OBJECTIVE: We aimed to compare baseline characteristics, coronary angiogram findings, and in-hospital outcomes between female and male patients with ST-segment elevation myocardial infarction (STEMI) under the age of 45 years. BACKGROUND: Although sex differences in risk factor profile have been documented for young patients with STEMI, limited data exist on the prevalence of spontaneous coronary artery dissection in these patients. METHODS: As part of an ongoing hospital-based registry of suspected STEMI, we analyzed the original data for 51 women under the age of 45 years matched with 93 men of similar age who underwent coronary angiography at two percutaneous coronary intervention centers, between January 2003 and December 2012. Two interventional cardiologists independently reviewed coronary angiograms for all patients. RESULTS: The mean age for all patients was 39 years (range, 24-44) and the overall prevalence of cigarette smoking, dyslipidemia, hypertension, and diabetes mellitus were 70, 32, 13, and 4%, respectively. Young women were more likely to present with spontaneous coronary artery dissection (22 vs. 3%, p = .003) and more of them experienced reinfarction during the hospital course (15 vs. 1%, p = .01). The in-hospital mortality rate was 2% for both sexes. CONCLUSIONS: Spontaneous coronary artery dissection is an important cause of myocardial infarction in young female adults, accounting for 22% (95% confidence interval, 11-35%) of women with STEMI under the age of 45 years. The true prevalence of spontaneous coronary artery dissection might even be underestimated, because of the limited availability of advanced imaging techniques at the time of our study.

Prehospital shock index to assess 28-day mortality for septic shock.

CONTEXT: In the prehospital setting, early identification of septic shock (SS) with high risk of mortality aims to initiate early treatments and to decide delivery unit (emergency department (ED) or intensive care unit (ICU)). In this context, there is a need for a prognostic measure of severity and death in order to early detect patients with a higher risk of pejorative evolution. In this study, we describe the association between prehospital shock index (SI) and mortality at day 28 of patients with SS initially cared for in the prehospital setting by a mobile intensive care unit (MICU). METHODS: Patients with SS cared for by a MICU between January 2016 and May 2019 were retrospectively analyzed. Using propensity score, the association between SI and mortality was assessed by Odd Ratio (OR) with 95 percent confidence interval [95 CI]. RESULTS: One-hundred and fourteen patients among which 78 males (68%) were analysed. The mean age was 71 ± 14 years old. SS was mainly associated with pulmonary (55%), digestive (20%) or urinary (11%) infection. Overall mortality reached 33% (n = 38) at day 28. Median SI [interquartile range] differed between alive and deceased patients: 0.73 [0.61-1.00] vs 0.80 [0.66-1.10], p < 0.001*). After adjusting for confounding factors, the OR of SI > 0.9 was 1.17 [1.03-1.32]. CONCLUSION: In this study, we report an association between prehospital SI and mortality of patients with prehospital SS. A SI > 0.9 is a readily available tool correlated with increased mortality of patients with SS initially cared for in the prehospital setting.

Association of Prehospital Time to In-Hospital Trauma Mortality in a Physician-Staffed Emergency Medicine System.

Importance: The association between total prehospital time and mortality in physician-staffed trauma systems remains uncertain. Objective: To describe the association of total prehospital time and in-hospital mortality in prehospital, physician-staffed trauma systems in France, with the hypothesis that total prehospital time is associated with increased mortality. Design, Setting, and Participants: This cohort study was conducted from January 2009 to December 2016. Data for this study were derived from 2 distinct regional trauma registries in France (1 urban and 1 rural) that both have a physician-staffed emergency medical service. Consecutive adult trauma patients admitted to either of the regional trauma referral centers during the study period were included. Data analysis took place from March 2018 to September 2018. Main Outcomes and Measures: The association between death and prehospital time was assessed with a multivariable model adjusted with confounders. Total prehospital time was the primary exposure variable, recorded as the time from the arrival of the physician-led prehospital care team on scene to the arrival at the hospital. The main outcome of interest was all-cause in-hospital mortality. Results: A total of 10 216 patients were included (mean [SD] age, 41 [18] years; 7937 men [78.3%]) affected by predominantly nonpenetrating injuries (9265 [91.5%]), with a mean (SD) Injury Severity Score of 17 (14) points. Of the patients, 6737 (66.5%) had at least 1 body region with an Abbreviated Injury Scale score of 3 or more. A total of 1259 patients (12.4%) presented in shock (with systolic pressure <90 mm Hg) and 2724 (26.9%) with severe head injury (Abbreviated Injury Scale score ≥3 points). On unadjusted analysis, increasing prehospital times (in 30-minute categories) were associated with a markedly and constant increase in the risk of in-hospital death. The odds of death increased by 9% for each 10-minute increase in prehospital time (odds ratio, 1.09 [95% CI, 1.07-1.11]) and after adjustment by 4% (odds ratio, 1.04 [95% CI, 1.01-1.07]). Conclusions and Relevance: In this study, an increase in total prehospital time was associated with increasing in-hospital all-cause mortality in trauma patients at a physician-staffed emergency medical system, after adjustment for case complexity. Prehospital time is a management objective in analogy to physiological targets. These findings plead for a further streamlining of prehospital trauma care and the need to define the optimal intervention-to-time ratio.

Deep Hypothermic Cardiac Arrest Treated by Extracorporeal Life Support in a Porcine Model: Does the Rewarming Method Matter?

OBJECTIVES: Extracorporeal life support (ECLS) is the reference rewarming technique of accidental deep hypothermic cardiac arrest (DHCA). This study was designed to examine the impact of different rewarming blood flow rates and temperature setting of ECLS on cardiopulmonary lesions after DHCA in a porcine model of accidental hypothermia. METHODS: Twenty-four pigs were cannulated for ECLS, cooled until DHCA occurred, and subjected to 30 minutes of cardiac arrest. During the rewarming phase, we compared a low blood flow rate of 1.5 L/min versus a high flow rate of 3.0 L/min as well as two-temperature-setting rewarming strategies: a temperature during ECLS adjusted to 5°C above the central core temperature versus 38°C maintained throughout the rewarming phase. Cardiac output, hemodynamics and pulmonary function parameters were evaluated. Biologic markers of ischemia-reperfusion injuries were analyzed at baseline and at the end of the experiment. RESULTS: DHCA occurred at 21.2 ± 2°C. There was a trend for better cardiac output in groups with high blood flow (p = 0.053), with no interaction between ECLS flow and temperature (p = 0.63), a trend toward lower pulmonary vascular resistance (PVR; p = 0.075) and a significant decrease in arterial PVR in groups with high blood flow (p = 0.013) with no interaction (p = 0.47 and p = 0.60 for PVR and arterial PVR, respectively). Serum interleukin-6, tumor necrosis factor-α, receptor for advanced glycation end products (RAGE), and neuron-specific enolase were significantly increased between baseline and endpoint. The increase in the serum RAGE concentration was higher in the 38°C rewarming temperature groups compared to 5°C above adjusted temperature. There were no other significant differences in biomarkers. CONCLUSIONS: We developed a porcine model of DHCA treated by ECLS. Our data suggest that cardiac output tended to improve with a high-flow-rate rewarming strategy while a high-temperature delta between core temperature and ECLS increased the RAGE markers of lung injury.

Real-time measurements of endogenous carbon monoxide production in isolated pig lungs.

Ischemia-reperfusion injuries are a critical determinant of lung transplantation success. The endogenous production of carbon monoxide (CO) is triggered by ischemia-reperfusion injuries. Our aim was, therefore, to assess the feasibility of exhaled CO measurements during the ex vivo evaluation of lungs submitted to ischemia-reperfusion injuries. Five pigs were euthanized and their lungs removed after pneumoplegia. After cold storage (30 min, 4°C), the lungs were connected to an extracorporeal membrane oxygenation circuit, slowly warmed-up, and ventilated. At the end of a 45-min steady state, CO measurements were performed by optical-feedback cavity-enhanced absorption spectroscopy, a specific laser-based technique for noninvasive and real-time low gas concentration measurements. Exhaled CO concentration from isolated lungs reached 0.45±0.19 ppmv and was above CO concentration in ambient air and in medical gas. CO variations peaked during the expiratory phase. Changes in CO concentration in ambient air did not alter CO concentrations in isolated lungs. Exhaled CO level was also found to be uncorrelated to heme oxygenase (HO-1) gene expression. These results confirm the feasibility of accurate and real-time CO measurement in isolated lungs. The presented technology could help establishing the exhaled CO concentration as a biomarker of ischemia-reperfusion injury in ex vivo lung perfusion.

Post-conditioning to improve cardiopulmonary resuscitation.

PURPOSE OF REVIEW: Despite decades of advances in prehospital and in-hospital medical care, patients with out-of-hospital cardiac arrest continue to have poor neurologic and cardiac function following otherwise successful resuscitation. This review examines the mechanisms and therapeutic strategies currently under development to activate the post-conditioning pathways and thereby improve survival and function. RECENT FINDINGS: Post-conditioning utilizes the reperfusion injury salvage kinase (RISK) and survivor activating factor enhancement (SAFE) pathways as common avenues to promote cell survival and function. Ischemic post-conditioning and multiple medications activate these pathways resulting in improved cardiac and neurological function in animal models of cardiac arrest. SUMMARY: Detailed knowledge of the RISK and SAFE pathways can be used for further drug development. Human studies are now underway to test some of these strategies, but further clinical trials are necessary to translate these therapies to clinical practice.