Migraine diagnosis and management in general emergency departments in France.

BACKGROUND: We conducted a prospective study of patients admitted to 22 general emergency departments in France over 1 week. PATIENTS AND METHODS: Of 15,835 adult patients, 483 (3.1%) had headache and 98 (0.6%) had migraine. RESULTS: Compared with the migraine population in France, our migraine patients were similar in terms of proportion of female patients (75%) and mean age (37.6 ± 13.8 years) but presented earlier in their disease course. Patients sought emergency treatment because of a severe attack (49%) or because of ineffective treatment (20%). Non-opioid analgesics excluding non-steroidal anti-inflammatory drugs (NSAIDs), and NSAIDs, were most commonly prescribed as acute treatment, yet it took more than 48 h for symptom resolution in 36% of 92 follow-up patients. CONCLUSIONS: Results suggest there is room for improvement in choice of agents prescribed. We propose additional education and training of clinicians to improve adherence to clinical practice guidelines.

Inspiratory impedance during active compression-decompression cardiopulmonary resuscitation: a randomized evaluation in patients in cardiac arrest.

BACKGROUND: Blood pressure is severely reduced in patients in cardiac arrest receiving standard cardiopulmonary resuscitation (CPR). Although active compression-decompression (ACD) CPR improves acute hemodynamic parameters, arterial pressures remain suboptimal with this technique. We performed ACD CPR in patients with a new inspiratory threshold valve (ITV) to determine whether lowering intrathoracic pressures during the "relaxation" phase of ACD CPR would enhance venous blood return and overall CPR efficiency. METHODS AND RESULTS: This prospective, randomized, blinded trial was performed in prehospital mobile intensive care units in Paris, France. Patients in nontraumatic cardiac arrest received ACD CPR plus the ITV or ACD CPR alone for 30 minutes during advanced cardiac life support. End tidal CO(2) (ETCO(2)), diastolic blood pressure (DAP) and coronary perfusion pressure, and time to return of spontaneous circulation (ROSC) were measured. Groups were similar with respect to age, gender, and initial rhythm. Mean maximal ETCO(2), coronary perfusion pressure, and DAP values, respectively (in mm Hg), were 13.1+/-0.9, 25.0+/-1.4, and 36.5+/-1.5 with ACD CPR alone versus 19.1+/-1.0, 43.3+/-1.6, and 56.4+/-1.7 with ACD plus valve (P<0.001 between groups). ROSC was observed in 2 of 10 patients with ACD CPR alone after 26.5+/-0.7 minutes versus 4 of 11 patients with ACD CPR plus ITV after 19.8+/-2.8 minutes (P<0.05 for time from intubation to ROSC). Conclusions-Use of an inspiratory resistance valve in patients in cardiac arrest receiving ACD CPR increases the efficiency of CPR, leading to diastolic arterial pressures of >50 mm Hg. The long-term benefits of this new CPR technology are under investigation.

[Management of severe acute asthma in adults]. / Conduite à tenir devant une crise d'asthme aigu grave de l'adulte.

Any life-threatening episode of asthma requires early pre-hospital specialized medical management by emergency medical crews. Gravity depends on both clinical criteria and a peak expiratory flow rate (PEFR) more than 30% below either the level predicted by the reference graph or the patient's reference value. Initial treatment combines continuous nebulizations containing a beta2-agonist and ipratropium bromide, with oxygen administration and intravenous corticosteroid bolus. Recommended as second-line treatment in the absence of adequate response are: intravenous magnesium sulphate and continuous-perfusion beta2-agonists (electric syringe), or, in the case of shock, epinephrine. If mechanical ventilation is required, its settings should aim for low tidal volumes, low frequency, and increased expiratory time.

Prolonged severe hypercapnia complicating near fatal asthma in a 35-year-old woman.

OBJECTIVE: We describe a patient with a prolonged and severe hypercapnia occurring during an episode of status asthmaticus induced by ophthalmic instillation of carteolol. SETTING: Prehospital Emergency Medical Service and Pulmonary Intensive Care Unit in a university hospital. PATIENT: A 35-year-old female developed an acute asthma attack while at home, which required advanced life support. INTERVENTION: On hospital admission, arterial blood gases revealed a PaCO2 of 208 mmHg. Hypercapnia persisted with a PaCO2 of more than 190 mmHg for 10 h, with pH always less than 7.00. The patient was finally discharged after 26 days without sequelae. CONCLUSION: This case illustrates the cerebral and cardiovascular tolerance of severe and prolonged hypercapnia associated with major acidosis.

Use of an inspiratory impedance threshold valve during cardiopulmonary resuscitation: a progress report.

Building upon studies on the mechanism of active compression-decompression (ACD) cardiopulmonary resuscitation, a new inspiratory impedance threshold valve has been developed to enhance the return of blood to the thorax during the decompression phase of CPR. Use of this device results in a greater negative intrathoracic pressure during chest wall decompression. This leads to improved vital organ perfusion during both standard and ACD CPR. Animal and human studies suggest that this simple device increases cardiopulmonary circulation by harnessing more efficiently the kinetic energy of the outward movement of the chest wall during standard CPR or active chest wall decompression. When used in conjunction with ACD CPR during clinical evaluation, addition of the impedance valve resulted in sustained systolic pressures of greater than 100 mmHg and diastolic pressures of greater than 55 mmHg. The new valve may be beneficial in patients in asystole or shock refractory ventricular fibrillation, when enhanced return of blood flow to the chest is needed to 'prime the pump'. The potential long-term benefits of this new valve remain under investigation.

Active compression-decompression cardiopulmonary resuscitation--instructor and student manual for teaching and training. Part I: The workshop.

In an attempt to standardize the teaching and training of active compression-decompression cardiopulmonary resuscitation (ACD-CPR), a group of leading emergency physicians, cardiologists, anesthesiologists, paramedics and nurses with practical, theoretical, educational, and scientific experience in the subject met in June 1995. The group was called The International Working Group of Teaching and Training Active Compression-Decompression CPR. The group was 'born' as a result of the first International Conference of Active Compression-Decompression CPR held in Copenhagen in March 1995. The following paper describes the background, development and text of and ACD-CPR course manual for both students and instructors.

Effect of active compression-decompression resuscitation (ACD-CPR) on survival: a combined analysis using individual patient data.

Active compression decompression resuscitation (ACD-CPR) has been developed as an alternative to standard cardiopulmonary resuscitation (S-CPR). To determine the effect of ACD-CPR on survival and neurologic outcome in patients with out-of-hospital cardiac arrest, this combined analysis involved individual patient data from 2866 patients from seven separate randomized prospective prehospital studies who had received ACD-CPR or S-CPR after out-of-hospital cardiac arrest in seven international sites. Significant improvement in 1-h survival (odds ratio (OR) = 0.83; confidence interval (CI): 0.695-0.99; P < 0.05) was found with ACD-CPR (n = 1410) versus S-CPR (n = 1456). The odds ratio for hospital discharge after ACD-CPR was similar (OR = 0.82; CI: 0.609-1.107, P = NS), but this finding was not statistically significant. Using the chi2-test for trend, there was a significant improvement in overall survival with ACD-CPR (P < 0.05) versus S-CPR. This improvement was largely due to the influence of results from one study site. Neurological outcome and complication rates were comparable between groups. Further study is needed to determine which emergency medical services systems may benefit from out-of-hospital use of ACD-CPR.

[Routes of administration of drugs for severe acute asthma]. / Voies d'administration des médicaments dans l'asthme aigu grave.

Beta2-mimetics represent the primary treatment for acute severe asthma. Their route of administration are nebulizer inhalation and inhalation chamber, or direct intratracheal route in patients receiving artificial ventilation. The subcutaneous route remains useful while awaiting implementation of nebulizer routine. The intravenous route is indicated in cases of non-rapid improvement in patients' receiving inhaled treatment.

Trends in death attributed to myocardial infarction, heart failure and pulmonary embolism in Europe and Canada over the last decade.

BACKGROUND: Worldwide, cardiovascular diseases and cancer account for ∼40% of deaths. Certain reports have shown a progressive decrease in mortality. Our main objective was to assess mortality trends related to myocardial infarction (MI), heart failure (HF) and pulmonary embolism (PE). METHODS: MI, HF and PE were studied as cause of death based on the analysis of death certificates in Canada (C), England and Wales (E), France (F) and Sweden (S). We also used a multiple cause approach. Age-standardized death rates (SDR) were calculated. RESULTS: The SDR for MI, HF or PE as the underlying cause of death, all decreased during the last decade. The decrease in SDR secondary to MI exceeded that for HF or PE. Concerning multiple cause of death, a greater decrease was also found for MI, compared with HF or PE. CONCLUSIONS: We confirm the beneficial trends in SDR with MI, HF or PE both as underlying or multiple causes in the studied countries. For HF and PE, multiple cause approach seems more accurate to describe the burden of these two pathologies. Our study also suggests that more efforts should be dedicated to HF and PE in order to achieve similar trends than in MI.

[Improving vital organs perfusion by the respiratory pump: physiology and clinical use]. / Amélioration de la perfusion des organes vitaux par la valve d'impédance inspiratoire et le concept de pompe respiratoire : rationnel physiologique et application clinique.

OBJECTIVE: In this article, we review the effects of the respiratory pump to improve vital organ perfusion by the use of an inspiratory threshold device. DATA SOURCES: Medline and MeSH database. STUDY SELECTION: All papers with a level of proof of I to III have been used. DATA EXTRACTION: The analysis of the papers has focused on the physiological modifications induced by intrathoracic pressure regulation. DATA SYNTHESIS: Primary function of breathing is to provide gas exchange. Studies of the mechanisms involved in animals and humans provide the physiological underpinnings for "the other side of breathing": to increase circulation to the heart and brain. We describe studies that focus on the fundamental relationship between the generation of negative intrathoracic pressure during inspiration through a low-level of resistance created by an impedance threshold device and the physiologic effects of a respiratory pump. A decrease in intrathoracic pressure during inspiration through a fixed resistance resulting in an intrathoracic pressure of -7 cmH2O has multiple physiological benefits including: enhanced venous return, cardiac stroke volume and aortic blood pressure; lower intracranial pressure; resetting of the cardiac baroreflex; elevated cerebral blood flow oscillations and increased tissue blood flow/pressure gradient. CONCLUSION: The clinical and animal studies support the use of the intrathoracic pump to treat different clinical conditions: hemorrhagic shock, orthostatic hypotension, septic shock, and cardiac arrest.

A randomized study of out-of-hospital continuous positive airway pressure for acute cardiogenic pulmonary oedema: physiological and clinical effects.

AIMS: In acute cardiogenic pulmonary oedema (ACPE), continuous positive airway pressure (CPAP) added to medical treatment improves outcome. The present study was designed to assess the benefit of CPAP as a first line treatment of ACPE in the out-of-hospital environment. METHODS AND RESULTS: The protocol lasted 45 min, divided into three periods of 15 min. Patients with ACPE were randomly assigned in two groups: 1/Early CPAP (n = 63): CPAP alone (T0-T15); CPAP + medical treatment (T15-T30); medical treatment alone (T30-T45) and 2/Late CPAP (n = 61): medical treatment alone (T0-T15); medical treatment + CPAP (T15-T30); medical treatment alone (T30-T45). Primary endpoint: effect of early CPAP on a dyspnoea clinical score and on arterial blood gases. Secondary endpoints: incidence of tracheal intubation, inotropic support, and in-hospital mortality. T0-T15: CPAP alone had a greater effect than medical treatment on the clinical score (P = 0.0003) and on PaO(2) (P = 0.0003). T15-T30: adding CPAP to medical treatment (late CPAP group) improved clinical score and blood gases and the two groups were no longer different at T30. T30-T45: in both groups, CPAP withdrawal worsened clinical score. Six patients in 'early CPAP' group vs. 16 in 'late CPAP' group were intubated [P = 0.01, odds-ratio: OR = 0.30 (0.09-0.89)]. Dobutamine was used only in the 'late CPAP' group (n = 5), (P = 0.02). Hospital death was higher in 'late CPAP' group (n = 8) than in 'early CPAP' group (n = 2) [P = 0.05, OR = 0.22 (0.04-1.0)]. CONCLUSION: When compared to usual medical care, immediate application of CPAP alone in out-of-hospital treatment of ACPO is significantly better improving physiological variables and symptoms and significantly reduces tracheal intubation incidence and in-hospital mortality.

Mechanical advances in cardiopulmonary resuscitation.

Challenged by the continued high mortality rates for patients in cardiac arrest, the American Heart Association and the European Resuscitation Council developed a new set of guidelines in 2000 to help advance several new and promising cardiopulmonary resuscitation (CPR) techniques and devices. This is the first time these organizations have taken such a bold move, in part because of the poor results with standard closed-chest cardiac massage. The new techniques, interposed abdominal counterpulsation and active compression decompression CPR, each provide greater blood flow to the vital organs in animal models of CPR and lead to higher blood pressures in patients in cardiac arrest. In some clinical studies, both techniques have resulted in a significant increase in survival after cardiac arrest in comparison with standard CPR. Three of the four new CPR devices that were recommended in the new guidelines also provide superior vital organ blood flow and increased blood pressures in comparison with standard CPR. The three devices that improve the efficiency of CPR are the circumferential vest, an active compression decompression CPR device, and an inspiratory impedance valve used in combination with the active compression decompression CPR device. The fourth device type, one that compresses the thorax using an automated mechanical piston compression mechanism, was recommended to reduce the number of personnel required to perform CPR. However, no studies on the automated mechanical compression devices have showed an improvement in hemodynamic variables or survival in comparison with standard CPR. Taken together, these new technologies represent an important step forward in the evolution of CPR from a pair of hands to devices designed to enhance CPR efficiency. Each of these advances is described, and the recent literature about each of them is reviewed.

Head injury: clonidine decreases plasma catecholamines.

Seven patients who had suffered head injury 3 to 5 days before the study was undertaken received clonidine (2.5 micrograms/kg iv over 10 min). This resulted in a reduction of plasma norepinephrine (p less than .05) and in normalization of plasma epinephrine (p less than .05). Neither common carotid blood flow nor diastolic blood flow as index of global cerebral perfusion as measured by pulsed Doppler changed. The reduction of sympathetic overactivity, probably due to the specific action of clonidine on alpha 2-adrenoceptors within the rostral ventrolateral medulla, may be of interest in the management of head injury because of the maintenance of cephalic hemodynamics.

The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation.

BACKGROUND: A quantitative scale of intubation difficulty would be useful for objectively comparing the complexity of endotracheal intubations. The authors have developed a quantitative score that can be used to evaluate intubating conditions and techniques with the aim of determining the relative values of predictive factors of intubation difficulty and of the techniques used to decrease such difficulties. METHODS: An Intubation Difficulty Scale (IDS) was developed, based on parameters known to be associated with difficult intubation. It was then evaluated prospectively in a group of 311 consecutive prehospital intubations and 315 intubations in an operating room. In the operating room, the IDS was compared with two other parameters: the time to completion of intubation and the visual analog scale (VAS). Time was measured by an independent observer. Operators in both groups completed a checklist regarding the conditions of intubation. RESULTS: There is a good correlation between the IDS scale and the VAS assessment of difficulty and time to completion of intubation. VAS and time to completion have a significant but lesser correlation to each other. Comparison of IDS with operator-assessed subjective categorical impression of difficulty by Kruskall-Wallis was statistically significant. CONCLUSIONS: The IDS correlates with but is less subjective than the VAS and categorical classification. IDS correlates with time to intubation, but it offers details regarding the difficulty encountered that time alone does not. This score may not only aid in evaluation of factors linked to difficult intubations, but it may provide a uniform approach to comparing studies related to this subject.

The effects of positive end-expiratory pressure during active compression decompression cardiopulmonary resuscitation with the inspiratory threshold valve.

UNLABELLED: The use of an inspiratory impedance threshold valve (ITV) during active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) improves perfusion pressures, and vital organ blood flow. We evaluated the effects of positive end-expiratory pressure (PEEP) on gas exchange, and coronary perfusion pressure gradients during ACD + ITV CPR in a porcine cardiac arrest model. All animals received pure oxygen intermittent positive pressure ventilation (IPPV) at a 5:1 compression-ventilation ratio during ACD + ITV CPR. After 8 min, pigs were randomized to further IPPV alone (n = 8), or IPPV with increasing levels of PEEP (n = 8) of 2.5, 5.0, 7.5, and 10 cm H(2)O for 4 consecutive min each, respectively. Mean +/- SEM arterial oxygen partial pressure decreased in the IPPV group from 150 +/- 30 at baseline after 8 min of CPR to 110 +/- 25 torr at 24 min, but increased in the PEEP group from 115 +/- 15 to 170 +/- 25 torr with increasing levels of PEEP (P <0.02 for comparisons within groups). Mean +/- SEM diastolic aortic minus diastolic left ventricular pressure gradient was significantly (P < 0.001) higher after the administration of PEEP (24 +/- 0 vs 17 +/- 1 mm Hg with 5 cm H(2)O of PEEP, and 26 +/- 0 vs 17 +/- 1 mm Hg with 10 cm H(2)O of PEEP), whereas the diastolic aortic minus right atrial pressure gradient (coronary perfusion pressure) was comparable between groups. Furthermore, systolic aortic pressures were significantly (P < 0.05) higher with 10 cm H(2)O of PEEP when compared with IPPV alone (68 +/- 0 vs 59 +/- 2 mm Hg). In conclusion, when CPR was performed with devices designed to improve venous return to the chest, increasing PEEP levels improved oxygenation. Moreover, PEEP significantly increased the diastolic aortic minus left ventricular gradient and did not affect the decompression phase aortic minus right atrial pressure gradient. These data suggest that PEEP reduces alveolar collapse during ACD + ITV CPR, thus leading to an increase in indirect myocardial compression. IMPLICATIONS: Inspiratory impedance during active compression-decompression cardiopulmonary resuscitation improves perfusion pressures, and vital organ blood flow during cardiac arrest. Increasing levels of positive end-expiratory pressure during performance of active compression-decompression cardiopulmonary resuscitation with an inspiratory impedance valve improves oxygenation, and increases the diastolic aortic-left ventricular pressure gradient and systolic arterial blood pressure.

In-hospital and long-term prognosis of elderly patients requiring endotracheal intubation for life-threatening presentation of cardiogenic pulmonary edema.

OBJECTIVE: We studied the in-hospital course, long-term prognosis, and functional status of elderly patients with life-threatening cardiogenic pulmonary edema requiring mechanical ventilation. DESIGN: Semiprospective evaluation. SETTING: Twelve intensive care units and one emergency prehospital medical department in university hospitals. PATIENTS: Patients, aged >75 yrs, with life-threatening cardiogenic pulmonary edema requiring invasive airway management during the prehospital phase between January 1994 and January 1999 were included. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: A total of 79 patients were studied, of which 55 were included in the prospective phase and 24 during the retrospective phase. The age range was 75-99 yrs, with a mean age of 82.4 +/- 5.9. The male/female ratio was 35:44. The in-hospital mortality was 26.6%. The mean follow-up time for all 58 survivors was 23 months (range, 2-56 months). Among those discharged, survival at 1 yr was 69%. At 3 months after hospital discharge, 49 (87%) patients lived at home, 46 (82%) were able to bathe themselves, 35 (62%) could walk at least one block, and 34 (61%) could climb one flight of stairs. CONCLUSIONS: Mortality after severe pulmonary edema requiring endotracheal intubation in a very elderly cohort has a predictably high mortality, although not related directly to the degree of presenting respiratory compromise. However, approximately 50% of the overall cohort returned to relatively good functional status, despite advanced age and a severely compromised presentation. Aggressive airway management appears, therefore, justified in this select group of patients.

Benefit of active compression-decompression cardiopulmonary resuscitation as a prehospital advanced cardiac life support. A randomized multicenter study.

BACKGROUND: We compared short-term prognosis of active compression-decompression (ACD) and standard (STD) cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrests. METHODS AND RESULTS: We randomized advanced cardiac life support (ACLS) with ACD ACLS CPR on odd days and STD ACLS CPR on even days. We measured the rates of return of spontaneous circulation (ROSC), survival at 1 hour (H1), at 24 hours (H24), and at 1 month (D30): hospital discharge (HD); neurological outcome; and complications. Mean times from collapse to basic cardiac life support CPR was 9 minutes and from collapse to ACLS CPR was 21 minutes. Compared with the STD ACLS patients (n = 258), ACD ACLS patients (n = 254) had higher survival rates (ROSC, 44.9% versus 29.8%, P = .0004; H1, 36.6% versus 24.8%, P = .003; H24, 26% versus 13.6%, P = .002; HD without neurological impairment, 5.5% versus 1.9%, P = .03) and a trend for improvement in neurological outcome at D30 (Glasgow-Pittsburgh Outcome Categories = 1.6 +/- 0.8 versus 2.3 +/- 1.1. P = .09). Sternal dislodgements (2.9% versus 0.4%, P = .03) and hemoptysis (5.4% versus 1.3%, P = .01) were more frequent in the ACD ACLS group. CONCLUSIONS: Despite long time intervals, ACD significantly improved short-term survival rates in out-of-hospital cardiac arrests compared with STD CPR.

A comparison of standard cardiopulmonary resuscitation and active compression-decompression resuscitation for out-of-hospital cardiac arrest. French Active Compression-Decompression Cardiopulmonary Resuscitation Study Group.

BACKGROUND: We previously observed that short-term survival after out-of-hospital cardiac arrest was greater with active compression-decompression cardiopulmonary resuscitation (CPR) than with standard CPR. In the current study, we assessed the effects of the active compression-decompression method on one-year survival. METHODS: Patients who had cardiac arrest in the Paris metropolitan area or in Thionville, France, more than 80 percent of whom had asystole, were assigned to receive either standard CPR (377 patients) or active compression-decompression CPR (373 patients) according to whether their arrest occurred on an even or odd day of the month, respectively. The primary end point was survival at one year. The rate of survival to hospital discharge without neurologic impairment and the neurologic outcome were secondary end points. RESULTS: Both the rate of hospital discharge without neurologic impairment (6 percent vs. 2 percent, P=0.01) and the one-year survival rate (5 percent vs. 2 percent, P=0.03) were significantly higher among patients who received active compression-decompression CPR than among those who received standard CPR. All patients who survived to one year had cardiac arrests that were witnessed. Nine of 17 one-year survivors in the active compression-decompression group and 2 of 7 in the standard group, respectively, initially had asystole or pulseless electrical activity. In 12 of the 17 survivors who had received active compression-decompression CPR, neurologic status returned to base line, as compared with 3 of 7 survivors who had received standard CPR (P=0.34). CONCLUSIONS: Active compression-decompression CPR performed during advanced life support significantly improved long-term survival rates among patients who had cardiac arrest outside the hospital.