[Acute pain management†: the role of inhaled methoxyflurane in clinical practice]. / Traitement de la douleur aiguë†: la place du méthoxyflurane inhalé dans la pratique clinique.

Since 2018, a new analgesic drug has been made available in Switzerland : methoxyflurane. This halogenated gas, controlled by the patient, offers a very effective analgesic effect comparable to opiates. Known since the 1960s and used mainly in pre-hospital emergency medicine in Australia and New Zealand, its use in Europe is increasing alongside standard analgesic treatments in the traumatic setting. Administered by inhalation, it does not require an intravenous access, which is ideal in prehospital emergency situations. This treatment could be used for the management of acute pain of various origins, such as renal lithiasis, or to facilitate different procedures, such as closed fracture reduction or chest tube insertion. Its indications are growing and its use will probably become commonplace with clinicians in a near future.

Depuis 2018, une nouvelle modalité antalgique est disponible en Suisse : le méthoxyflurane. Ce gaz halogéné, contrôlé par le·la patient·e, offre une antalgie très efficace, comparable aux opiacés. Utilisé depuis les années 1960 en médecine préhospitalière dans les régions d'Australie et de Nouvelle-Zélande, il fait ses preuves en Europe où on l'emploie avec les différents antalgiques habituels dans les situations traumatiques d'urgence. Par son administration inhalée, il ne nécessite aucune perfusion. Ce traitement pourrait être utilisé pour la gestion de douleurs aiguës d'origines diverses, telles que la colique néphrétique, ou encore faciliter différentes procédures, comme la réduction fermée de fracture ou la pose de drains. Son indication thérapeutique est croissante et son utilisation deviendra vraisemblablement commune.

[Elevated troponin without a myocardial infarction]. / Troponine élevée sans infarctus du myocarde.

The interpretation of troponin elevation whitout a typical myocardial infarction symptomatology is a daily challenge in the acute care setting. Using current investigative techniques, doctors navigate between the five types of myocardial infarction established by the Fourth Universal Definition. However, due to the development of ultrasensitive troponin assays, the myocardial injury without ischemia, acute or chronic, is became a more common entity. The purpose of this article is to describe the situations without typical symptoms of myocardial ischemia and their mechanisms to better differentiate them.

L'interprétation d'une élévation de la troponine sans une clinique d'infarctus du myocarde représente un défi au quotidien dans les services de soins aigus. A l'aide des techniques actuelles d'investigation, le médecin doit s'orienter entre les cinq types d'infarctus du myocarde établis par la Quatrième définition universelle. Cependant, en raison du développement des techniques ultrasensibles de dosage de la troponine, la lésion myocardique sans ischémie, aiguë ou chronique, est devenue une entité de plus en plus reconnue. Le but de cet article est de décrire les situations d'élévation de la troponine sans ischémie myocardique et leurs mécanismes afin de pouvoir mieux les différencier.

[Recent advances in internal medicine]. / Médecine interne générale: l'année 2017 en revue par les internistes hospitaliers.

In medicine, there are progresses which radically transform practices, change recommendations and win unanimous support in the medical community. There are some which divide, questioning principles that seemed established. There are also small advances, which can answer the questions that internists ask themselves in the daily care of their patients. Here are several articles published in 2017, read and commented for you by hospitalists, selected according to their impact on the medical world.

En médecine, il y a des découvertes qui révolutionnent les pratiques, changent les recommandations et rassemblent toute la communauté médicale. Il y en a qui divisent, en remettant en question des principes qui semblaient établis. Il y a aussi de petites avancées qui permettent de répondre aux questions que se posent les internistes dans la prise en charge quotidienne de leurs patients. Voici quelques articles parus en 2017, lus et commentés pour vous par des internistes hospitaliers et sélectionnés en fonction de leur retentissement dans le monde médical.

[Normobaric oxygen therapy in acute medical care: myths versus reality]. / Oxygénothérapie normobare en médecine aiguë: entre mythes et réalité.

Oxygen adiministration for both medical and traumatic emergencies is regarded as an essential component of resuscitation. However, many recent studies suggest that the use of oxygen should be more restrictive. Detrimental effects of normobaric oxygen therapy in patients suffering from hypercapnic respiratory diseases have been demonstrated, especially because of the suppression of the hypoxic drive. Apart from this particular situation, correction of hypoxemia is still a widely accepted treatment target, although there is growing evidence that hyperoxemia could be harmful in acute coronary syndromes and cardio-respiratory arrests. In other pathologies, such as stroke or hemorragic shock, the situation is still unclear, and further studies are needed to clarify the situation. Generally speaking, oxygen therapy should from now on be goal-directed, and early monitoring of both pulse oximetry and arterial blood gases is advised.

Factors associated with acute respiratory distress syndrome in brain-injured patients: A systematic review and meta-analysis.

PURPOSE: Acute respiratory distress syndrome (ARDS) is common in patients with acute brain injury admitted to the ICU. We aimed to identify factors associated with ARDS in this population. METHODS: We searched MEDLINE, Embase, Cochrane Central, Scopus, and Web of Science from inception to January 14, 2022. Three reviewers independently screened articles and selected English-language studies reporting risk factors for ARDS in brain-injured adult patients. Data were extracted on ARDS incidence, adjusted and unadjusted risk factors, and clinical outcomes. Risk of bias was reported using the Quality in Prognostic Studies tool. Certainty of evidence was assessed using GRADE. RESULTS: We selected 23 studies involving 6,961,284 patients with acute brain injury. The pooled cumulative incidence of ARDS after brain injury was 17.0% (95%CI 10.7-25.8). In adjusted analysis, factors associated with ARDS included sepsis (odds ratio (OR) 4.38, 95%CI 2.37-8.10; high certainty), history of hypertension (OR 3.11, 95%CI 2.31-4.19; high certainty), pneumonia (OR 2.69, 95%CI 2.35-3.10; high certainty), acute kidney injury (OR 1.44, 95%CI 1.30-1.59; moderate certainty), admission hypoxemia (OR 1.67, 95%CI 1.29-2.17; moderate certainty), male sex (OR 1.30, 95%CI 1.06-1.58; moderate certainty), and chronic obstructive pulmonary disease (OR 1.27, 95%CI 1.13-1.44; moderate certainty). Development of ARDS was independently associated with increased odds of in-hospital mortality (OR 3.12, 95% CI 1.39-7.00). CONCLUSIONS: Multiple risk factors are associated with ARDS in brain-injured patients. These findings could be used to develop prognostic models for ARDS or as prognostic enrichment strategies for patient enrolment in future clinical trials.

Methoxyflurane in Non-Life-Threatening Traumatic Pain-A Retrospective Observational Study.

Pain management is a key issue in prehospital trauma. In Switzerland, paramedics have a large panel of analgesic options. Methoxyflurane was recently introduced into Switzerland, and the goal of this study was to describe both the effect of this medication and the satisfaction of its use. This was a retrospective cohort study, performed in one emergency ambulance service. It included adult patients with traumatic pain and a self-assessment of 3 or more on the visual analogue scale or verbal numerical rating scale. The primary outcome was the reduction in pain between the start of the care and the arrival at the hospital. Secondary outcomes included successful analgesia and staff satisfaction. From December 2018 to 4 June to October 2020, 263 patients were included in the study. Most patients had a low prehospital severity score. The median pain at arrival on site was 8 and the overall decrease in pain observed was 4.2 (95% CI 3.9-4.5). Regarding secondary outcomes, almost 60% had a successful analgesia, and over 70% of paramedics felt satisfied. This study shows a reduction in pain, following methoxyflurane, similar to outcomes in other countries, as well as the attainment of a satisfactory level of pain reduction, according to paramedics, with the advantage of including patients in their own care.

Endoscopic removal of a gastric pharmacobezoar induced by clomipramine, lorazepam, and domperidone overdose: a case report.

INTRODUCTION: Gastric pharmacobezoars are a rare entity that can induce mechanical gastric outlet obstructions and sometimes prolong toxic pharmacological effects. Certain medications, such as sustained-release forms, contain cellulose derivatives that may contribute to the adhesion between pills and lead to the creation of an aggregate resulting in a pharmacobezoar. Case reports are rare, and official guidelines are needed to help medical teams choose proper treatment options. CASE PRESENTATION: Our patient was a 40-year-old Caucasian woman with borderline personality disorder and active suicidal thoughts who was found unconscious after a massive drug consumption of slow-release clomipramine, lorazepam, and domperidone. On her arrival in the emergency room, endotracheal intubation was preformed to protect her airway, and a chest x-ray revealed multiple coffee grain-sized opaque masses in the stomach. She was treated with activated charcoal followed by two endoscopic gastric decontaminations 12 h apart in order to extract a massive gastric pharmacobezoar by manual removal of the tablets. CONCLUSION: This case demonstrates that in the case of a massive drug consumption, a pharmacobezoar should be suspected, particularly when cellulose-coated pills are ingested. Severe poisoning due to delayed drug release from the gastric aggregate is a potential complication. Detection by x-ray is crucial, and treatment is centered on removal of the aggregate. The technique of decontamination varies among experts, and no formal recommendations exist to date. It seems reasonable that endoscopic evaluation should be performed in order to determine the appropriate technique of decontamination. Care should be patient-oriented and take into account the clinical presentation and any organ failure, and it should not be determined solely by the suspected medication ingested. Thus, serum levels are not sufficient to guide management of tricyclic antidepressant intoxication.

Apple, condom, and cocaine - body stuffing in prison: a case report.

BACKGROUND: Drug dealers and drug users resort to body stuffing to hastily conceal illicit drugs by ingesting their drug packets. This practice represents a medical challenge because rupture of the often insecure packaging can be toxic and even lethal. In an emergency setting, official guidelines are needed to help the medical team decide on the proper treatment. A preliminary observation period is generally accepted but its duration varies from hours to eventual packet expulsion. CASE PRESENTATION: This case involves a 20-year-old white man in detention who claimed to have ingested one cocaine packet wrapped in plastic food-wrap and a condom in anticipation of an impending cell search. He reached out to medical professionals on day 4 after having unsuccessfully tried several methods to expel the drug packet, including swallowing olive oil, natural laxatives, liters of water, and 12 carved apple chunks. An initial computed tomography scan confirmed multiple packet-sized images throughout his stomach and bowel. After 24 hours of observation and normal bowel movements without expelling any packets, a subsequent scan found only one air-lined packet afloat in the gastric content. Due to the prolonged retention of the package there was an increased risk of rupture. The packet was eventually removed by laparoscopic gastrotomy. CONCLUSIONS: This case report illustrates that observation time needs to be adapted to each individual case of body stuffing. Proof of complete drug package evacuation ensures secure patient discharge. Body stuffers should be routinely asked for a detailed history, including how the drug is wrapped, and whether or not they ingested other substances to help expel the packets. The history enables the accurate interpretation of imaging. Repeated imaging can help follow the progress of packets if not all have been expelled during the observation period. Drug packets should be surgically removed in case of prolonged retention. To ensure the best possible outcomes, patients should have access to high-quality, private, and confidential medical care, which is equal to that offered to the general population. This is paramount to earning trust and collaboration from people in detention who resort to body stuffing.