Is the shock index correlated with blood loss? An experimental study on a controlled hemorrhagic shock model in piglets.

INTRODUCTION: The quantification of blood loss in a severe trauma patient allows prognostic quantification and the engagement of adapted therapeutic means. The Advanced Trauma Life Support classification of hemorrhagic shock, based in part on hemodynamic parameters, could be improved. The search for reproducible and non-invasive parameters closely correlated with blood depletion is a necessity. An experimental model of controlled hemorrhagic shock allowed us to obtain hemodynamic and echocardiographic measurements during controlled blood spoliation. The primary aim was to demonstrate the correlation between the Shock Index (SI) and blood depletion volume (BDV) during the hemorrhagic phase of an experimental model of controlled hemorrhagic shock in piglets. The secondary aim was to study the correlations between blood pressure (BP) values and BDV, SI and cardiac output (CO), and pulse pressure (PP) and stroke volume during the same phase. METHODS: We analyzed data from 66 anesthetized and ventilated piglets that underwent blood spoliation at 2 mL.kg-1.min-1 until a mean arterial pressure (MAP) of 40 mmHg was achieved. During this bleeding phase, hemodynamic and echocardiographic measurements were performed regularly. RESULTS: The correlation coefficient between the SI and BDV was 0.70 (CI 95%, [0.64; 0.75]; p < 0.01), whereas between MAP and BDV, the correlation coefficient was -0.47 (CI 95%, [-0.55; -0.38]; p < 0.01). Correlation coefficient between SI and CO and between PP and stroke volume were - 0.45 (CI 95%, [-0.53; -0.37], p < 0.01) and 0.62 (CI 95%, [0.56; 0.67]; p < 0.01), respectively. CONCLUSIONS: In a controlled hemorrhagic shock model in piglets, the correlation between SI and BDV seemed strong.

Development and validation of a clinico-biological score to predict outcomes in patients with drowning-associated cardiac arrest.

BACKGROUND: While several scoring systems have been developed to predict short-term outcome in out-of-hospital cardiac arrest patients, there is currently no dedicated prognostic tool for drowning-associated cardiac arrest (DACA) patients. METHODS: Patients experiencing DACA from two retrospective multicenter cohorts of drowning patients were included in the present study. Among the patients from the development cohort, risk-factors for day-28 mortality were assessed by logistic regression. A prediction score was conceived and assessed in patients from the validation cohort. RESULTS: Among the 103 included patients from the development cohort, the day-28 mortality rate reached 51% (53/103). Identified independent early risk-factors for day-28 mortality included cardiopulmonary resuscitation duration longer than 20 min (OR 6.40 [95% CI 1.88-23.32]; p = 0.003), temperature at Intensive Care Unit admission <34 °C (OR 8.84 [95% CI 2.66-32.92]; p < 0.001), need for invasive mechanical ventilation (OR 6.83 [95% CI 1.47-40.87]; p = 0.02) and lactate concentration > 7 mmol/L (OR 3.56 [95% CI 1.01-13.07]; p = 0.04). The Area Under the ROC Curve (AUC) of the developed score based on those variables reached 0.91 (95% CI, 0.86-0.97). The optimal cut-off for predicting poor outcomes was 4 points with a sensitivity of 92% (95% CI, 82-98%), a specificity of 82% (95% CI, 67-91%), a positive predictive value (PPV) of 84% (95% CI, 72-95%) and a negative predictive value (NPV) of 91% (95% CI, 79-96%). The assessment of this score on the validation cohort of 81 patients exhibited an AUC of 0.82. Using the same 4 points threshold, sensitivity, specificity, PPV and NPV values of the validation cohort were: 81%, 67%, 72% and 77%, respectively. CONCLUSION: In patients suffering from drowning induced initial cardiac arrest admitted to ICU with a DACA score ≥ 4, the likelihood of survival at day-28 is significantly lower. Prospective validation of the DACA score and assessment of its usefulness are warranted in the future.

CD169 and CD64 could help differentiate bacterial from CoVID-19 or other viral infections in the Emergency Department.

The identification of a bacterial, viral, or even noninfectious cause is essential in the management of febrile syndrome in the emergency department (ED), especially in epidemic contexts such as flu or CoVID-19. The aim was to assess discriminative performances of two biomarkers, CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), using a new flow cytometry procedure, in patients presenting with fever to the ED during epidemics. Eighty five adult patients presenting with potential infection were included during the 2019 flu season in the ED of La Timone Hospital. They were divided into four diagnostic outcomes according to their clinical records: no-infection, bacterial infection, viral infection and co-infection. Seventy six patients with confirmed SARS-CoV-2 infection were also compared to 48 healthy volunteers. For the first cohort, 38 (45%) patients were diagnosed with bacterial infections, 11 (13%) with viral infections and 29 (34%) with co-infections. mCD169 was elevated in patients with viral infections, with a majority of Flu A virus or Respiratory Syncytial Virus, while nCD64 was elevated in subjects with bacterial infections, with a majority of Streptococcus pneumoniae and Escherichia coli. nCD64 and mCD169 showed 90% and 80% sensitivity, and 78% and 91% specificity, respectively, for identifying patients with bacterial or viral infections. When studied in a second cohort, mCD169 was elevated in 95% of patients with SARS-CoV-2 infections and remained at normal level in 100% of healthy volunteers. nCD64 and mCD169 have potential for accurately distinguishing bacterial and acute viral infections. Combined in an easy and rapid flow cytometry procedure, they constitute a potential improvement for infection management in the ED, and could even help for triage of patients during emerging epidemics.

Pneumothorax diagnosis with lung sliding quantification by speckle tracking: A prospective multicentric observational study.

INTRODUCTION: Lung ultrasound is commonly used for the diagnosis of pneumothorax. However, recognition of pleural sliding is subjective and can be difficult for novice. The primary objective was to compare a novices physician's performance in diagnosing pneumothorax from ultrasound (US) scans either with visual evaluation or with maximum longitudinal pleural strain (MLPS). The secondary objective was to compare the diagnostic relevance of US with visual evaluation or MLPS to diagnose pneumothorax with an intermediately experienced and an expert physician. METHODS: We conducted a prospective, observational study in two emergency department and two intensive care unit, between February 2019 and June 2020. We included 99 adult patients with suspected pneumothorax, who received a chest computed tomography (CT). Three physicians with different experience of interpreting US scans (a novice physician, an intermediately experienced physician, and an expert) analyzed the US scans of 99 patients with suspected pneumothorax (50 (51%) with confirmed pneumothorax), which were confirmed by CT scan. RESULTS: With a threshold of 5%, the MLPS sensitivity was 94% (95% CI [83%; 98%]), and the specificity was 100% (95% CI [93%; 100%]). The novice physician had an area under the curve (AUC) with visual analysis of 0.75 (95% CI [0.67; 0.83]) vs 0.86 (95% CI [0.79; 0.94]) with MLPS (p = 0.04). The intermediate physician's AUC for diagnosing pneumothorax with visual analysis was 0.93 (95% CI [0.88; 0.99]) vs 1.00 (95% CI [1.00; 1.00]) with MLPS (p < 0.01) and for the expert physician it was 0.98 (95% CI [0.95;1.00]) vs 0.97 (95% CI [0.93; 1.00]), respectively (p = 0.69). CONCLUSION: In our study, speckle tracking analysis improved the accuracy of US for the novice and the intermediate but not the expert sonographer in the diagnosis of pneumothorax.

Evaluation and Comparison of Different Prehospital Triage Scores of Trauma Patients on In-Hospital Mortality.

Introduction: Several prehospital major trauma patient triage scores have been developed, the triage revised trauma score (T-RTS), Vittel criteria, Mechanism/Glasgow Coma Scale/Age/Systolic blood pressure score (MGAP), and the new trauma score (NTS). These scoring schemes allow a rapid and accurate prognostic assessment of the severity of potential lesions. The aim of our study was to compare these scores with in-hospital mortality predictions in a cohort of consecutive trauma patients admitted in a Level 1 trauma center. Materials: Between 2013 and 2016, 1,112 patients were admitted to the "major trauma" spinneret of a Level 1 trauma center in the south of France. All prehospital data needed to calculate the T-RTS, Vittel criteria, the MGAP score, and the NTS were collected. The main evaluation criterion was in-hospital mortality at 30 days for all causes. The predictive performances of these scores were evaluated and compared with each other using the analysis of the receiver operating curves. Results: A total of 1,001 patients were included in the analysis, 238 (24%) females, aged 43 ± 19 years with ISS 15 ± 13. The area under the curve was for each score: T-RTS, AUC = 0.84, [0.82-0.87]; Vittel criteria, AUC = 0.87 [0.85-0.89]; MGAP score, AUC = 0.91 [0.89-0.92] and NTS, AUC = 0.90 [0.88-0.92]. By comparing the ROC curves of these scores, the MGAP and NTS scores were statistically higher than the T-RTS. With the current thresholds, the sensitivity, specificity, positive and negative predictive values of these scores were 91%, 35%, 10%, 98% for T-RTS, 100%, 2%, 8%, 100% for Vittel criteria, 91%, 71%, 24%, 99% for MGAP score, 82%, 86%, 33%, 98% for NTS. Only Vittel's criteria allowed undertriage below 5% as recommended by the American College of Surgeons Committee on Trauma (ACSCOT). Conclusion: The comparison of these different triage scores concluded with a superiority of the MGAP and NTS scores compared with the T-RTS. Including the calculation of MGAP or NTS scores with the Vittel criteria would reduce the risk of overtriage in the Level 1 trauma centers by further directing patients at low risk of death to a lower-level trauma facility.

Out-of-hospital Times Using Helicopters Versus Ground Services for Emergency Patients.

OBJECTIVE: Minimizing out-of-hospital time reduces morbidity and mortality in patients with severe trauma, acute coronary syndrome, or acute stroke. Our objective was to compare out-of-hospital times by helicopter versus ground services when the estimated time of arrival on the scene was over 20 minutes. METHODS: We proposed a retrospective observational monocentric study following 2 cohorts. The helicopter group and the ground group included patients with severe trauma, acute coronary syndrome, or acute stroke transported by helicopter or ground services. RESULTS: Two hundred thirty-nine patients were included; 118 were in the ground group, and 121 were in the helicopter group. Distances for the helicopter group were higher (62.1 ± 22.5 km vs. 27.6 ± 10.4 km, P < .001). When distances were over 35 km, the helicopter group was faster. We identified distance, need for surgery, and intensive care hospitalization as 3 predicting factors for choosing helicopters over ground modes of transport. CONCLUSION: In cases of severe trauma, acute coronary syndrome, or acute stroke, emergency medical helicopter transport can be chosen over ground transport when patients are in a severe state and when the distance is further than 35 km from the hospital.

Compression with a pocket-sized ultrasound device to diagnose proximal deep vein thrombosis.

INTRODUCTION: Compression ultrasonography (CUS) is a validated technique for the diagnosis of deep venous thrombosis (DVT), but has never been studied with pocket-sized ultrasound device (PUD). The main objective of this study was to assess the diagnostic performance of CUS made by emergency physicians (EPs) using a PUD. MATERIALS: This was a prospective, diagnostic test assessment, single-center study. Patients underwent VCU performed by a trained EP with PUD (CUS-PUD) for searching proximal DVT (PDVT) and were then seen by an expert vascular physician who blindly performed a duplex venous ultrasound, which was the criterion standard. CUS-PUD's diagnostic performance was evaluated by sensitivity (Se), specificity (Sp), and positive and negative predictive values (PPV and NPV). RESULTS: The sample included 57 patients of whom 56 were analyzed. Eleven (20%) PDVT were diagnosed with CUS-PUD: 7 (64%) femoral and 4 (36%) popliteal. The CUS-PUD's Se was 100% [72%; 100%], Sp 100% [92%; 100%]. The PPV was 100% [74%; 100%], and the NPV was 100% [90%; 100%]. CONCLUSION: CUS-PUD performed with a pocket-sized ultrasound appears to be feasible in emergency practice for the diagnosis of proximal DVT. A study with a larger sample size will have to describe the accuracy.

Integration of lung ultrasound in the diagnostic reasoning in acute dyspneic patients: A prospective randomized study.

INTRODUCTION: Misdiagnosis in acute dyspneic patients (ADP) has consequences on their outcome. Lung ultrasound (LUS) is an accurate tool to improve diagnostic performance. The main goal of this study was to assess the determinants of increased diagnostic accuracy using LUS. MATERIALS: Multicentre, prospective, randomized study including emergency physicians and critical care physicians treating ADP on a daily basis. Each participant received three difficult clinical cases of ADP: one with only clinical data (OCD), one with only LUS data (OLD), and one with both. Ultrasound video loops of A, B and C profiles were associated with the cases. Which physician received what data for which clinical case was randomized. Physicians assessed the diagnostic probability from 0 to 10 for each possible diagnosis. The number of uncertain diagnoses (NUD) was the number of diagnoses with a diagnostic probability between 3 and 7, inclusive. RESULTS: Seventy-six physicians responded to the study cases (228 clinical cases resolved). Among the respondents, 28 (37%) were female, 64 (84%) were EPs, and the mean age was 37±8 years. The mean NUDs, respectively, when physicians had OCD, OLD, and both were 2.9±1.8, 2.2±1.7, 2.2±1.8 (p = 0.02). Ultrasound data and ultrasound frequency of use were the only variables related to the NUD. Higher frequency of ultrasound use by physicians decreased the number of uncertain diagnoses in difficult clinical cases with ultrasound data (OLD or associated with clinical data). CONCLUSION: LUS decreases the NUD in ADP. The ultrasound frequency of use decreased the NUD in ADP clinical cases with LUS data.

Diagnostic performance of a clinical ultrasound-based algorithm for acute heart failure in patients presenting to the emergency department with dyspnea. / Rendimiento diagnóstico de un algoritmo basado en ecografía clínica para el diagnóstico de insuficiencia cardiaca aguda en pacientes que consultan en urgencias por disnea.

OBJECTIVES: To study the diagnostic performance of an ultrasound-based algorithm that includes the deceleration time (DT) of early mitral filling to establish a diagnosis of acute heart failure (AHF) in patients who come to an emergency department because of dyspnea. MATERIAL AND METHODS: Prospective analysis in a convenience sample of patients who came to a hospital emergency department with acute dyspnea. The algorithm included ultrasound findings and 4 echocardiographic findings as follows: mitral annular plane systolic excursion, Doppler mitral flow velocity, tissue Doppler imaging measure of the lateral annulus, and the DT of early mitral filling. The definitive diagnosis was made by 2 physicians blinded to each other's diagnosis and the ultrasound findings. RESULTS: A total of 166 adult patients with a mean (SD) age of 76 (13) years were included; 79 (48%) were women. AHF was the definitive diagnosis in 62 patients (37%). Diagnostic agreement was good between the 2 physicians (κ = 0.71). The algorithm classified all the patients, and there were no undetermined diagnoses. Diagnostic performance indicators for the ultrasound-based algorithm integrating early DT findings were as follows: area under the receiver operating characteristic curve, 0.91 (95% CI, 0.86-0.96); sensitivity, 87% (95% CI, 76%-94%); specificity, 95% (95% CI, 89%-98%); positive likelihood ratio, 18.1 (95% CI, 7.7-42.8); and negative likelihood ratio, 0.14 (95% CI, 0.07-0.26). CONCLUSION: The ultrasound-based algorithm integrating the DT of early mitral filling performs well for diagnosing AHF in emergency patients with dyspnea. The inclusion of early DT allows all patients to be diagnosed.

OBJETIVO: Analizar el rendimiento diagnóstico de un algoritmo ecográfico que incluye el tiempo de desaceleración precoz del flujo mitral (TD) para establecer el diagnóstico de insuficiencia cardiaca aguda (ICA) en pacientes que consultan en un servicio de urgencias hospitalario (SUH) por disnea. METODO: Análisis prospectivo de una muestra de conveniencia de pacientes que consultan por disnea aguda en un SUH. El algoritmo ecográfico incluyó la ecografía pulmonar y cuatro parámetros ecocardiográficos, se midió MAPSE (desplazamiento sistólico del plano del anillo mitral), medidas doppler de flujo mitral, medidas doppler tisular en el anillo mitral lateral y TD. El diagnóstico final fue asignado por 2 médicos ciegos entre sí y a los hallazgos ecográficos. RESULTADOS: Se incluyeron 166 pacientes adultos, la edad media fue de 76 años (DE 13) y 79 eran mujeres (48%). Hubo 62 pacientes (37%) con un diagnóstico final de ICA. La concordancia entre asignadores fue buena para el diagnóstico de ICA (κ = 0,71). El algoritmo clasificó a todos los pacientes, no hubo ningún diagnóstico indeterminado. El rendimiento diagnóstico del algoritmo mostró un área bajo la curva de 0,91 (IC 95%: 0,86-0,96), sensibilidad del 87% (IC 95%: 76%-94%), especificidad del 95% (IC 95%: 89%-98%), razón de verosimilitud positiva del 18,1 (IC 95%: 7,7-42,8), razón de verosimilitud negativa del 0,14 (IC 95%: 0,07-0,26). CONCLUSIONES: Un algoritmo ecográfico que incluye el TD tiene un buen rendimiento para el diagnóstico de ICA en pacientes que acuden a SUH por disnea. Además, el uso de TD permite clasificar a todos los pacientes.

Acute mesenteric ischemia: which predictive factors of delayed diagnosis at emergency unit?

PURPOSE: Acute mesenteric ischemia (AMI) is frequently diagnosed late, leading to a poor prognosis. Our aims were to identify predictive factors of delayed diagnosis and to analyze the outcomes of patients with AMI admitted in emergency units. METHODS: All the patients with AMI (2015-2020), in two Emergency units, were retrospectively included. Two groups were defined according to the time of diagnosis between the arrival at emergency unit and the CT scan: ≤ 6 h (early), > 6 h (delayed). RESULTS: 119 patients (mean age = 71 ± 7 years) were included. The patients with a delayed diagnosis (n = 33, 28%) were significantly associated with atypical presentation, including lower rates of abdominal pain (73 vs 89%, p = 0.003), abdominal tenderness (33 vs 43%, p = 0.03), and plasma lactate (4 ± 2 vs 6 ± 7 mmol/l, p = 0.03) when compared with early diagnosis. After multivariate analysis, the absence of abdominal pain was the only independent predictive factor of delayed diagnosis (Odd Ratio = 0.17; 95% CI = 0.03-0.88, p = 0.03). Patients with delayed diagnosis tended to be associated to lower rates of revascularization (9 vs 17%, p = 0.4), higher rates of major surgical morbidity (90 vs 57%, p = 0.1), longer length of stay (16 ± 23 vs 13 ± 15 days, p = 0.4) and, at the end of follow-up, higher rate of short small bowel syndrome (18 vs 7%, p = 0.095). CONCLUSION: AMI is a challenge for emergency physicians. History of patient, physical exam, biological data are not sufficient to diagnose AMI. New biomarkers, and awareness of emergency physicians should improve and accelerate the diagnosis of AMI.

Evaluation of a New Echocardiographic Tool for Cardiac Output Monitoring: An Experimental Study on A Controlled Hemorrhagic Shock Model in Anesthetized Piglets.

BACKGROUND: Cardiac output (CO) monitoring is recommended in patients with shock. The search for a reliable, rapid, and noninvasive tool is necessary for clinical practice. A new echocardiographic CO flow index (COF) is the automatic calculation of the sub-aortic VTI multiplied by the automatic calculation of the heart rate (HR). The primary objective of this study was to show the correlation between COF and CO measured by thermodilution (COth) in a controlled hemorrhagic shock model in anesthetized piglets. Secondary objectives were to show the correlation between COth and CO calculated from left outflow tract (LVOT) measurement and manual VTI (COman), and CO measured by LVOT measurement and VTIauto (COauto). METHODS: Prospective interventional experimental study. In seventeen ventilated and anesthetized piglets, a state of hemorrhagic shock was induced, maintained, then resuscitated and stabilized. The gold standard for CO and stroke volume measurement was thermodilution (COth). RESULTS: 191 measurements were performed. The correlation coefficients (r) between COth and COF, COman, and COauto were 0.73 [0.62; 0.81], 0.66 [0.56; 0.74], and 0.73 [0.63; 0.81], respectively. CONCLUSIONS: In this study, the COF appears to have a strong correlation to the COth. This automatic index, which takes into account the HR and does not require the measurement of LVOT, could be a rapidly obtained index in clinical practice.

Can blood loss be assessed by echocardiography? An experimental study on a controlled hemorrhagic shock model in piglets.

BACKGROUND: Assessment of the volemic loss is a major challenge during the management of hemorrhagic shock. Echocardiography is an increasingly used noninvasive tool for hemodynamic assessment. In mechanically ventilated patients, some studies suggest that respiratory variations of mean subaortic time-velocity integral (∆VTI) would be predictive of fluid filling response. An experimental model of controlled hemorrhagic shock provides a precise approach to study correlation between blood volume and cardiac ultrasonographic parameters. OBJECTIVES: The main objective was to analyze the ∆VTI changes during hemorrhage in an anesthetized-piglet model of controlled hemorrhagic shock. The secondary objective was to evaluate ∆VTI during the resuscitation process after hemorrhage and other echocardiographic parameters changes during the whole protocol. METHODS: Twenty-four anesthetized and ventilated piglets were bled until mean arterial pressure reached 40 mm Hg. Controlled hemorrhage was maintained for 30 minutes before randomizing the piglets to two resuscitation groups: fluid filling group resuscitated with saline solution and noradrenaline group resuscitated with saline solution and noradrenaline. Echocardiography and hemodynamic measures, including pulsed pressure variations (PPV), were performed at different stages of the protocol. RESULTS: The correlation coefficient between ΔVTI and PPV with the volume of bleeding during the hemorrhagic phase were respectively 0.24 (95% confidence interval, 0.08-0.39; p < 0.01) and 0.57 (95% CI, 0.44-0.67; p < 0.01). Two parameters had a moderate correlation coefficient with hemorrhage volume (over 0.5): mean subaortic time-velocity index (VTI) and mitral annulus diastolic tissular velocity (E'). CONCLUSION: In this hemorrhagic shock model, ΔVTI had a low correlation with the volume of bleeding, but VTI and E' had a correlation with blood volume comparable to that of PPV.

Point-of-care chest ultrasound to diagnose acute heart failure in emergency department patients with acute dyspnea: diagnostic performance of an ultrasound-based algorithm. / Rendimiento de un algoritmo basado en ecografía cardiopulmonar a la cabecera del paciente (POCUS) para el diagnóstico de insuficiencia cardiaca aguda en pacientes que consultan en urgencias por disnea aguda.

OBJECTIVES: Cardiopulmonary ultrasound imaging can be useful for diagnosing acute heart failure (AHF). We aimed to evaluate the diagnostic performance of an algorithm based on point-of-care ultrasound (POCUS) in patients coming to the emergency department with acute dyspnea. MATERIAL AND METHODS: Prospective analysis of a convenience sample of patients with acute dyspnea in 2 hospital emergency departments. The POCUS algorithm included lung ultrasound findings and 3 echocardiographic measurements taken from an apical view of 4 chambers: mitral annular plane systolic excursion, Doppler mitral flow velocity, and tissue Doppler imaging of the lateral mitral annulus. The definitive diagnosis was made by 2 physicians blinded to the POCUS findings. RESULTS: A total of 103 adult patients with a mean (SD) age of 73 (12) years were included; about half (51 patients) were women. Forty-two patients (41%) were finally diagnosed with AHF. Interindividual agreement on the physicians' diagnoses was good (k = 0.82). The POCUS algorithm assigned an AHF diagnosis to 76 patients (74%); 56 of them (85%) were in sinus rhythm. The diagnostic performance indicators for the algorithm were as follows: area under the receiver operating characteristic curve, 0.94 (95% CI, 0.88-1.00); sensitivity 96% (95% CI, 78%-100%); specificity, 93% (95% CI, 8%-98%); positive predictive value, 85% (95% CI, 67%-100%); negative predictive value, 98% (95% CI, 88%-100%). CONCLUSION: The POCUS-based algorithm for diagnosing AHF performed well in patients coming to the emergency department with acute dyspnea.

OBJETIVO: La ecografía cardiopulmonar puede ser útil para diagnosticar insuficiencia cardiaca aguda (ICA). Se evaluó el rendimiento diagnóstico de un algoritmo basado en ecografía cardiopulmonar a la cabecera del paciente (POCUS) para el diagnóstico de ICA en pacientes que consultan en urgencias por disnea aguda. METODO: Se evaluó prospectivamente una muestra de conveniencia de pacientes con disnea aguda en dos servicios de urgencias hospitalarios (SUH). El algoritmo POCUS incluía la ecografía pulmonar y tres mediciones ecocardiográficas realizadas en un plano apical de cuatro cámaras. Se midió el MAPSE (desplazamiento sistólico del plano del anillo mitral), doppler de flujo mitral y doppler tisular en el anillo mitral lateral. El diagnóstico final fue asignado por dos médicos ciegos entre sí y a los hallazgos ecográficos. RESULTADOS: Se incluyeron 103 pacientes adultos, la edad media fue 73 (12) años, 51 (50%) mujeres. El diagnóstico final fue ICA en 42 (41%) pacientes. La concordancia entre asignadores fue buena para el diagnóstico de ICA (k = 0,82). El algoritmo asignó un diagnóstico en 76 (74%) pacientes, 57 (85%) estaban en ritmo sinusal. El rendimiento diagnóstico del algoritmo de los 76 pacientes categorizados mostró un área bajo la curva de 0,94 (IC 95%: 0,88-1,00), sensibilidad 96% (IC 95%: 78-100%), especificidad 93% (IC 95%: 8-98%), valor predictivo positivo 85% (IC 95%: 67-100%), valor predictivo negativo 98% (IC 95%: 88-100%). CONCLUSIONES: El rendimiento de un algoritmo basado en ecografía cardiopulmonar POCUS fue bueno para diagnosticar ICA en pacientes que consultan en urgencias por disnea aguda.

Cell Analysis from Dried Blood Spots: New Opportunities in Immunology, Hematology, and Infectious Diseases.

Blood cell analysis is a major pillar of biomedical research and healthcare. These analyses are performed in central laboratories. Rapid shipment from collection site to the central laboratories is currently needed because cells and biomarkers degrade rapidly. The dried blood spot from a fingerstick allows the preservation of cellular molecules for months but entire cells are never recovered. Here leucocyte elution is optimized from dried blood spots. Flow cytometry and mRNA expression profiling are used to analyze the recovered cells. 50-70% of the leucocytes that are dried on a polyester solid support via elution after shaking the support with buffer are recovered. While red blood cells lyse upon drying, it is found that the majority of leucocytes are preserved. Leucocytes have an altered structure that is improved by adding fixative in the elution buffer. Leucocytes are permeabilized, allowing an easy staining of all cellular compartments. Common immunophenotyping and mRNAs are preserved. The ability of a new biomarker (CD169) to discriminate between patients with and without Severe Acute Respiratory Syndrome induced by Coronavirus 2 (SARS-CoV-2) infections is also preserved. Leucocytes from blood can be dried, shipped, and/or stored for at least 1 month, then recovered for a wide variety of analyses, potentially facilitating biomedical applications worldwide.

Early assessment of patients with COVID-19 and dyspnea using lung ultrasound scoring. / Evaluación precoz mediante ecografía pulmonar de pacientes con disnea por COVID-19.

OBJECTIVES: The main objective was to evaluate the precision of the Modified Lung Ultrasound (MLUS score) for predicting the need for respiratory support in the first 48 hours in patients with dyspnea due to the coronavirus disease 2019 (COVID-19). The secondary objectives were 1) to compare the MLUS and National Early Warning Score 2 (NEWS2), as well as the combination of both scores, as predictors of severity according to the World Health Organization (WHO) Ordinal Scale for Clinical Improvement; and 2) to compare severity assessed by ultrasound scoring to severity assessed by lung computed tomography (CT). MATERIAL AND METHODS: Multicenter prospective observational cohort study conducted from March 30 to April 30, 2020, in 2 university hospitals. Adult patients with dyspnea due to COVID-19 were included. An initial lung ultrasound was performed, and the results of MLUS, NEW2, and lung CT evaluations were recorded. Patients were classified by risk according to the WHO scale at 48 hours, as follows: low risk (score less than 5) or high risk (score of 5 or more). RESULTS: A total of 100 patients were included: 35 (35%) were classified as low risk and 65 (65%) as high risk. The correlation between the MLUS and WHO assessments was positive and very high (Spearman rank correlation 􀁕 = 0.832; P .001). The area under the receiver operating characteristic curves of the MLUS, NEW2 and combined ultrasound scores, in relation to prediction of risk classification were, respectively, 0.96 (0.93-0.99), 0.89 (0.82-0.95) and 0.98 (0.96-1.0). The MLUS and lung CT assessments were correlated. CONCLUSION: An early lung ultrasound score can predict clinical severity in patients with dyspnea due to COVID-19.

OBJETIVO: El objetivo principal fue evaluar la precisión de la escala de ecografía pulmonar modificada (MLUS) para predecir la necesidad de soporte respiratorio en las primeras 48 horas en pacientes con disnea por COVID-19. Los objetivos secundarios fueron comparar la escala MLUS con la escala National Early Warning Score 2 (NEW2) y la combinación de ambas para predecir la gravedad según la escala de la OMS y comparar las escalas de gravedad calculadas por ecografía y tomografía computarizada (TC) pulmonar. METODO: Estudio observacional de cohortes prospectivo multicéntrico realizado desde 30 de marzo al 30 de abril de 2020 en 2 hospitales universitarios. Se incluyeron pacientes adultos con disnea por COVID-19. Se les realizó una ecografía pulmonar inicial y se calculó la escala MLUS, escala NEW2 y la escala de gravedad calculada por TC pulmonar. Los pacientes se clasificaron como de riesgo bajo (BR) si 5 puntos o de riesgo alto (AR) si 5 puntos según la escala de la OMS a las 48 horas. RESULTADOS: Se incluyeron 100 pacientes, 35 (35%) fueron de BR y 65 (65%) de AR. La correlación entre la escala MLUS y las puntuaciones de la escala ordinal de la OMS fue positiva y muy alta (rho de Spearman = 0,832; p 0,001). El área bajo la curva COR de la escala MLUS, NEW2 y combinada fue de 0,96 (0,93-0,99), 0,89 (0,82-0,95) y 0,98 (0,96-1,0), respectivamente, para predecir el grupo de RA. Hubo relación entre las escalas MLUS y lesiones pulmonares en la TC. CONCLUSIONES: Una ecografía pulmonar inicial puede predecir la gravedad clínica de los pacientes con disnea por COVID-19.

Drowning Classification: A Reappraisal of Clinical Presentation and Prognosis for Severe Cases.

BACKGROUND: Drowning is still a major cause of accidental death worldwide. In 1997, Szpilman proposed a classification of drowning that has become the reference. As considerable efforts have been made to improve prevention and care, it seemed appropriate to reassess the prognosis and clinical presentation of drowning patients more than 20 years after this first publication. The aim of this study is to provide a reappraisal of patients who need advanced health care and a precise description of their respective neurologic, respiratory, and hemodynamic profiles. METHODS: This retrospective study was conducted over four consecutive summer periods between 2014 and 2017 in ICUs located in France, French Polynesia, and the French Antilles. Patients were classified according to the drowning classification system proposed by Szpilman. RESULTS: During the study period, 312 drowning patients were admitted with severe clinical presentation (grades 2-6). All patients benefited from rapid extraction from the water (< 10 min for all) and specialized care (emergency medical services), starting from the prehospital period. Although the global hospital mortality was similar to that previously reported (18.5%), great differences existed among the severity grades. Respective grade mortalities were low for grades 2 through 5 (grade 2, 0%; grade 3, 3%; grade 4, 0%; grade 5, 2%), and the mortality for grade 6 remained similar to that previously reported (54%). These results confirmed that the occurrence of cardiac arrest after drowning is still bad prognosis. Conversely, for other grades, this study strengthens the importance of specialized intervention to interrupt the drowning process. CONCLUSIONS: On the basis of these results, drowning-related cardiac arrest is still the prognosis cornerstone. For other victims, the prognosis was better than previously expected, which strengthens the importance of specialized intervention to interrupt the drowning process.

Flow cytometry evaluation of infection-related biomarkers in febrile subjects in the emergency department.

Aim: In an Emergency Department (ED), the etiological identification of infected subjects is essential. 13 infection-related biomarkers were assessed using a new flow cytometry procedure. Materials & methods: If subjects presented with febrile symptoms at the ED, 13 biomarkers' levels, including CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), were tested and compared with clinical records. Results: Among 50 subjects, 78% had bacterial infections and 8% had viral infections. nCD64 showed 82% sensitivity and 91% specificity for identifying subjects with bacterial infections. mCD169, HLA-ABC ratio and HLA-DR on monocytes had high values in subjects with viral infections. Conclusion: Biomarkers showed promising performances to improve the ED's infectious stratification.

Comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed COVID-19 pneumonia.

PURPOSE: The relationship between lung ultrasound (LUS) and chest computed tomography (CT) scans in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is not clearly defined. The primary objective of our study was to assess the performance of LUS in determining severity of SARS-CoV-2 pneumonia compared with chest CT scan. Secondary objectives were to test the association between LUS score and location of the patient, use of mechanical ventilation, and the pulse oximetry (SpO2)/fractional inspired oxygen (FiO2) ratio. METHODS: A multicentre observational study was performed between 15 March and 20 April 2020. Patients in the Emergency Department (ED) or Intensive Care Unit (ICU) with acute dyspnoea who were PCR positive for SARS-CoV-2, and who had LUS and chest CT performed within a 24-h period, were included. RESULTS: One hundred patients were included. LUS score was significantly associated with pneumonia severity assessed by chest CT and clinical features. The AUC of the ROC curve of the relationship of LUS versus chest CT for the assessment of severe SARS-CoV-2 pneumonia was 0.78 (CI 95% 0.68-0.87; p < 0.0001). A high LUS score was associated with the use of mechanical ventilation, and with a SpO2/FiO2 ratio below 357. CONCLUSION: In known SARS-CoV-2 pneumonia patients, the LUS score was predictive of pneumonia severity as assessed by a chest CT scan and clinical features. Within the limitations inherent to our study design, LUS can be used to assess SARS-CoV-2 pneumonia severity.

Burnout Syndrome among Emergency Department Staff: Prevalence and Associated Factors.

OBJECTIVES: Emergency department (ED) professionals are exposed to burnout syndrome due to excessive workload and high demands for care. The objective of our study was to assess the prevalence burnout among all ED staff and to determine associated factors. METHODS: A cross-sectional survey was conducted in 3 EDs. The data were collected using a standardized questionnaire. It included demographical and occupational data, general health questions, burnout level (Maslach Burnout Inventory), job strain (Karasek), and quality of life (Medical Outcome Study Short Form). RESULTS: Of the 529 professionals working in EDs, 379 responses were collected (participation rate of 71.6%). Emotional exhaustion (EE) and depersonalization (DP), the major components of burnout, were reported, respectively, by 15.8% and 29.6% of the professionals. Burnout prevalence was 34.6%, defined as a severely abnormal level of either EE or DP. The medical category was significantly more affected by the burnout compared with their colleagues: nearly one ED physician out of two had a burnout (50.7%). In the multivariate analysis of covariance, job strain and a low mental component score were the two main factors independently associated with burnout (p < 0.05). CONCLUSION: The results of our study show that ED professionals are a vulnerable group. Preventive approaches to stress and burnout are needed to promote quality of work life.

Drowning in fresh or salt water: respective influence on respiratory function in a matched cohort study.

INTRODUCTION: For the most severe drowned patients, hypoxemia represents one of the major symptoms. As the influence of the type of water (fresh or salt water) on respiratory function is still unclear, the primary endpoint of this multicenter study was to compare hypoxemia according to the type of water. METHODS: Medical records of adult patients who experienced a drowning event and were consequently admitted to 10 ICU for acute respiratory failure were analyzed retrospectively using data collected over three consecutive summer periods. From an initial cohort of acute respiratory failure drowned patients, patients were matched by age, sex, Glasgow Coma Scale, and occurrence of cardiac arrest (yes or no). RESULTS: Among an initial cohort of 242 patients, 38 pairs were matched correctly. At the initial assessment, carried out upon ICU admission, hypoxemia was found to be deeper in the fresh water group (PaO2/FiO2: 141 ± 76 vs. 220 ± 122, P < 0.05). However, there was no significant difference in tissue oxygenation (assessed by blood lactate level) between groups. In terms of biology results, sodium levels were higher in the salt water group in the initial assessment (144 ± 6.8 vs. 140 ±5.2 mmol/l, P = 0.004), but no difference was observed later. No difference was recorded in the outcome or length of stay in ICU between groups. CONCLUSION: Drowning in fresh water was associated with deeper hypoxemia in the initial assessment. Despite this initial difference, latter respiratory and biological parameters or outcome were similar in both groups.