Predictive criteria for acute heart failure in emergency department patients with acute dyspnoea: the PREDICA study.

OBJECTIVES: The early identification of patients with Acute Heart Failure Syndrome (AHFS) among patients admitted to the Emergency Department (ED) with dyspnoea can facilitate the introduction of appropriate treatments. The objectives are to identify the predictive factors for AHFS diagnosis in patients with acute dyspnoea (primary objective) and the clinical 'gestalt' (secondary objective) in ED. METHODS: PREDICA is an observational, prospective, multicentre study. The enrolment of patients admitted to the ED for nontraumatic acute dyspnoea and data collection on admission were recorded by the patient's emergency physician. The AHFS endpoints were assessed following a duplicate expert evaluation by pairs of cardiologists and emergency physicians. Step-by-step logistic regression was used to retain predictive criteria, and the area under the receiver operating characteristic (ROC) curve of the model was constructed to assess the ability of the selected factors to identify real cases. The probability of AHFS was estimated on a scale from 1 to 10 based on the emergency physician's perception and understanding (gestalt). RESULTS: Among 341 patients consecutively enrolled in three centres, 149 (44%) presented AHFS. Eight predictive factors of AHFS were detected with a performance test showing an area under the model ROC curve of 0.86. Gestalt greater than or equal to five showed sensitivity of 78% and specificity of 90% (AUC 0.91) and diagnosed 88% of AHF in our population. CONCLUSIONS: We identified several independant predictors of final AHFS diagnosis. They should contribute to the development of diagnostic strategies in ED. However, unstructured gestalts seem to perform very well alone.

[Protocol for advanced prehospital emergency care of severe head injury]. / Description d'un protocole de prise en charge préhospitalière du traumatisé crânien grave.

OBJECTIVES: To analyze the frequency of systemic factors leading to secondary brain insults in victims of serious head trauma in a prehospital setting and to evaluate a protocol for the advanced prehospital emergency care by mobile intensive care unit (i.e., the French Samu-Smur system). STUDY DESIGN: Prospective study, over a period of 24 months. PATIENTS AND METHODS: This prospective study involved 60 victims of severe head injuries (with the exception of polytrauma patients). Tracheal intubation was performed on each patient under direct laryngoscopy and after induction of anaesthesia (fentanyl-etomidate-rocuronium). Controlled ventilation and vascular loading (objectives: SpO(2) >or= 97%, PETCO(2) between 30 and 35 mmHg, SAP >or= 90 mmHg) were administered. RESULTS: Hypoxaemia was found to be the most frequent cause of secondary insults (57% of patients with SpO(2) < 97%). In the case involving an accident that occurred 17 km from the hospital (with extremes of 6-65 km), the speed of medical intervention was note-worthy: tracheal intubation was performed 50 min after the accident, and the patient was admitted into a trauma centre 101 min after impact (median). However, faster intervention could be obtained if the transmission of the alert was improved. The conditions under which the tracheal intubation was performed were found to be satisfactory (difficult intubation 1.6%) without deteriorating the haemodynamic status. This is probably related to the use of muscle relaxants and the choice of etomidate as the first line hypnotic in the prehospital emergency care.

Epidemiology of severe brain injuries: a prospective population-based study.

BACKGROUND: The aim of this prospective study was to estimate annual incidences of hospitalization for severe traumatic brain injury (TBI) (maximum Abbreviated Injury Score in the head region [HAIS] 4 or 5) in a defined population of 2.8 million. METHODS: Severe TBI patients were included in the emergency departments in the 19 hospitals of the region. A prospective data form was completed with initial neurologic state, computed tomographic scan lesions, associated injuries, length of unconsciousness, and length of stay in acute care centers. Outcome at the time the patient left acute hospitalization was retrospectively assessed from medical notes. RESULTS: During the 1-year period (1996), 497 residents fulfilled the inclusion criteria, leading to an annual incidence rate of 17.3 per 100,000 population; 58.1% were HAIS5. Mortality rate was 5.2 per 100,000. Men accounted for 71.4% of cases. Median age was 44 years, with a quarter of patients more than 70 years old. Traffic accidents were the most frequent causes (48.3%), but falls accounted for 41.8% of all patients. Age and severity were different according to the major categories of external causes. In HAIS5 patients, 86.5% were considered as comatose (coma lasting more than 24 hours or leading to immediate death) but only 60.9% had an initial Glasgow Coma Scale score < 9. In the HAIS4 group, 7.2% had an initial Glasgow Coma Scale score < 9. Fatality rates were 30.0% in the whole study group, 7.7% in HAIS4, 12.8% in HAIS5 without coma, and 51.2% in HAIS5 with coma. CONCLUSION: This study shows a decrease in severe TBI incidence when results are compared with another study conducted 10 years earlier in the same region. This is because of a decrease in traffic accidents. However, this results in an increase in the proportion of falls in elderly patients and an increase in the median age in our patients. This increased age influences the mortality rate.

Benzodiazepines and hip fractures in elderly people: case-control study.

OBJECTIVE: To determine whether benzodiazepines are associated with an increased risk of hip fracture. DESIGN: Case-control study. PARTICIPANTS: All incident cases of hip fracture not related to traffic accidents or cancer in patients over 65 years of age. 245 cases were matched to 817 controls. SETTING: Emergency department of a university hospital. MAIN OUTCOME MEASURES: Exposure to benzodiazepines and other potential risk or protective factors or lifestyle items. RESULTS: The use of benzodiazepines as determined from questionnaires, medical records, or plasma samples at admission to hospital was not associated with an increased risk of hip fracture (odds ratio 0.9, 95% confidence interval 0.5 to 1.5). Hip fracture was, however, associated with the use of two or more benzodiazepines, as determined from questionnaires or medical records but not from plasma samples. Of the individual drugs, only lorazepam was significantly associated with an increased risk of hip fracture (1.8, 1.1 to 3.1). CONCLUSION: Except for lorazepam, the presence of benzodiazepines in plasma was not associated with an increased risk of hip fracture. The method used to ascertain exposure could influence the results of case-control studies.

Pharmacological therapy of spinal cord injury during the acute phase.

STUDY DESIGN: Prospective, randomized clinical trial. SETTING: France. OBJECTIVES: To evaluate the safety and effect on neurological outcome of nimodipine, methylprednisolone, or both versus no medical treatment in spinal-cord injury during the acute phase. METHOD: One hundred and six patients who had spinal trauma (including 48 with paraplegia and 58 with tetraplegia) were randomly separated into four groups: M=methylprednisolone (30 mg x kg(-1) over 1 h, followed by 5.4 mg x kg(-1) x h(-1) for 23 h), N=nimodipine (0.015 mg x kg(-1) x h(-1) for 2 h followed by 0.03 mg x kg(-1)h(-1) for 7 days), MN (both agents) or P (neither medication). Neurological assessment (ASIA score) was performed by a blinded senior neurologist before treatment and at 1-year follow-up. Early spinal decompression and stabilization was performed as soon as possible after injury. RESULTS: One hundred patients were reassessed at 1 year. Neurological improvement was seen in each group (P<0.0001), however no additional neurological benefit from treatment was observed. Infectious complications occurred more often in patients treated with M. Early surgery (49 patients underwent surgery within 8 h of their accident) did not influence the neurological outcome. The only predictor of the latter was the extent of the spinal injury (complete or incomplete lesion). CONCLUSION: The present study confirms the absence of benefit of pharmacological therapy in this indication. Because of the paucity of clinical studies that demonstrate the efficacy of pharmacological treatment in spinal injury during the acute phase, systematic use of pharmaceutical agents should be reconsidered.

Mitochondrial energy metabolism in brain-dead organ donors.

OBJECTIVES: Change from aerobic to anaerobic metabolism has been described in brain-dead organ donors (BDOD) managed for organ procurement. Such modifications could lead to a depletion in intracellular adenine nucleotides and in part explain primary graft dysfunction. The purpose of this study was to investigate the mitochondrial energy metabolism in BDOD using permeabilized muscle fibers. METHODS: With institutional approval, the study was performed prospectively in 15 consecutive BDOD. In each patient, muscle biopsy and blood samples for the determination of plasma lactate and pyruvate were obtained just before organ removal. Mitochondrial respiratory parameters of skeletal muscle were determined in saponin-skinned muscle fibers. Mitochondrial oxygen consumption rates were measured polarographically using different substrates and inhibitors of the respiratory chain complexes. Results were compared to those obtained from muscle biopsies performed in 10 healthy patients during orthopedic surgery. RESULTS: Fifteen donors, 13 men and 2 women, aged 35 +/- 11 yrs, were studied. All patients had a high lactate-to-pyruvate ratio (10). Mitochondrial respiration rates were significantly decreased during adenosine triphosphate (ATP) synthesis. CONCLUSIONS: Major changes in energy metabolism occurred during brain death with a decrease in ATP synthesis capacity. High-risk donors should be recognized for a better graft evaluation.

[Medical treatment of spinal cord injury in the acute stage]. / Traitement médicamenteux de la lésion médullaire traumatique au stade aigu.

OBJECTIVES: To evaluate the effect on neurologic outcome and the safety of nimodipine (N), methylprednisolone (M), or both (MN) versus no medical treatment (P) in spinal cord injury at the acute phase. STUDY DESIGN: Prospective, randomized clinical trial. PATIENTS: One hundred and six patients with a spinal trauma, including 48 with paraplegia and 58 with tetraplegia. METHOD: After eligibility, patients were randomly allocated in one of the following groups: M = methylprednisolone 30 mg.kg-1 over 1 hour, followed by 5.4 mg.kg-1.h-1 for 23 hours, N = nimodipine 0.015 mg.kg-1.h-1 over 2 hours followed by 0.03 mg.kg-1.h-1 for 7 days, MN or P. Neurologic assessment (ASIA score) was performed by a senior neurologist before treatment and at the 1-year follow-up. Early spinal decompression and stabilization was performed as soon as possible after injury. RESULTS: One hundred patients were reassessed at the 1-year follow-up. Neurologic improvement was seen in each group (P < 0.0001), however no neurologic benefit from treatment was observed. Infectious complications occurred more often in patients treated with M. Early surgery (49 patients), within the first 8 hours did not influence the neurologic outcome. The only predictor of the latter was the extent of the spinal injury (complete or incomplete lesion). CONCLUSION: Currently, no evidence of the benefit of medical treatment in this indication is existing. Because of the lack of clinical studies proving efficacy of pharmacological treatment in this specific pathology, a systematic use of medications cannot be recommended.

-Coagulopathy suggestive of a primary fibrinolysis after head injuries with brain death-. / Coagulopathie évocatrice d'une fibrinolyse primaire après traumatisme crânien avec mort cérébrale.

Coagulopathies associated with severe head trauma are usually of disseminated intravascular coagulation type with secondary fibrinolysis. We report a case whose semeiology was in part suggestive of a primary fibrinolysis.

The use of 0.25% lidocaine with fentanyl and pancuronium for intravenous regional anesthesia.

The present study was designed to assess the efficacy of fentanyl and pancuronium combined with dilute lidocaine solution for intravenous regional anesthesia of the arm. Forty adult patients undergoing upper limb surgery were randomly allocated to receive either 0.6 mL/kg of 0.5% lidocaine (3 mg/kg) or 0.6 mL/kg of 0.25% lidocaine (1.5 mg/kg) with 1 microg/kg of fentanyl and 0.5 mg of pancuronium. The onset of sensory and motor blocks was significantly shorter in the 0.5% lidocaine group (P < 0.05). However, no differences in analgesia or motor blockade were found between the two groups at 20 min tourniquet time. Regional anesthesia was considered successful in more than 85% of patients. One patient in the 0.25% lidocaine group experienced a transient diplopia after tourniquet release. Postoperative analgesia time was similar in the two groups. We conclude that the addition of fentanyl plus pancuronium to the lidocaine solution reduces the dose of the local anesthetic and possibly systemic toxicity.

Hemodynamic effects of spinal anesthesia in the elderly: single dose versus titration through a catheter.

Sixty elderly patients (> 70 yr old) undergoing surgery for hip fracture were prospectively studied in order to compare hemodynamic tolerance of titrated doses of hyperbaric bupivacaine using continuous spinal anesthesia (CSA) versus single-dose spinal anesthesia (SDSA). Patients were randomized into two groups (CSA group: n = 30; SDSA group: n = 30). The SDSA patients received 10-15 mg of 0.5% hyperbaric bupivacaine (based on age and height), and the CSA patients received a starting dose of 5 mg of 0.5% hyperbaric bupivacaine, followed after 15 min by optional reinjection of 2.5 mg every 5 min until a T10 level sensory block was reached. Onset of anesthesia, noninvasive hemodynamic variables and the need for ephedrine were studied for 4 h after induction of anesthesia. Spinal anesthesia was successful in all patients. Decreases in mean arterial pressure were significantly less frequent and less pronounced in the CSA group (19.9% +/- 1.6% of the baseline value) than in the SDSA group (40.2% +/- 1.9%, P < 0.0001). The mean dose of ephedrine was significantly less in the CSA group (1.8 +/- 0.7 mg, administered to only 37% of patients) than in the SDSA group (19.4 +/- 3.3 mg administered to all patients, P < 0.0001). No late complications related to the spinal anesthesia technique were observed in either group. We concluded that CSA, using small titrated doses of 0.5% hyperbaric bupivacaine, is safe, efficient, and provides better hemodynamic stability than SDSA in elderly patients.

[Subarachnoid hemorrhage caused by aneurysm rupture. Initial management of patients]. / Hémorragie méningée par rupture anévrismale:prise en charge initiale du patient.

Subarachnoid haemorrhage is a severe illness with a high mortality and morbidity. Its diagnosis is considered in the case of a brutal, violent and unusual headache. It is confirmed rapidly with the conventional techniques such as CT-scan and lumbar puncture. The main complications (ischaemia, rebleeding, hydrocephalus) occur during the first two weeks and are a usual event in case of a lack of diagnosis or specialised medical, surgical and radiological management. Among the complications, rebleeding badly affects prognosis, and only early surgery or interventional radiology may improve the outcome. Delayed ischaemia may be prevented by medical management with correction of hypovolaemia and administration of calcium antagonists, before and after surgery, particularly between the 4th and the 10th day. When signs of ischaemia occur, aggressive treatment should be administered in order to improve cerebral perfusion pressure and cerebral blood flow. The treatment is aimed to prevent the complications of subarachnoid haemorrhage and to establish optimal conditions for surgical and radiological procedures.

[Bilateral bronchial rupture: problems of respiratory management]. / Rupture bronchique bilatérale: problèmes de prise en charge ventilatoire.

The authors report the case of bilateral bronchial rupture in a 39-year-old multiple trauma patient. During the thoracotomy for right main bronchus repair, a partial left bronchial rupture was recognized because of severe hypoxaemia after left selective intubation.

[Traumatic diaphragmatic rupture with delayed unusual disclosure]. / Rupture diaphragmatique traumatique de révélation tardive inhabituelle.

The authors report the case of a delayed presentation of a traumatic diaphragmatic rupture in a 22-year-old patient admitted to hospital for a minor surgical procedure under general anaesthesia. Nine months before, he had a road traffic accident with a minor thoracic trauma. Three days after surgery, the patient was readmitted for a tension hydrothorax due to the herniation and the perforation of the stomach into the left pleural cavity. Such a delayed presentation of a traumatic diaphragmatic rupture remains uncommon. The peroperative ventilatory factors involved in the development of the hernia are discussed.

[Autotransfusion, with blood drained from a hemothorax, using the ConstaVac device]. / Autotransfusion avec du sang d'hémothorax à l'aide du dispositif ConstaVac.

The technique of autotransfusion with blood drained from a haemothorax has been described nearly 80 years ago. The shed blood is easy to collect and is incoagulable. This technique as two indications: lifesaving autotransfusion in the prehospital phase and blood saving and/or transfusional safety at hospital arrival. This prospective study assessed its value as well as the advantages and disadvantages of the ConstaVac system in 30 patients suffering from haemothorax. This apparatus consists of a 800 mL collecting reservoir on a support equipped with an electric aspirator and a battery. The collected blood is transferred into a reinfusion bag while remaining in a closed circuit. The retransfused volume was 685 +/- 430 mL, representing 80% of the collected volume. The retransfusion took place in less than four hours. The patients with an isolated haemothorax did not receive any homologous blood. Only one technical problem occurred, related to the excessive volume of the haemothorax. The shed blood has decreased content of platelets, fibrinogen, and is incoagulable. Moreover, it is hemolyzed. Its hematocrit is lower than the patient's one. On the other hand, the concentration of 2,3 DPG remains normal. These modifications have no detrimental consequences on the patients as long as the autotransfused volume does not exceed two litres. Infectious problems are rare. Handling requires strict asepsis. The ConstaVac system is marketed for postoperative autotransfusion. It is compact, self-contained and very easy to use. It is the only system able of ensuring blood drainage and retransfusion simultaneously, without requiring any opening of the circuit.(ABSTRACT TRUNCATED AT 250 WORDS)