A retrospective comparison of mechanical cardio-pulmonary ventilation and manual bag valve ventilation in non-traumatic out-of-hospital cardiac arrests: A study from the Belgian cardiac arrest registry.

BACKGROUND: The optimal ventilation modalities to manage out-of-hospital cardiac arrest (OHCA) remain debated. A specific pressure mode called cardio-pulmonary ventilation (CPV) may be used instead of manual bag ventilation (MBV). We sought to analyse the association between mechanical CPV and return of spontaneous circulation (ROSC) in non-traumatic OHCA. METHODS: MBV and CPV were retrospectively identified in patients with non-traumatic OHCA from the Belgian Cardiac Arrest Registry. We used a two-level mixed-effects multivariable logistic regression analysis to determine the association between the ventilation modalities and outcomes. The primary and secondary study criteria were ROSC and survival with a Cerebral Performance Category (CPC) score of 1 or 2 at 30 days. Age, sex, initial rhythm, no-flow duration, low-flow duration, OHCA location, use of a mechanical chest compression device and Rankin status before arrest were used as covariables. RESULTS: Between January 2017 and December 2021, 2566 patients with OHCA who fulfilled the inclusion criteria were included. 298 (11.6%) patients were mechanically ventilated with CPV whereas 2268 were manually ventilated. The use of CPV was associated with greater probability of ROSC both in the unadjusted (odds ratio: 1.28, 95% confidence interval [CI]: 1.01-1.63; p = 0.043) and adjusted analyses (adjusted odds ratio [aOR]: 2.16, 95%CI 1.37-3.41; p = 0.001) but not with a lower CPC score (aOR: 1.44, 95%CI 0.72-2.89; p = 0.31). CONCLUSIONS: Compared with MBV, CPV was associated with an increased risk of ROSC but not with improved an CPC score in patients with OHCA. Prospective randomised trials are needed to challenge these results.

Postresuscitation oxygen reserve index-guided oxygen titration in out-of-hospital cardiac arrest survivors: A randomised controlled trial.

BACKGROUND AND PURPOSE: Hyperoxia after return of spontaneous circulation is potentially harmful, and oxygen titration in a prehospital setting is challenging. This study aimed to compare outcomes of oxygen reserve index-supported prehospital oxygen titration during prehospital transport with those of standard oxygen titration. METHODS AND TRIAL DESIGN: We enrolled patients who experienced return of spontaneous circulation after cardiac arrest in a prospective randomized study. Patients were randomly divided (1:1) to undergo oxygen titration based on the oxygen reserve index and SpO2 (intervention) or SpO2 only (control). FIO2 titration targeted SpO2 level maintenance at 94-98%. The primary outcome was the normoxia index, reflecting the proportion of both hyperoxia- and hypoxia-free time during prehospital intervention. RESULTS: A total of 92 patients were included in the study. The mean normoxia index was 0.828 in the control group and 0.847 in the intervention group (difference = 0.019 [95 % CI, -0.056-0.095]), with no significant difference between the groups. No significant differences were found in the incidence of hypoxia or hyperoxia between groups. No difference was found in the mean PaO2 at hospital admission (116 mmHg [IQR: 89-168 mmHg] in the control group vs 115 mmHg [IQR: 89-195 mmHg] in the intervention group; p = 0.86). No difference was observed in serum neuron-specific enolase levels 48 h post-ROSC after adjustment for known confounders. CONCLUSION: Oxygen reserve index- combined with pulse oximetry-based prehospital oxygen titration did not significantly improve the normoxia index compared with standard oxygen titration based on pulse oximetry alone (NCT03653325).

Effect of intranasal sufentanil on acute post-traumatic pain in the emergency department: a randomised controlled trial.

BACKGROUND: Intranasal sufentanil is a potent opioid which can be used in patients with traumatic injuries presenting to the ED. Although previous studies have demonstrated the superiority of intranasal sufentanil over intravenous morphine in terms of pain relief, its clinical superiority in patients with traumatic injuries receiving adequate multimodal analgesia with acetaminophen and non-steroidal anti-inflammatory drugs is uncertain. We compared pain relief offered by intranasal sufentanil with that offered by oral and intravenous opioids in patients with acute traumatic injuries also receiving a specified regimen of non-opioid treatment. METHODS: In this single-centre, open-label, parallel-group, randomised controlled superiority trial conducted between January 2020 and February 2022, trauma patients presenting to the ED with a pain score of ≥7 on a visual analogue scale (VAS) were randomised to receive either intranasal sufentanil or other oral/intravenous opioids alongside oral/intravenous acetaminophen and non-steroidal anti-inflammatory drugs. The primary outcome was reduction in VAS score 15-20 min after randomisation. RESULTS: An intention-to-treat analysis included 170 out of 205 patients screened for inclusion. The intranasal sufentanil group (83 patients) showed a significantly greater reduction in pain when compared with the oral/intravenous opioid group (87 patients) 15-20 min after randomisation (reduction in VAS score 3.0 (IQR 1.7-5.0) vs 1.5 (IQR 0.9-3.0); p<0.001). Similarly, a greater reduction in pain was observed in the intranasal sufentanil group 60 min after randomisation (5.0 (IQR 3.0-7.0) vs 3.0 (IQR 2.0-5.3); p<0.001). However, side effects were more frequent in the intervention group (71.1% vs 23%; p<0.001). CONCLUSIONS: Intranasal sufentanil was associated with more effective pain relief than oral/intravenous opioids in patients with traumatic injuries treated with coanalgesia. Intranasal sufentanil could be considered for the management of pain in patients with traumatic injuries associated with severe pain. TRIAL REGISTRATION NUMBER: NCT04137198.

Severe vitamin D deficiency in patients admitted to the emergency department with severe sepsis is associated with an increased 90-day mortality.

BACKGROUND: The role of vitamin D in the response to infection has been increasingly acknowledged. However, the influence of severe vitamin D deficiency on the outcome of patients admitted for severe sepsis is unknown. Hence, this study aimed to investigate the association between severe vitamin D deficiency and sepsis-related outcomes in patients presenting to the ED. METHODS: This single centre prospective study included patients presenting to the ED with severe sepsis from April 2014 until December 2017. 25-Hydroxy vitamin D (25(OH)D) was measured in a blood sample drawn within 24 hours of admission to the ED, and severe vitamin D deficiency was defined as 25(OH)D <12 ng/mL. 90-day mortality was compared between patients with and without severe vitamin D deficiency by a multivariable analysis adjusting for confounders and according to a Kaplan-Meier survival analysis. RESULTS: 263 patients were initially screened and 164 patients with severe sepsis were included in this study, 18% of whom had septic shock. Severe vitamin D deficiency was present in 46% of patients. The overall 90-day mortality rate was 26.2% and the median length of stay was 14 days. In a logistic regression accounting for sepsis severity and age-adjusted comorbidities, severe vitamin D deficiency was associated with increased mortality (OR=2.69 (95% CI 1.03 to 7.00), p=0.043), and lower chances of hospital discharge (sub-HR=0.66 (95% CI 0.44 to 0.98)). In the subgroup of patients admitted to the intensive care unit, severe vitamin D deficiency was associated with an increased 28-day adjusted mortality (HR=3.06 (95% CI 1.05 to 8.94), p=0.04) and lower chances of discharge (sub-HR=0.51 (95% CI 0.32 to 0.81)). CONCLUSIONS: Severe vitamin D deficiency at ED admission is associated with higher mortality and longer hospital stay in patients with severe sepsis.

Extracorporeal Life Support for Recurrent Hypothermic Cardiac Arrest: A Case Report.

Hypothermia-associated cardiac arrest (HACA) is a challenge for emergency physicians. Standard cardiopulmonary resuscitation (CPR) remains the primary intervention for the treatment of HACA, but extracorporeal life support (ECLS) may be needed as an adjunct to CPR. In this report, we present the case of an adult Asian patient who experienced two episodes of HACA at a two-year interval. In both episodes, the patient was treated with ECLS in addition to standard CPR. We discuss the fundamentals of HACA and how to safely and effectively incorporate ECLS into its management. No-flow time, age, comorbidities, and the cause of the cardiac arrest are criteria to consider when deciding on the duration of CPR and the intensity of the resources deployed. Hypothermia is a reversible cause of cardiac arrest, justifying prolonged CPR. According to the Hypothermia Outcome Prediction after ECLS (HOPE) score, active rewarming through ECLS is recommended. However, a history of cardiac arrest is rare and might be considered a severe comorbidity contraindicating ECLS use. Nevertheless, the indication is determined on a case-by-case basis.

Diagnostic Accuracy of Procalcitonin upon Emergency Department Admission during SARS-CoV-2 Pandemic.

INTRODUCTION: Procalcitonin is a marker for bacterial diseases and has been used to guide antibiotic prescription. Procalcitonin accuracy, measured at admission, in patients with community-acquired pneumonia (CAP), is unknown in the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. OBJECTIVES: To evaluate the diagnostic accuracy of procalcitonin to assess the need for antibiotic treatment in patients with CAP presenting to the emergency department during the SARS-CoV-2 pandemic. METHODS: We performed a real-world diagnostic retrospective accuracy study of procalcitonin in patients admitted to the emergency department. Measures of diagnostic accuracy were calculated based on procalcitonin results compared to the reference standard of combined microbiological and radiological analysis. Sensitivity, specificity, positive and negative predictive values, and area under (AUC) the receiver-operating characteristic (ROC) curve were calculated in two analyses: first assessing procalcitonin ability to differentiate microbiologically proven bacteria from viral CAP and then clinically diagnosed bacterial CAP from viral CAP. RESULTS: When using a procalcitonin threshold of 0.5 ng/mL to identify bacterial etiology within patients with CAP, we observed sensitivity and specificity of 50% and 64.1%, and 43% and 82.6%, respectively, in the two analyses. The positive and negative predictive values of a procalcitonin threshold of 0.5 ng/mL to identify patients for whom antibiotics should be advised were 46.4% and 79.7%, and 48.9% and 79% in the two analyses, respectively. The AUC for the two analyses was 0.60 (95% confidence interval [CI] 0.52-0.68) and 0.62 (95% CI, 0.55-0.69). CONCLUSIONS: Procalcitonin measured upon admission during the SARS-CoV-2 pandemic should not guide antibiotic treatment in patients with CAP.

Risk assessment, consequences, and epidemiology of electric scooter accidents admitted to an emergency department: a prospective observational study.

PURPOSE: This study aimed to describe the demographic and clinical characteristics of individuals involved in electric scooter (E-scooter) accidents and the factors associated with these incidents. METHODS: We conducted a prospective observational study of individuals involved in E-scooter accidents admitted to the emergency department of Saint-Pierre Hospital. The highest abbreviated injury score above or equal to two classified the injury as significant. Injuries during working hours were compared to those during off-working hours. RESULTS: During the study period from June 1, 2019, to June 30, 2020, 170 individuals were admitted to the emergency department following an E-scooter accident. In 73.5% of the accidents, rented E-scooters were involved. Of the patients, 68.2% were male, 6.4% wore helmets, and 30% were under the influence of alcohol. Upper limb and cranial injuries were more frequently severe (abbreviated injury score ≥ 2) than other injuries (p < 0.05). Accidents during off-working hours were significantly related to alcohol consumption (p < 0.001), non-usage of helmets (p < 0.01), head and neck injuries (p < 0.01), and rented E-scooters (p < 0.01). Alcohol consumption was itself associated with the non-usage of helmets (p < 0.05) and major head and neck injuries (p < 0.001). CONCLUSION: Given the increasing popularity of E-scooters as an alternative mode of transportation, our study can inform public policy on patterns of injuries associated with E-scooter utilization for future injury prevention policies. Using helmets, avoiding alcohol consumption, and regulating use at night can improve outcomes in E-scooter accidents. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04778332.

Agreement between Arterial and Capillary pH, pCO2, and Lactate in Patients in the Emergency Department.

BACKGROUND: Blood gas analysis (BGA) is a frequent painful procedure in emergency departments. The primary objective of the study was a quantitative analysis to assess the mean difference and 95% confidence interval of the difference between capillary and arterial BGA for pH, pCO2, and lactate. Secondary objective was to measure the sensitivity and specificity of capillary samples to detect altered pH, hypercarbia, and lactic acidosis. Adults admitted to the ED were screened for inclusion. We studied the agreement between the two methods for pH, pCO2, and lactate with Bland-Altman bias plot analysis and receiver operating characteristic curves. RESULTS: One hundred ninety-seven paired analyses were included. Mean difference for pH between arterial and capillary BGA was 0.0095, and 95% limits of agreement (LOA) were -0.048 to 0.067. For pCO2, mean difference was -0.3 mmHg, and 95% LOA were -8.5 to 7.9 mmHg. Lactate mean difference was -0.93 mmol/L, and 95% LOA were -2.7 to 0.8 mmol/L. At a threshold of 7.34, capillary pH had 98% sensitivity and 97% specificity to detect acidemia; at 45.9 mmHg, capillary pCO2 had 89% sensitivity and 96% specificity to detect hypercarbia. At a threshold of 3.5 mmol/L, capillary lactate had 66% sensitivity to detect lactic acidosis. CONCLUSION: Capillary BGA cannot replace arterial BGA despite high concordance between the two methods for pH and pCO2 and moderate concordance for lactate. Capillary measures had good accuracy when used as a screening tool to detect altered pH and hypercarbia but insufficient sensitivity and specificity when screening for lactic acidosis.

SARS-CoV-2 Diagnostic Tests: Algorithm and Field Evaluation From the Near Patient Testing to the Automated Diagnostic Platform.

Introduction: Since the first wave of COVID-19 in Europe, new diagnostic tools using antigen detection and rapid molecular techniques have been developed. Our objective was to elaborate a diagnostic algorithm combining antigen rapid diagnostic tests, automated antigen dosing and rapid molecular tests and to assess its performance under routine conditions. Methods: An analytical performance evaluation of four antigen rapid tests, one automated antigen dosing and one molecular point-of-care test was performed on samples sent to our laboratory for a SARS-CoV-2 reverse transcription PCR. We then established a diagnostic algorithm by approaching median viral loads in target populations and evaluated the limit of detection of each test using the PCR cycle threshold values. A field performance evaluation including a clinical validation and a user-friendliness assessment was then conducted on the antigen rapid tests in point-of-care settings (general practitioners and emergency rooms) for outpatients who were symptomatic for <7 days. Automated antigen dosing was trialed for the screening of asymptomatic inpatients. Results: Our diagnostic algorithm proposed to test recently symptomatic patients using rapid antigen tests, asymptomatic patients using automated tests, and patients requiring immediate admission using molecular point-of-care tests. Accordingly, the conventional reverse transcription PCR was kept as a second line tool. In this setting, antigen rapid tests yielded an overall sensitivity of 83.3% (not significantly different between the four assays) while the use of automated antigen dosing would have spared 93.5% of asymptomatic inpatient screening PCRs. Conclusion: Using tests not considered the "gold standard" for COVID-19 diagnosis on well-defined target populations allowed for the optimization of their intrinsic performances, widening the scale of our testing arsenal while sparing molecular resources for more seriously ill patients.

Single-tablet regimen of emtricitabine/tenofovir disoproxil fumarate plus cobicistat-boosted elvitegravir increase adherence for HIV postexposure prophylaxis in sexual assault victims.

BACKGROUND: Postexposure prophylaxis (PEP) is a recommended public health intervention after a sexual assault to prevent HIV infection. METHODS: We conducted a retrospective case-control study on how use of a single-tablet regimen (STR) of elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (Stribild) affected adherence to PEP and attendance of a follow-up visit to the STI clinic compared with those who received a multitablet regimen (MTR). Data from sexual assault victims consulting for PEP were prospectively recorded between January 2011 and December 2017. Data were systematically collected on patient demographics, time of medical contact, source risk factors, type of exposure, attendance to follow-up visit, reported completion of PEP and adherence based on pharmacy records. RESULTS: A total of 422 patients received PEP following a sexual assault, of whom 52% had documented completion of a 28-day PEP regimen and 71% attended a follow-up clinic visit. Patients who received an elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (EVG/COBI/FTC/TDF)-based STR had a similar likelihood of attending their first follow-up visit (OR: 0.97; 95% CI: 0.64 to 1.48, p=0.90) but were more likely to complete the PEP regimen (OR: 1.70; 95% CI: 1.16 to 2.50, p=0.007). After adjusting for confounders, those who were prescribed an STR regimen were more likely to complete the PEP regimen (OR: 1.66, 95% CI: 1.09 to 2.53, p=0.019) than those who were prescribed an MTR such as stavudine/lamivudine/lopinavir/ritonavir or zidovudine/lamivudine/indinavir/ritonavir. CONCLUSIONS: Sexual assault victims who were prescribed an STR based on EVG/COBI/FTC/TDF were more likely to complete PEP than those who were prescribed an MTR.

Adherence to HIV post-exposure prophylaxis: A multivariate regression analysis of a 5 years prospective cohort.

BACKGROUND: Non-occupational post-exposure prophylaxis (nPEP) is a recommended public health intervention after a sexual or percutaneous exposure to human immunodeficiency virus (HIV). METHODS: We conducted a prospective observational study recording consultations for nPEP at a reference HIV center in Brussels, Belgium from January 2011 to December 2015. We recorded attendance to follow-up, reported completion of nPEP and pharmacy records to measure adherence. Multivariate logistic regressions were performed to identify independent risk factors for adherence to nPEP and attendance to first follow-up visit at the STI clinic. FINDINGS: Among 1881 patients receiving nPEP, 66.4% had a documented completion of a 28-day course of nPEP and 87.3% attended their first follow-up clinic visit. MSM (OR, 1.40; 95%CI, 1.04-1.90), being a native Belgian (OR, 1.50; 95%CI, 1.18-1.90), older age (OR, 1.02; 95%CI, 1.01-1.04), being a sexual assault survivor (OR, 0.59; 95%CI, 0.38-0.91), having had a previous nPEP treatment (OR, 1.44; 95%CI, 1.02-2.02), consultation during daytime (OR, 1.35; 95%CI, 1.07-1.70) and benefitting from a health insurance (OR, 2.11; 95%CI, 1.58-2.89) were significant independent predictors for adherence to nPEP. Patients whose initial treatment was AZT/3TC/IDV/r had similar adherence than patients on d4T/3TC/LPV/r (OR, 0.898; 95%CI, 0.68-1.20). INTERPRETATION: Multiple independent risk factors for nPEP retention into care and adherence are present at treatment initiation and might be targeted by tailored interventions. Sexual assault victims are overexposed to deleterious consequences of the lack of health insurance on compliance.

Prescription of Non-Occupational Post-Exposure HIV Prophylaxis by Emergency Physicians: An Analysis on Accuracy of Prescription and Compliance.

We conducted a retrospective analysis of data from a prospective nPEP (non-Occupational Post Exposure Prophylaxis) registry based on patients consulting at one academic Emergency department located in Brussels, Belgium. We review here 1,357 cases consulting from January 2011 to December 2013.The objective of the study is to determine whether emergency physicians prescribe nPEP according to national guideline with support from IDS (infectious disease specialists). As this intervention has a high cost we wanted to verify correct allocation of treatment to high risk patients. Moreover we wanted to determine whether compliance to nPEP when prescribed by an Emergency Physician was different from literature reports. Finally we wanted to describe the population consulting for nPEP at our center. Emergency physicians prescribed nPEP more frequently in high risk exposures (98.6%) compared to intermediate risk exposures (53.2%); adequately allocating resources from a public health perspective. Appropriateness of prescription when evaluated according to nPEP Belgian guidelines was 98.8%.Compliance with nPEP prescribed by Emergency physicians was 60% in our study. Compliance was the highest in MSM (Men who have Sex with Men) while sexual assault victims showed the lowest compliance. Altogether this study suggests that Emergency physicians can safely and adequately prescribe nPEP when supported by a comprehensive guideline. Recognizing intrinsic differences within heterogeneous populations consulting for nPEP may improve compliance to this high-cost public health intervention.

Transcranial Doppler to assess sepsis-associated encephalopathy in critically ill patients.

BACKGROUND: Transcranial Doppler can detect cerebral perfusion alteration in septic patients. We correlate static Transcranial Doppler findings with clinical signs of sepsis-associated encephalopathy. METHODS: Forty septic patients were examined with Transcranial Doppler on the first and third day of sepsis diagnosis. The pulsatility index (PI) and cerebral blood flow index (CBFi) were calculated by blood velocity in the middle cerebral artery (cm/sec). Patients underwent a daily cognitive assessment with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) test. RESULTS: Twenty-one patients (55%) were found to present confusion. The majority of the patients presented a PI > 1.1 (76%). PI on the first day (but not the third day) could predict a positive CAM-ICU test in septic patients (PI cut-off: 1.3, AUC: 0.905, p < 0.01, sensitivity: 95%, specificity: 88%, AUC: 0.618, p = 0.24). Multivariable analysis showed that PI on the first day is related to a positive CAM-ICU test independent of age and APACHE II score (OR: 5.6, 95% CI: 1.1-29, p = 0.03). A decrease of the PI on the third day was observed in the group that presented initially high PI (>1.3) (2.2 ± 0.71 vs. 1.81 ± 0.64; p = 0.02). On the other hand, an increase in PI was observed in the other patients (1.01 ± 0.15 vs. 1.58 ± 0.57; p < 0.01). On only the first day, the mean blood velocity in the middle cerebral artery and CBFi were found to be lower in those patients with a high initial PI (36 ± 21 vs. 62 ± 28 cm/sec; p < 0.01, 328 ± 101 vs. 581 ± 108; p < 0.01, respectively). CONCLUSIONS: Cerebral perfusion disturbance observed with Transcranial Doppler could explain clinical symptoms of sepsis-associated encephalopathy.