Abstract Objective The aim of the study was to compare in emergency settings 2 analgesic regimens, morphine with ketamine (K group) or morphine with placebo (P group), for severe acute pain in trauma ...patients. Methods This was a prospective, multicenter, randomized, double-blind, clinical trial. Seventy-three trauma patients with a severe acute pain defined as a visual analog scale (VAS) score of at least 60/100 were enrolled. Patients in the K group received 0.2 mg · kg−1 of intravenous ketamine over 10 minutes, and patients in the P group received isotonic sodium chloride solution. In both groups, patients were given an initial intravenous morphine injection of 0.1 mg · kg−1 , followed by 3 mg every 5 minutes. Efficient analgesia was defined as a VAS score not exceeding 30/100. The primary end points were morphine consumption and VAS at 30 minutes (T30). Results At T30, morphine consumption was significantly lower in the K group vs the P group, with 0.149 mg · kg−1 (0.132-0.165) and 0.202 mg · kg−1 (0.181-0.223), respectively ( P < .001). The VAS score at T30 did not differ significantly between the 2 groups, with 34.1 (25.6-42.6) in the K group and 39.5 (32.4-46.6) in the P group ( P = not significant). Conclusion Ketamine was able to provide a morphine-sparing effect.
Summary Background Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction has traditionally been supported by unfractionated heparin, which has never been directly ...compared with a new anticoagulant using consistent anticoagulation and similar antiplatelet strategies in both groups. We compared traditional heparin treatment with intravenous enoxaparin in primary PCI. Methods In a randomised open-label trial, patients presenting with ST-elevation myocardial infarction were randomly assigned (1:1) to receive an intravenous bolus of 0·5 mg/kg of enoxaparin or unfractionated heparin before primary PCI. Wherever possible, medical teams travelling in mobile intensive care units (ambulances) selected, randomly assigned (using an interactive voice response system at the central randomisation centre), and treated patients. Patients who had received any anticoagulant before randomisation were excluded. Patients and caregivers were not masked to treatment allocation. The primary endpoint was 30-day incidence of death, complication of myocardial infarction, procedure failure, or major bleeding. The main secondary endpoint was the composite of death, recurrent acute coronary syndrome, or urgent revascularisation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov , number NCT00718471. Findings 910 patients were assigned to treatment with enoxaparin (n=450) or unfractionated heparin (n=460). The primary endpoint occurred in 126 (28%) patients after anticoagulation with enoxaparin versus 155 (34%) patients on unfractionated heparin (relative risk RR 0·83, 95% CI 0·68–1·01, p=0·06). The incidence of death (enoxaparin, 17 4% vs heparin, 29 6% patients; p=0·08), complication of myocardial infarction (20 4% vs 29 6%; p=0·21), procedure failure (100 26% vs 109 28%; p=0·61), and major bleeding (20 5% vs 22 5%; p=0·79) did not differ between groups. Enoxaparin resulted in a significantly reduced rate of the main secondary endpoint (30 7% vs 52 11% patients; RR 0·59, 95% CI 0·38–0·91, p=0·015). Death, complication of myocardial infarction, or major bleeding (46 10% vs 69 15% patients; p=0·03), death or complication of myocardial infarction (35 8% vs 57 12%; p=0·02), and death, recurrent myocardial infarction, or urgent revascularisation (23 5% vs 39 8%; p=0·04) were all reduced with enoxaparin. Interpretation Intravenous enoxaparin compared with unfractionated heparin significantly reduced clinical ischaemic outcomes without differences in bleeding and procedural success. Therefore, enoxaparin provided an improvement in net clinical benefit in patients undergoing primary PCI. Funding Direction de la Recherche Clinique, Assistance Publique-Hôpitaux de Paris; Sanofi-Aventis.
Dr House, TV, and Reality Lapostolle, Frédéric, MD, PhD; Montois, Sylvie; Alhéritière, Armelle, MD ...
The American journal of medicine,
02/2013, Letnik:
126, Številka:
2
Journal Article
Recenzirano
Abstract Background Medical practice in the media is usually far from reality. Thus, the viewer may be led astray. The world-famous fictional Dr House has to face a difficult diagnosis every week. ...His practice does not seem to reflect reality. The aim of this study was to assess the diagnosis strategy involved in this television program. Methods An observer has previewed the 2011 season. The episode running time, the patient's age and sex, the list of all investigations and interventions, the final diagnosis, and the patient's outcome were collected. Number and proportion of French viewers for each episode were recorded. Results We analyzed 18 episodes. The median running time was 42.5 (42.1-43.2) minutes. Main patient characters were 12 men (66%) and 6 women (33%); the average age was 31 (22-38) years. There were 225 investigations or interventions reported, averaging 14 (9-15) per episode, representing one examination every 3.1 (2.9-4.8) minutes. The most frequently prescribed investigations were magnetic resonance imaging (MRI; 13; 72%), blood sample (11; 61%), and biopsy (10; 56%). The most frequent interventions were surgery, anti-infectious treatments, and steroid treatments (9 each; 50%). Two patients (11%) died. The median number of spectators was 8.4 (8.1-8.7) million, corresponding to 33% (33%-34%) of the French national audience. Conclusion The population and the examination strategies used by Dr House were unrealistic. Because of this distortion, patients may not understand, nor accept the delay, the investigation choices, the intervention costs, risks, nor failures of a daily medical practice. Physicians should be aware of this “information bias.”
Abstract Introduction Much less is known about pain prevalence in pediatric patients in an out-of-hospital than emergency department setting. The purpose of this study was to determine pain ...prevalence in children in a prehospital emergency setting and to identify the factors associated with pain relief. Materials and Methods This prospective cohort study in consecutive patients 15 years or younger was conducted by 5 mobile intensive care units working 24/7 (January-December 2005). The presence of pain, its intensity, and alleviation by the administration of analgesics were recorded. Results A total of 258 of 433 pediatric patients were included, of whom 96 were suffering from acute pain (37%; 95% confidence interval CI, 31-43) that was intense to severe in 67% of cases. Trauma was the only factor significantly associated with acute pain (odds ratio, 818; 95% CI, 153-4376). Overall, 92% of the children in pain received at least one analgesic drug; 41% received a combination of drugs. Opioid administration was significantly associated with intense to severe pain (odds ratio, 7; 95% CI, 2-25). On arrival at hospital, 67% of the children were still in pain; but 84% had experienced some pain relief regardless of their sex, age, or disorder. Conclusion In a prehospital emergency setting, more than a third of children experience acute pain with a high prevalence of intense to severe pain. Scoring pain in children, and especially in the newborn, is beleaguered by a lack of suitable scales. Despite this, it was possible to treat 90% of children in pain and provide relief in 80% of cases.
Abstract Objective The aim of the study was to assess the ease-of-use, safety, and usefulness of an automated external chest compression device for cardiopulmonary resuscitation. Methods Adults with ...out-of-hospital cardiac arrest (OHCA) were included prospectively. The emergency medical services (EMS) in a large suburb northeast of Paris (France) recorded data for standard criteria for EMS care for CA and specific criteria on device use—application time, ease of application and use (visual analog scale score: 0, impossible; 5, very easy), technical incidents, and clinical complications. Results We attended 4868 OHCA patients (January 2005 to April 2010) and used the device in 285 patients (6%) (212 males 74%, 73 females 26%; median age, 56 43-70 years). Results (medians with 25-75 percentiles) were as follows: time to apply device, 30 seconds (20-60); ease of application and activation, 5 (4-5) and 5 (5-5), respectively; duration of use, 30 (20-41) minutes; return to spontaneous circulation (ROSC), 76 patients (27%); and time to ROSC, 19 (12-32) minutes after placement. Twenty-seven patients (9%) with refractory CA benefited from extracorporeal life support. Overall, 32 patients were alive after 24 hours, 11 at 7 days, and 3 at 1 month. An additional 23 patients (8%) with refractory CA were selected for non–heart-beating kidney procurement. Ten patients were used to harvest kidneys and 15 were transplanted. There were 21 technical incidents (7%) and 19 clinical complications (7%). Conclusion The device was easy to use in routine emergency practice and of particular value in facilitating access to extracorporeal life support or non–heart-beating organ procurement. These uses should be itemized in all OHCA studies.
Study objective We compare the quality of ECG recordings obtained with conventional and prewired electrodes in an emergency setting. Methods This was a prospective, randomized, open comparison study ...in an emergency medical services setting. Participants were patients undergoing ECG between April and May 2007 (n=105). Two 12-lead ECG recordings were made in random order with conventional and prewired electrodes. Artifacts, ie, signal noise (>0.4 seconds of recording affected) and baseline instability (>1-mV variation), were analyzed and scored by 3 blinded reviewers. Results were expressed as number of affected leads, score/lead (0 to 3 scale for signal noise; 0 to 4 scale for baseline instability), and number of leads that were totally artifact free. Time to make recordings was measured. Results Recordings were nearly as easy and took 20% less time with prewired than with conventional electrodes (118 interquartile ratio (IQR) 90 to 150 versus 144 IQR 120 to 182). With prewired electrodes, fewer leads were affected by noise (1 IQR 0 to 3 versus 3 IQR 0 to 6) and baseline instability (0 IQR 0 to 2 versus 2 IQR 0 to 4). The mean score/lead was lower for both noise (1 IQR 0 to 3 versus 3 IQR 0 to 8) and instability (0 IQR 0 to 2 versus 2 IQR 0 to 5); the number of artifact-free leads was greater (38 36% versus 19 18%). There was no significant difference between electrode types in the prevalence of P-wave and QRS complex abnormalities. Conclusion Recordings with prewired electrodes took significantly less time. Signal noise and baseline instability were significantly reduced. The time saved was not at the expense of the quality of the recording.
Abstract Study Objective To compare two brands of disposable plastic laryngoscope blades, Vital View plastic blades and Heine XP plastic blades, with the reusable Heine Classic+ Macintosh metal ...blades. Design Prospective randomized, controlled, single-blinded study. Setting Operating room of a university-affiliated hospital. Patients 519 patients without criteria for predicted difficult intubation, undergoing scheduled surgery during general anesthesia. Interventions Patients were randomized to three groups according to laryngoscope blade brand. Measurements Difficult tracheal intubation was evaluated by the Intubation Difficulty Scale (IDS) (IDS > 5 = procedure involving moderate to major difficulty). Main Results The percentage of intubations with an IDS > 5 was 3.1% in Group M (metal blade group), 5.1% in Group V (Vital View plastic blade group), and 10.0% in Group H (Heine plastic blade group). A significant difference was noted between Groups M and H ( P = 0.02) but not between Groups M and V. Conclusions Intubation may be more challenging when using Heine XP plastic blades but no significant difference exists between Vital-View plastic blades and Heine Classic+ metal blades.
Study objective The quality of endoscopy depends on the quality of upper gastrointestinal tract preparation. We determine whether in acute upper gastrointestinal bleeding the frequency of ...satisfactory stomach visualization was different after intravenous erythromycin, a nasogastric tube with gastric lavage, or both. Methods We performed a prospective, randomized, multicenter (6 emergency departments) study in patients with acute upper gastrointestinal bleeding presenting with hematemesis or melena. The patients were randomized into 3 groups: (1) intravenous erythromycin infusion without nasogastric tube placement (erythromycin group), (2) nasogastric tube placement without erythromycin (nasogastric group), and (3) intravenous erythromycin infusion combined with nasogastric tube placement (nasogastric-erythromycin group). The main outcome measure was the proportion of satisfactory stomach visualization. Results Two hundred fifty-three patients (181 men, mean age 61 years SD 15 years, 84 with cirrhosis) were randomized: 84 (erythromycin group), 85 (nasogastric group), and 84 (nasogastric-erythromycin group). Overall, there was 85% satisfactory stomach visualization; between-group differences were not significant: −4% (95% confidence interval CI −15% to 6%) for the erythromycin group and nasogastric-erythromycin group, 2% (95% CI −14% to 9%) for the erythromycin group and nasogastric group, and −6.5% (95% CI −17% to 4%) for the nasogastric group and nasogastric-erythromycin group. The duration of the endoscopic procedure, rebleeding frequency, the need for a second endoscopy, the number of transfused blood units, and mortality at days 2, 7, and 30 did not differ significantly between groups. Conclusion In acute upper gastrointestinal bleeding, administration of intravenous erythromycin provides satisfactory endoscopic conditions, without the need for a nasogastric tube and gastric lavage.
Acute attacks of hereditary angioedema are characterized by recurrent localized edema. These attacks can be life threatening and are associated with substantial morbidity and mortality.
To determine ...factors associated with hospital admission of patients with an acute attack of hereditary angioedema presenting at the emergency department.
This was a multicenter prospective observational study of consecutive patients (January 2011 through December 2013) experiencing an acute hereditary angioedema attack and presenting at the emergency department at 1 of 4 French reference centers for bradykinin-mediated angioedema. Attacks requiring hospital admission were compared with those not requiring admission.
Of 57 attacks in 29 patients, 17 (30%) led to hospital admission. In multivariate analysis, laryngeal and facial involvements were associated with hospital admission (odds ratio 18.6, 95% confidence interval 3.9-88; odds ratio 7.7, 95% confidence interval 1.4-43.4, respectively). Self-injection of icatibant at home was associated with non-admission (odds ratio 0.06, 95% confidence interval 0.01-0.61). The course was favorable in all 57 cases. No upper airway management was required.
Most patients attended the emergency department because they were running out of medication and did not know that emergency treatment could be self-administered. Risk factors associated with hospital admission were laryngeal and facial involvement, whereas self-injection of icatibant was associated with a return home.
