Efficient ventilation is important during cardiopulmonary resuscitation (CPR). Nevertheless, there is insufficient knowledge on how the patient’s position affects ventilatory parameters during ...mechanically assisted CPR. We studied ventilatory parameters at different positive end-expiratory pressure (PEEP) levels and when using an inspiratory impedance valve (ITD) during horizontal and head-up CPR (HUP-CPR).
In this human cadaver experimental study, we measured tidal volume (VT) and pressure during CPR at different randomized PEEP levels (0, 5 or 10 cmH2O) or with an ITD. CPR was performed, in the following order: horizontal (FLAT), at 18° and then at 35° head-thorax elevation. During the inspiratory phase we measured the net tidal volume (VT) adjusted to predicted body weight (VTPBW), reversed airflow (RAF), and maximum and minimum airway pressure (Pmax and Pmin).
Using ten thawed fresh-frozen cadavers we analyzed the inspiratory phase of 1843 respiratory cycles, 229 without CPR and 1614 with CPR. In a mixed linear model, thoracic position and PEEP significantly impacted VTPBW (p < 0.001 for each), and the insufflation time, thoracic position and PEEP significantly affected the RAF (p < 0.001 for each) and Pmax (p < 0.001). For Pmin, only PEEP was significant (p < 0.001). In subgroup analysis, at 35° VTPBW and Pmax were significantly reduced compared with the flat or 18° position.
When using mechanical ventilation during CPR, it seems that the PEEP level and patient position are important determinants of respiratory parameters. Moreover, tidal volume seems to be lower when the thorax is positioned at 35°.
Mountainous areas pose a challenge for the out-of-hospital cardiac arrest (OHCA) chain of survival. Survival rates for OHCAs in mountainous areas may differ depending on the location. Increased ...survival has been observed compared to standard location when OHCA occurred on ski slopes. Limited data is available about OHCA in other mountainous areas. The objective was to compare the survival rates with a good neurological outcome of OHCAs occurring on ski slopes (On-S) and off the ski slopes (OffS) compared to other locations (OL).
Analysis of prospectively collected data from the cardiac arrest registry of the Northern French Alps Emergency Network (RENAU) from 2015 to 2021. The RENAU corresponding to an Emergency Medicine Network between all Emergency Medical Services and hospitals of 3 counties (Isère, Savoie, Haute-Savoie). The primary outcome was survival at 30 days with a Cerebral Performance Category scale (CPC) of 1 or 2 (1: Good Cerebral Performance, 2: Moderate Cerebral Disability).
A total of 9589 OHCAs were included: 213 in the On-S group, 141 in the Off-S group, and 9235 in the OL group. Cardiac etiology was more common in On-S conditions (On-S: 68.9% vs OffS: 51.1% vs OL: 66.7%, p < 0.001), while Off-S cardiac arrests were more often due to traumatic circumstances (OffS: 39.7% vs On-S: 21.7% vs OL: 7.7%, p < 0.001). Automated external defibrillator (AED) use before rescuers' arrival was lower in the Off-S group than in the other two groups (On-S: 15.2% vs OL: 4.5% vs OffS: 3.7%; p < 0.002). The first AED shock was longer in the Off-S group (median time in minutes: OffS: 22.0 (9.5–35.5) vs On-S: 10.0 (3.0–19.5) vs OL: 16.0 (11.0–27.0), p = 0.03). In multivariate analysis, on-slope OHCA remained a positive factor for 30-day survival with a CPC score of 1 or 2 with a 1.96 adjusted odds ratio (95% confidence interval (CI), 1.02–3.75, p = 0.04), whereas off-slope OHCA had an 0.88 adjusted odds ratio (95% CI, 0.28–2.72, p = 0.82).
OHCAs in ski-slopes conditions were associated with an improvement in neurological outcomes at 30 days, whereas off-slopes OHCAs were not. Ski-slopes rescue patrols are efficient in improving outcomes.
To provide an overview of cadaver models for cardiac arrest and to identify the most appropriate cadaver model to improve cardiopulmonary resuscitation through a systematic review.
The search ...strategy included PubMed, Embase, Current contents, Pascal, OpenSIGLE and reference tracking. The search concepts included “heart arrest”, “cardiopulmonary resuscitation” and “cadavers”. All studies, published until February 2019, in English or French, on research or simulation in the field of cardiac arrest and using cadaver models were eligible for inclusion.
Overall, 29 articles out of the 244 articles located were selected. The characteristics of the studies and the cadaver models were heterogenous. Indeed, 31% of the studies lacked a proper description of the model used and its specificities. Fresh cadavers were used in 55% of the studies and chest compressions were performed in 90%. This model was appreciated for its realism in terms of mechanical properties and tissue conservation. Thiel-embalmed cadavers also showed promising results concerning lung and chest compliance. The lack of circulation stood out as the strongest limitation of all types of human cadaver models.
Four types of cadaver models are used in cardiac arrest research. The great heterogeneity of these models coupled with unequal quality in reporting makes comparisons between studies difficult. There is a need for uniform reporting and standardisation of human cadaver models in cardiac arrest research.
Early airway management during cardiopulmonary resuscitation (CPR) prevents aspiration of gastric contents. Endotracheal intubation is the gold standard to protect airways, but supraglottic airway ...devices (SGA) may provide some protection with less training. Bag-mask ventilation (BMV) is the most common method used by rescuers. We hypothesized that SGA use by first rescuers during CPR could increase ventilation success rate and also decrease intragastric pressure and pulmonary aspiration.
We performed a randomized cross-over experimental trial on human cadavers. Protocol A: we assessed the rate of successful ventilation (chest rise), intragastric pressure, and CPR key time metrics. Protocol B: cadaver stomachs were randomized to be filled with 300 mL of either blue or green serum saline solution through a Foley catheter. Each rescuer was randomly assigned to use SGA or BMV during a 5-minute standard CPR period. Then, in a crossover design, the stomach was filled with the second color solution and another 5-minute CPR period was performed using the other airway method. Pulmonary aspiration, defined as the presence of colored solution below the vocal cords, was assessed by a blinded operator using bronchoscopy. A generalized linear mixed model was used for statistical analysis.
Protocol A: Forty-eight rescuers performed CPR on 11 cadavers. Median ventilation success was higher with SGA than BMV: 75.0% (IQR: 59.8-87.3) vs. 34.7% (IQR: 25.0-50.0), (p = 0.003). Gastric pressure and differential (maximum minus minimum) gastric pressure were lower in the SGA group: 2.21 mmHg (IQR: 1.66; 2.68) vs. 3.02 mmHg (IQR: 2.02; 4.22) (p = 0.02) and 5.70 mmHg (IQR: 4.10; 7.60) vs. 8.05 mmHg (IQR: 5.40; 11.60) (p = 0.05). CPR key times were not different between groups. Protocol B: Ten cadavers were included with 20 CPR periods. Aspiration occurred in 2 (20%) SGA procedures and 5 (50%) BMV procedures (p = 0.44).
Use of SGA by rescuers improved the ventilation success rate, decreased intragastric pressure, and did not affect key CPR metrics. SGA use by basic life support rescuers appears feasible and efficient.
Introduction
: La première promotion d’internes de diplôme d’études spécialisées (DES) de médecine d’urgence est arrivée en novembre 2020 sur un statut inédit de Docteur Junior. De par leur ...nouveauté, il apparaît intéressant d’évaluer la satisfaction et la formation de cette promotion.
Matériel et méthodes
: Une enquête nationale a été réalisée par les membres de la Commission jeunes de la SFMU et diffusée via les réseaux sociaux et les coordonnateurs de DES. Le questionnaire était composé d’une partie sociodémographique, d’une partie sur l’enseignement reçu, une sur les points positifs et négatifs de la maquette et une sur les choix de stage de Docteur Junior. Les variables qualitatives étaient exprimées en pourcentage. Les variables quantitatives étaient exprimées par une moyenne et un écart-type.
Résultats
: Sur les 460 étudiants ayant choisi le DESMU en 2017, 142 (31 %) réponses ont été obtenues pour un âge moyen de 28 (± 2) ans, 73 étaient des hommes (51 %), 72 travaillaient en CHU (51 %). Les éléments de choix les plus évoqués sont l’ambiance de l’équipe et la réalisation d’un stage antérieur dans le service. Les étudiants ont bénéficié majoritairement de cours magistraux présentiels et de simulation. Le choix de l’appariement a été respecté pour 86 % des cas. La majorité des étudiants ne souhaite retirer aucun stage de la maquette.
Conclusion
: Les internes sont majoritairement satisfaits de leur formation et de l’appariement. Ils choisissent leur lieu de stage de Docteur Junior en fonction de précédents stages dans la structure et d’une bonne ambiance dans l’équipe.
Introduction
: The first promotion of emergency medicine residency arrived in November 2020 with a new status named “Junior Doctor”. Due to their novelty, it seems interesting to assess the satisfaction, training, and desire for a future career of this population.
Methods
: A national survey was performed by the youth commission of the French Society of Emergency Medicine and disseminated using social networks and local teachers. The survey was composed of a sociodemographic part, a part on the teaching received during residency, and a part on the positive and negative points of the new residency program. Qualitative variables were expressed as a number (percentage). Quantitative variables were expressed using mean and standard deviation.
Results
: Of the 460 students who choose emergency medicine residency in 2017, 142 (31%) responses were obtained for an average age of 28 (± 2) years old, 73 were men (51%), 72 worked in university hospital (51%). Friendship in the team and a previous internship in the department were the main factors of the choice. The students mainly benefited from face-to-face lectures and simulation. The choice of matching was respected for 86% of cases. Most students do not wish to remove any internship location from the model.
Conclusion
: The residents are mostly satisfied with their training and matching. They choose their place of “Junior Doctor” internship based on previous internships in the structure and a good atmosphere in the team.
Adrenaline is recommended during cardio-pulmonary resuscitation. The optimal dose remains debated, and the effect of lower than recommended dose is unknown.
To compare the outcome of patients treated ...with the recommended, lower or higher cumulative doses of adrenaline.
Patients were included from the French National Cardiac Arrest Registry and were grouped based on the received dose of adrenaline: recommended, higher and lower dose.
The primary endpoint was good neurologic outcome at 30 days post-OHCA, defined by a cerebral performance category (CPC) of less than 3. Secondary endpoints included return of spontaneous circulation and survival to hospital discharge. A multiple propensity score adjustment approach was performed.
27 309 patients included from July 1st 2011 to January 1st 2019 were analysed, mean age was 68 (57-78) years and 11.2% had ventricular fibrillation. 588 (2.2%) patients survived with a good CPC score. After adjustment, patients in the high dose group had a significant lower rate of good neurologic outcome (OR, 0.6; 95% CI, 0.5-0.7). There was no significant difference for the primary endpoint in the lower dose group (OR, 0.8; 95% CI, 0.7-1.1). There was a lower rate of survival to hospital discharge in the high-dose group vs. standard group (OR, 0.5; 95% CI, 0.5-0.6).
The use of lower doses of adrenaline was not associated with a significant difference on survival good neurologic outcomes at D30. But a higher dose of adrenaline was associated with a lower rate of survival with good neurological outcomes and poorer survival at D30.
The innate immune system responds not only to bacterial signals, but also to non-infectious danger-associated molecular patterns that activate the NLRP3 inflammasome complex after tissue injury. ...Immune functions vary over the course of the day, but it is not clear whether these changes affect the activity of the NLRP3 inflammasome. We investigated whether the core clock component nuclear receptor subfamily 1 group D member 1 (NR1D1, also called Rev-erbα) regulates expression, activity of the NLRP3 inflammasome, and its signaling pathway.
We collected naïve peritoneal macrophages and plasma, at multiple times of day, from Nr1d1–/– mice and their Nr1d1+/+ littermates (controls) and analyzed expression NLRP3, interleukin 1β (IL1B, in plasma), and IL18 (in plasma). We also collected bone marrow–derived primary macrophages from these mice. Levels of NR1D1 were knocked down with small hairpin RNAs in human primary macrophages. Bone marrow–derived primary macrophages from mice and human primary macrophages were incubated with lipopolysaccharide (LPS) to induce expression of NLRP3, IL1B, and IL18; cells were incubated with LPS and adenosine triphosphate to activate the NLRP3 complex. We analyzed caspase 1 activity and cytokine secretion. NR1D1 was activated in primary mouse and human macrophages by incubation with SR9009; some of the cells were also incubated with an NLRP3 inhibitor or inhibitors of caspase 1. Nr1d1–/– mice and control mice were given intraperitoneal injections of LPS to induce peritoneal inflammation; plasma samples were isolated and levels of cytokines were measured. Nr1d1–/– mice, control mice, and control mice given injections of SR9009 were given LPS and D-galactosamine to induce fulminant hepatitis and MCC950 to specifically inhibit NLRP3; plasma was collected to measure cytokines and a marker of liver failure (alanine aminotransferase); liver tissues were collected and analyzed by quantitative polymerase chain reaction, immunohistochemistry, and flow cytometry.
In peritoneal macrophages, expression of NLRP3 and activation of its complex varied with time of day (circadian rhythm)—this regulation required NR1D1. Primary macrophages from Nr1d1–/– mice and human macrophages with knockdown of NR1D1 had altered expression patterns of NLRP3, compared to macrophages that expressed NR1D1, and altered patterns of IL1B and 1L18 production. Mice with disruption of Nr1d1 developed more-severe acute peritoneal inflammation and fulminant hepatitis than control mice. Incubation of macrophage with the NR1D1 activator SR9009 reduced expression of NLRP3 and secretion of cytokines. Mice given SR9009 developed less-severe liver failure and had longer survival times than mice given saline (control).
In studies of Nr1d1–/– mice and human macrophages with pharmacologic activation of NR1D1, we found NR1D1 to regulate the timing of NLRP3 expression and production of inflammatory cytokines by macrophages. Activation of NR1D1 reduced the severity of peritoneal inflammation and fulminant hepatitis in mice.
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Long-term granulocyte-colony stimulating factor treatment has been shown to be safe and effective in severe chronic neutropenia patients. However, data on its use during pregnancy are limited. To ...address this issue, we analyzed all pregnancies reported to the European branch of the Severe Chronic Neutropenia International Registry since 1994. A total of 38 pregnancies in 21 women with chronic neutropenia (16 pregnancies in 10 women with congenital, 10 in 6 women with cyclic, 12 in 5 women with idiopathic neutropenia) were reported. Granulocyte-colony stimulating factor was administered throughout pregnancy in 16 women and for at least one trimester in a further 5 women. No major differences were seen between treated and untreated women with respect to pregnancy outcome, newborn complications and infections. In addition, we evaluated the genetic transmission of known or suspected genetic defects in 16 mothers having 22 newborns as well as in 8 men fathering 15 children. As a proof of inheritance, neutropenia was passed on to the newborn in 58% from female and in 62% from male patients with ELANE mutations, but also to some newborns from parents with unknown gene mutation. Based on our results, granulocyte-colony stimulating factor therapy has been shown to be safe for mothers throughout pregnancies and for newborns without any signs of teratogenicity. With an increasing number of adult patients, genetic counseling prior to conception and supportive care of mothers during pregnancy are crucial. The acceptance of having affected children may reflect the high quality of life obtained due to this treatment.
Brief contact interventions (BCIs) might be reliable suicide prevention strategies. BCI efficacy trials, however, gave equivocal results. AlgoS trial is a composite BCI that yielded inconclusive ...results when analyzed with Intention-To-Treat strategy. In order to elicit intervention strengths and weaknesses, post-hoc analyses of AlgoS data were performed.
AlgoS was a randomized controlled trial conducted in 23 French hospitals. Suicide attempters were randomly assigned to either the intervention group (AlgoS) or the control group (Treatment as usual TAU). In the AlgoS arm, first-time suicide attempters received crisis cards; non first-time suicide attempters received a phone call, and post-cards if the call could not be completed, or if the participant was in crisis and/or non-compliant with the post-discharge treatment. An As Treated strategy, accounting for the actual intervention received, was combined with subgroup analyses.
1,040 patients were recruited and randomized into two groups of N = 520, from which 53 withdrew participation; 15 were excluded after inclusion/exclusion criteria reassessment. AlgoS first attempters were less likely to reiterate suicide attempt (SA) than their TAU counterparts at 6 and 13-14 months (RR 95% CI: 0.46 0.25-0.85 and 0.50 0.31-0.81 respectively). AlgoS non-first attempters had similar SA rates as their TAU counterparts at 6 and 13-14 months (RR 95% CI: 0.84 0.57-1.25 and 1.00 0.73-1.37 respectively). SA rates were dissimilar within the AlgoS non-first attempter group.
This new set of analysis suggests that crisis cards could be efficacious to prevent new SA attempts among first-time attempters, while phone calls were probably not significantly efficacious among multi-attempters. Importantly, phone calls were informative of new SA risk, thus a key component of future interventions.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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