The themes of qualitative assessments that characterize the experience of family members offered the choice of observing cardiopulmonary resuscitation (CPR) of a loved one have not been formally ...identified.
In the context of a multicenter randomized clinical trial offering family members the choice of observing CPR of a patient with sudden cardiac arrest, a qualitative analysis, with a sequential explanatory design, was conducted. The aim of the study was to understand family members' experience during CPR. All participants were interviewed by phone at home three months after cardiac arrest. Saturation was reached after analysis of 30 interviews of a randomly selected sample of 75 family members included in the trial. Four themes were identified: 1- choosing to be actively involved in the resuscitation; 2- communication between the relative and the emergency care team; 3- perception of the reality of the death, promoting acceptance of the loss; 4- experience and reactions of the relatives who did or did not witness the CPR, describing their feelings. Twelve sub-themes further defining these four themes were identified. Transferability of our findings should take into account the country-specific medical system.
Family presence can help to ameliorate the pain of the death, through the feeling of having helped to support the patient during the passage from life to death and of having participated in this important moment. Our results showed the central role of communication between the family and the emergency care team in facilitating the acceptance of the reality of death.
Abstract Aim Relationship between cardiopulmonary arrest and resuscitation (CPR) durations and survival after out-of-hospital cardiac arrest (OHCA) remain unclear. Our primary aim was to determine ...the association between survival without neurologic sequelae and cardiac arrest intervals in the setting of witnessed OHCA. Methods We analyzed 27,301 non-traumatic, witnessed OHCA patients in France included in the national registry from June 1, 2011 through December 1, 2015. We analyzed cardiac arrest intervals, designated as no-flow (NF; from collapse to start of CPR) and low-flow (LF; from start of CPR to cessation of resuscitation) in relation to 30-day survival without sequelae. We determined the influence of recognized prognostic factors (age, gender, initial rhythm, location of cardiac arrest) on this relation. Results For the entire cohort, the area delimited by a value of NF greater than 12 min (95% confidence interval: 11–13 min) and LF greater than 33 min (95% confidence interval: 29–45 min), yielded a probability of 30-day survival of less than 1%. These sets of values were greatly influenced by initial cardiac arrest rhythm, age, sex and location of cardiac arrest. Extended CPR duration (greater than 40 min) in the setting of initial shockable cardiac rhythm is associated with greater than 1% survival with NF less than 18 min. The NF interval was highly influential on the LF interval regardless of outcome, whether return of spontaneous circulation (p < 0.001) or death (p < 0.001). Conclusion NF duration must be considered in determining CPR duration in OHCA patients. The knowledge of (NF, LF) curves as function of age, initial rhythm, location of cardiac arrest or gender may aid in decision-making vis-à-vis the termination of CPR or employment of advanced techniques.
Abstract
Background
In out-of-hospital cardiac arrest (OHCA), bystander initiated cardiopulmonary resuscitation (CPR) increases the chance of return of spontaneous circulation and survival with a ...favourable neurological status. Socioeconomic disparities have been highlighted in OHCA field. In areas with the lowest average socioeconomic status, OHCA incidence increased, and bystander CPR decreased. Evaluations were performed on restricted geographical area, and European evaluation is lacking. We aimed to analyse, at a national level, the impact of area-level social deprivation on the initiation of CPR in case of a witnessed OHCA.
Methods
We included all witnessed OHCA cases with age over 18 years from July 2011 to July 2018 form the OHCA French national registry. We excluded OHCA occurred in front of rescue teams or in nursing home, and patients with incomplete address or partial geocoding. We collected data from context, bystander and patient. The area-level social deprivation was estimated by the French version of the European Deprivation Index (in quintile) associated with the place where OHCA occurred. We assessed the associations between Utstein variables and social deprivation level using a mixed-effect logit model with bystander-initiated CPR.
Results
We included 23,979 witnessed OHCA of which 12,299 (51%) had a bystander-initiated CPR. More than one third of the OHCA (8,326 (35%)) occurred in an area from the highest quintile of social deprivation. The higher the area-level deprivation, the less the proportion of bystander-initiated CPR (56% in Quintile 1 versus 48% in Quintile 5). The In the multivariable analysis, bystander less often began CPR in areas with the highest deprivation level, compared to those with the lowest deprivation level (OR=0.69, IC95%: 0.63-0.75).
Conclusions
The level of social deprivation of the area where OHCA occurred was associated with bystander-initiated CPR. It decreased in the more deprived areas although these areas also concentrate more younger patients.
Patients in the garadacimab group had a better quality of life observed at 1 month and 6 months compared with patients in the placebo group. The mean Angioedema Quality-of-Life (AE-QoL) questionnaire ...total score at day 182 was lower in the garadacimab group than in the placebo group (23·7-point reduction from the run-in period in the garadacimab group and less than a 6-point mean reduction in the placebo group). The intrinsic strengths of this study are: a strong methodology and design (randomised controlled trial), inclusion of patients aged 12 years and older, an investigator-assessed primary endpoint, and secondary endpoints that investigated quality of life.
The coronavirus disease-2019 (COVID-19) pandemic has imposed unforeseen and unprecedented constraints on emergency departments (EDs). In this study, we detail the organizational and managerial tools ...recently implemented among 5 academic EDs in a French region particularly affected by COVID-19 and analyze how EDs responded to the COVID-19-related disease burden during different phases of the epidemic. Initially, they focused on the early detection of suspected cases by identifying 3 predominant COVID-19 syndromes. During this diagnostic process, patients were placed in respiratory isolation (facial mask before triage) and droplet isolation (ED rooms). A 3-level strategy for triage, clinical pathways in the EDs, and the organization of hospital spaces was based on the real-time polymerase chain reaction (RT-PCR) COVID-19 positivity rate, with ED strategies adapted to the exigencies of each level. This crisis demonstrated hospitals' adaptability and capacity to mobilize in the face of new risks, with hospitals and EDs coordinating their management to reallocate resources, optimize interoperability, and rethink patient pathways. This report on their processes may assist hospitals and EDs in areas currently spared by the new variants.
The growing need for emergency imaging has greatly increased the number of conventional X-rays, particularly for traumatic injury. Deep learning (DL) algorithms could improve fracture screening by ...radiologists and emergency room (ER) physicians. We used an algorithm developed for the detection of appendicular skeleton fractures and evaluated its performance for detecting traumatic fractures on conventional X-rays in the ER, without the need for training on local data. This algorithm was tested on all patients (N = 125) consulting at the Louis Mourier ER in May 2019 for limb trauma. Patients were selected by two emergency physicians from the clinical database used in the ER. Their X-rays were exported and analyzed by a radiologist. The prediction made by the algorithm and the annotation made by the radiologist were compared. For the 125 patients included, 25 patients with a fracture were identified by the clinicians, 24 of whom were identified by the algorithm (sensitivity of 96%). The algorithm incorrectly predicted a fracture in 14 of the 100 patients without fractures (specificity of 86%). The negative predictive value was 98.85%. This study shows that DL algorithms are potentially valuable diagnostic tools for detecting fractures in the ER and could be used in the training of junior radiologists.
Objective There appears to be differences in the clinical presentation of hereditary angioedema (HAE) and angiotensin-converting enzyme inhibitor-induced (ACE-I) angioedema (AE). The aim of this ...study was to compare the clinical characteristics of these two AE forms. Methods We conducted a retrospective study of consecutive patients with HAE or ACE-I AE. The attack characteristics experienced by the patients were compared by a logistic regression analysis using generalized estimating equations. Results A total of 56 patients were included in this study (ACE-I AE, n=25; HAE, n=31). A total of 534 attacks were documented. Severe attacks were more common in the patients who had an acute episode of ACE-I AE than HAE. Swelling of the tongue, lips and larynx were significantly associated with ACE-I AE OR: 8.70 (95% CI, 1.04-73.70), OR: 20.4 (95% CI, 4.9-84.2) and OR: 7.50 (95% CI, 1.20-48.30), respectively. Conclusion Swelling of the tongue, lips and larynx are significantly more frequent in drug-induced AE than HAE.
The benefit of corticosteroids in acute urticaria is controversial. Our objective was to determine the factors associated with relapses in patients presenting with acute urticaria. A retrospective ...observational study, including all patients with acute urticaria who visited the angioedema reference center of Academic Public Hospitals – Saint‐Antoine in Paris between January 2015 and June 2017, was conducted. The study inclusion criterion was a diagnosis of acute urticaria in an adult patient. The urticaria was spontaneous or inducible urticaria. The primary outcome was relapse at day 7 and the secondary outcome was relapse at week 6. A total of 184 patients with a first episode of acute urticaria were included. Most of the patients were female (66%) with a mean age of 42 ± 16 years. Corticosteroid administration for treatment of acute urticaria was used in 102 (55%) patients. Overall, 85 (46%) patients had relapses after less than 7 days whereas 168 (91%) patients had relapses after more than 6 weeks. In univariate analysis, the rate of corticosteroid administration was significantly higher in cases of relapse after less than 7 days. No difference in relapse rates after more than 6 weeks appeared. In the multivariate analysis, the independent factor associated with relapses after less than 7 days was the administration of corticosteroids as treatment of acute urticaria (odds ratio, 1.93; 95% confidence interval, 1.06–3.57; P = 0.03). The prevalence of corticosteroid administration for patients with acute urticaria was high. Corticosteroid administration was an independent risk factor associated with relapses after less than 7 days.
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.
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