Hypothermie accidentelle Pasquier, M.; Blancher, M.
Annales françaises de médecine d'urgence,
09/2019, Letnik:
9, Številka:
5
Journal Article
Recenzirano
L’hypothermie accidentelle est définie comme une baisse non intentionnelle de la température centrale du corps en dessous de 35 °C. La prévention de l’hypothermie est essentielle. La mesure de la ...température centrale est nécessaire au diagnostic d’hypothermie et permet d’en juger la sévérité. En présence de signes de vie, et en présence d’une hypothermie pure, l’instabilité hémodynamique apparente ne devrait en principe pas faire l’objet d’une prise en charge spécifique. Un risque d’arrêt cardiaque (AC) est présent si la température chute en dessous de 30–32 °C. En raison du risque d’AC, un patient hypotherme devrait bénéficier de l’application d’un monitoring avant toute mobilisation, laquelle devra être prudente. En cas d’AC, seule la mesure de la température oesophagienne est fiable. Si l’hypothermie est suspectée comme étant potentiellement responsable de l’AC du patient, celui-ci doit être transporté sous réanimation cardiopulmonaire vers un hôpital disposant d’une méthode de réchauffement par circulation extracorporelle (CEC). La valeur de la kaliémie ainsi que les autres paramètres à disposition (âge, sexe, valeur de la température corporelle, durée du low flow, présence d’une asphyxie) permettront de décider de l’indication d’une CEC de réchauffement. Le pronostic des patients victimes d’un AC sur hypothermie est potentiellement excellent, y compris sur le plan neurologique.
Accidental hypothermia is an unexpected decrease of core temperature (CT) of less than 35 °C. A protective strategy from cold exposure is a crucial attitude. Temperature measurement is essential for diagnosing hypothermia and assessing severity. During non-trauma related cold exposure, several adaptive processes will slowly and physiologically affect vital signs. For patients with severe hypothermia and vital signs, hemodynamic and neurological instability should not benefit from any specific treatment. Cardiac arrest (CA) may occur if CT decreases under 30–32 °C. Due to high risks of CA during movements (rescue collapse), any hypothermic patient should be monitored for vital signs before any mobilization. Hypothermic patients should always be moved carefully. In case of CA, only oesophagus core temperature measurement is relevant. If hypothermia is suspected to be the cause of CA, continuous cardiopulmonary resuscitation should be performed. Patients should be transported to a medical center with extracorporeal life support (ECLS) facilities. Setting up ECLS will mostly depend on potassium rate but other factors will also have to be taken into account (age, gender, CT value, low flow duration, and possible asphyxia). Hypothermic CA outcome is potentially excellent, along with full neurological recovery.
Cardiac arrest related to accidental hypothermia may occur at temperatures below 32 °C. Our goal was to describe the clinical characteristics and outcomes of patients who suffered from witnessed ...hypothermic cardiac arrest (CA) and assess the occurrence of hypothermic CA as a function of patient body temperature.
We conducted a systematic review of the literature on cases of hypothermic CA due to rescue collapse. Patient information data from hypothermic CA patients were collected and combined with additional unpublished data to assess the clinical characteristics and outcome of hypothermic CA patients.
A total of 214 patients was included in this systematic review. Of the 206 witnessed hypothermic CA patients with a recorded body temperature, the average body temperature was 23.9 ± 2.7 °C with five patients (2.4%) having a core body temperature of >28 °C. The highest temperature of a patient surviving hypothermic witnessed cardiac arrest without other associated risk factors for cardiac arrest was 29.4 °C. The first recorded cardiac rhythm was asystole in 33 of the 112 patients (30%) for whom this information was available. The survival rate at hospital discharge of these hypothermic cardiac arrest patients was 73% (153 of 210 patients) and most survivors had favourable neurological outcome (89%; 102 of 105 patients).
CA that is solely caused by hypothermia did not occurs for patients with a body temperature >30 °C. Our findings provide valuable new information that can be incorporated into the international clinical management guidelines of accidental hypothermia.
The International Commission for Mountain Emergency Medicine (ICAR MedCom) developed updated recommendations for the management of avalanche victims.
ICAR MedCom created Population Intervention ...Comparator Outcome (PICO) questions and conducted a scoping review of the literature. We evaluated and graded the evidence using the American College of Chest Physicians system.
We included 120 studies including original data in the qualitative synthesis. There were 45 retrospective studies (38%), 44 case reports or case series (37%), and 18 prospective studies on volunteers (15%). The main cause of death from avalanche burial was asphyxia (range of all studies 65–100%). Trauma was the second most common cause of death (5–29%). Hypothermia accounted for few deaths (0–4%).
For a victim with a burial time ≤ 60 minutes without signs of life, presume asphyxia and provide rescue breaths as soon as possible, regardless of airway patency. For a victim with a burial time > 60 minutes, no signs of life but a patent airway or airway with unknown patency, presume that a primary hypothermic CA has occurred and initiate cardiopulmonary resuscitation (CPR) unless temperature can be measured to rule out hypothermic cardiac arrest. For a victim buried > 60 minutes without signs of life and with an obstructed airway, if core temperature cannot be measured, rescuers can presume asphyxia-induced CA, and should not initiate CPR. If core temperature can be measured, for a victim without signs of life, with a patent airway, and with a core temperature < 30 °C attempt resuscitation, regardless of burial duration.
The end-tidal carbon dioxide (ETCO2) is frequently measured in cardiac arrest (CA) patients, for management and for predicting survival. Our goal was to study the PaCO2 and ETCO2 in hypothermic ...cardiac arrest patients.
We included patients with refractory CA assessed for extracorporeal cardiopulmonary resuscitation. Hypothermic patients were identified from previously prospectively collected data from Poland, France and Switzerland. The non-hypothermic CA patients were identified from two French cohort studies. The primary parameters of interest were ETCO2 and PaCO2 at hospital admission. We analysed the data according to both alpha-stat and pH-stat strategies.
We included 131 CA patients (39 hypothermic and 92 non-hypothermic). Both ETCO2 (p < 0.001) and pH-stat PaCO2 (p < 0.001) were significantly lower in hypothermic compared to non-hypothermic patients, which was not the case for alpha-stat PaCO2 (p = 0.15). The median PaCO2-ETCO2 gradient was greater for hypothermic compared to non-hypothermic patients when using the alpha-stat method (46 mmHg vs 30 mmHg, p = 0.007), but not when using the pH-stat method (p = 0.10). Temperature was positively correlated with ETCO2 (p < 0.01) and pH-stat PaCO2 (p < 0.01) but not with alpha-stat PaCO2 (p = 0.5). The ETCO2 decreased by 0.5 mmHg and the pH-stat PaCO2 by 1.1 mmHg for every decrease of 1° C of the temperature. The proportion of survivors with an ETCO2 ≤ 10 mmHg at hospital admission was 45% (9/25) for hypothermic and 12% (2/17) for non-hypothermic CA patients.
Hypothermic CA is associated with a decrease of the ETCO2 and pH-stat PaCO2 compared with non-hypothermic CA. ETCO2 should not be used in hypothermic CA for predicting outcome.
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 date, the decision to set up therapeutic extra-corporeal life support (ECLS) in hypothermia-related cardiac arrest is based on the potassium value only. However, no information is available about ...how the analysis should be performed. Our goal was to compare intra-individual variation in serum potassium values depending on the sampling site and analytical technique in hypothermia-related cardiac arrests.
Adult patients with suspected hypothermia-related refractory cardiac arrest, admitted to three hospitals with ECLS facilities were included. Blood samples were obtained from the femoral vein, a peripheral vein and the femoral artery. Serum potassium was analysed using blood gas (BGA) and clinical laboratory analysis (CL).
Of the 15 consecutive patients included, 12 met the principal criteria, and 5 (33%) survived. The difference in average potassium values between sites or analytical method used was ≤1 mmol/L. The agreement between potassium values according to the three different sampling sites was poor. The ranges of the differences in potassium using BGA measurement were - 1.6 to + 1.7 mmol/L; - 1.18 to + 2.7 mmol/L and - 0.87 to + 2 mmol/L when comparing respectively central venous and peripheral venous, central venous and arterial, and peripheral venous and arterial potassium.
We found important and clinically relevant variability in potassium values between sampling sites. Clinical decisions should not rely on one biological indicator. However, according to our results, the site of lowest potassium, and therefore the preferred site for a single potassium sampling is central venous blood. The use of multivariable prediction tools may help to mitigate the risks inherent in the limits of potassium measurement.
ClinicalTrials.gov Identifier: NCT03096561.
La transfusion de produits sanguins labiles demeure souvent nécessaire au cours d’une chirurgie cardiaque mais son utilisation doit être restreinte à cause de ses effets secondaires. L’administration ...via le circuit de circulation extracorporelle (CEC) des produits sanguins permet une transfusion aisée et rapide. Le recours aux culots globulaires pendant la CEC est relativement fréquent du fait de l’hémodilution secondaire à la CEC et de l’augmentation des complications postopératoires lorsque l’hématocrite per-CEC diminue en dessous de 20 %. Cette transfusion de culots globulaires ne semble pas s’accompagner de complications per-CEC. L’apport de concentrés plaquettaires durant la CEC est illogique du fait de la destruction des plaquettes pendant la CEC et doit être proscrite. La transfusion de plasma frais congelé pendant la CEC est rarement indiquée mais elle est possible. Elle permet de diminuer la résistance à l’héparine.
Cardiac surgery frequently requires blood transfusion. The use of transfusion should be restricted due to side effects. Blood transfusion via the cardiopulmonary bypass (CPB) circuit is easy and allows a fast transfusion. The administration of packed red cells is relatively frequent because of the CPB-induced hemodilution and of the higher rate of postoperative complications when the haematocrit during CPB decreases below 20%. This transfusion of packed red cells does not seem to be associated with complications during CPB. Platelet transfusion during bypass is illogical because of the destruction of platelets during CPB and must be avoided. Fresh frozen plasma transfusion during CPB is seldom indicated but is possible. It could reverse heparin resistance.
Bronchopleural fistula (BPF) is a feared postoperative complication of pneumonectomy that carries significant morbidity and mortality. BPF can be treated by various surgical and medical techniques. ...Endobronchial techniques have been used for the delivery of biological glue, sealants, coils, and covered stents with variable degrees of success, depending on the size of the fistula. A recent case report described the endobronchial closure of a BPF through the implantation of an Amplatzer ASD device, commonly used for transcatheter closure of atrial septal defects. In this case report, we describe closure of a BFP using the Amplatzer PFO device.
In order to confirm the validity of the Pneumonia Severity Index (PSI) for patients in Europe, data from adults with pneumonia who were enrolled in two prospective multicentre studies, conducted in ...France (Pneumocom-1, n = 925) and Spain (Pneumocom-2, n = 853), were compared with data from the original North American study (Pneumonia PORT, n = 2287). The primary outcome was 28-day mortality; secondary outcomes were subsequent hospitalisation for outpatients, and intensive care unit admission and length of stay for inpatients. All outcomes within individual risk classes, and mortality rates in low-risk (PSI I–III) and higher-risk patients, were compared across the three cohorts. Overall mortality rates were 4.7% in Pneumonia PORT, 6.3% in Pneumocom-2 and 10.6% in Pneumocom-1 (p <0.01), ranging from 0.4% to 1.6% (p 0.06) for low-risk patients and from 13.0% to 19.1% (p 0.24) for high-risk patients. Despite significant differences in baseline patient characteristics, none of the study outcomes differed within the low-risk classes. The sensitivity and negative predictive value of low-risk classification for mortality exceeded 93% and 98%, respectively. Thus, in two independent European cohorts, the PSI predicted patient outcomes accurately and reliably, particularly for low-risk patients. These findings confirm the validity of the PSI when applied to patients from Europe.
Il est communément admis que l’aponévrotomie percutanée à l’aiguille ne doit pas être réalisée au niveau digital en raison des risques de lésion nerveuse iatrogène. Le but de cette étude est de ...vérifier si l’aponévrotomie percutanée à l’aiguille digitale est responsable ou non de complication sensitive par lésion des nerfs collatéraux, grâce à l’analyse sensitive précise d’une série de vingt-cinq aponévrotomies palmodigitales ou digitales pures. Notre série comportait 20 patients opérés entre septembre 2006 et juin 2008, soit un total de 25 doigts. Seul un patient présentait des troubles sensitifs préopératoires. Il s’agissait d’un doigt multiopéré. Les patients ont été opérés en ambulatoire par deux chirurgiens seniors par aponévrotomie percutanée étagée palmodigitale. L’analyse des résultats a consisté à étudier au dernier recul la douleur, la fonction globale du membre supérieur, la sensibilité discriminative par le test statique des deux points de Weber, et le test des monofilaments de Semmes Weinstein. Le recul postopératoire moyen était de dix mois. La douleur était en moyenne de 1,8 sur 10 et le
quick DASH score de 19,77 sur 100. L’analyse statistique des tests de sensibilité discriminative a montré qu’il n’existait pas de différence significative dans la moyenne des résultats entre l’hémipulpe du doigt opéré et celle du doigt non opéré (test de Weber 0,1
<
p
<
0,5 ; test de Semmes Weinstein 0,5
<
p
<
1). Un seul patient avait un mauvais résultat à la fois au Weber et au Semmes Weinstein. Il s’agissait d’un patient multiopéré. Notre étude montre que l’aponévrotomie digitale percutanée à l’aiguille n’entraîne aucun trouble sensitif. Par conséquent, il est possible d’étendre les indications d’aponévrotomie percutanée à l’aiguille de la maladie de Dupuytren dans la région digitale.
It is well known that percutaneous fasciotomy must not be realized at the digital level because of the risks of iatrogenic nervous injury. The purpose of this study is to verify if the percutaneous fasciotomy in the digital level is responsible or not for sensory complication by injury of the collateral nerves, thanks to the precise sensory analysis of a series of twenty five palmodigital or digital fasciotomies. Our series included 20 patients operated on between September 2006 and June 2008, as a total of 25 fingers. Only one patient presented preoperative sensory disorders. It was a multi-operated finger. The patients were operated on in one-day surgery by two senior surgeons using percutaneous fasciotomy in the palm and the digit. The analysis of the results consisted in studying at follow-up pain, DASH score, and discriminative sensibility by the static test of Weber, and the test of mono strands of Semmes Weinstein. The postoperative average follow-up was of 10 months. The pain was on average 1.8/10 and the DASH score of 19.77/100. The statistical analysis of the discriminative sensibility showed that there was no significant difference in the average of the results between the hemi-pulp of the operated finger and that of the not operated finger (test of Weber 0.1
<
p
<
0.5; test of Semmes Weinstein 0.5
<
p
<
1). A single patient had a bad result at the same time in the Weber and in the Semmes Weinstein. It was a patient operated on several times. Our study shows that the digital percutaneous fasciotomy provokes no sensory disorder. Consequently, it is possible to spread the indications of percutaneous fasciotomy to Dupuytren's contracture in the digital region.
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