Safety of hyperbaric oxygen therapy in mechanically ventilated patients.

BACKGROUND: To evaluate the epidemiology of patients who require mechanical ventilation during hyperbaric oxygen therapy. MATERIALS AND METHODS: One-hundred-fifty patients who required mechanical ventilation during hyperbaric oxygen therapy were prospectively studied during a 6-year period in a French university hyperbaric centre. We analysed the indication of hyperbaric oxygen therapy, agent used for sedation, presence of a chest tube, need for vasopressor agents and tolerance and appearance of side effects. Finally, we compared the outcomes of patients according to the presence or absence of acute respiratory distress syndrome (ARDS). RESULTS: Eleven children and 139 adult patients were included (n = 150) in the study. In both populations, carbon monoxide poisoning (51%) and iatrogenic gas embolism (33%) were the two main causes of intubation and mechanical ventilation. The combination of midazolam and sufentanil was used in 85 (67%) patients. All of the patients were given a bolus of a neuromuscular blocker during the hyperbaric session, despite the presence of ARDS in 35 patients. Patient-ventilator asynchrony was the most frequent side effect in 6 (5%) patients and was often the consequence of suboptimal sedation. Mortality was higher in the group with ARDS (23%). CONCLUSIONS: Carbon monoxide poisoning and iatrogenic gas embolism are the two main diseases of the patients who required mechanical ventilation during hyperbaric oxygen therapy in this study. Mechanical ventilation is a safe method for patients during hyperbaric oxygen therapy. Sedation needs to be perfected to avoid patient-ventilator asynchrony.

Epidemiology of unintentional drowning in a metropolis of the French Mediterranean coast: a retrospective analysis (2000-2011).

Drowning affects more than 500,000 people worldwide and is responsible for at least 350,000 deaths each year. In France, 1235 drowning resulting in 496 deaths were recorded in the summer 2012. This retrospective study has investigated the epidemiology of drowning in the city of Marseille (South of France) between 2000 and 2011. We identified 449 cases of unintentional drowning. The highest incidence was found among males with a median age of 36 years. The incidence was 5.3 victims per 10,000 inhabitants with a mortality rate of 1.2 per 10,000. These accidents occurred mainly at sea (89%) and during the summer season. A majority of drowning victims (69%) were admitted in a hospital. This is the only study in France to analyse data on drowning throughout the year and over a long period. Drowning is a serious condition burdened by 22% of victims who die.

2-point ultrasonography to confirm correct position of the gastric tube in prehospital setting.

UNLABELLED: X-ray remains the "gold standard" test to control the gastric tube (GT) position. The aim of this study is to estimate the diagnostic accuracy of a 2-point ultrasonography to confirm GT placement in the prehospital setting. METHOD: The emergency physician performed an ultrasound examination during GT insertion. The aim was to determine whether or not the GT could be viewed in the esophagus and/or in the stomach. RESULTS: Thirty-two intubated patients were included. In 100% of cases, the GT was instantly identified by ultrasound at esophagus and in 62.5% at stomach. In 6 cases, the GT was not seen in the stomach, but the injection of air through the GT allowed to confirm intragastric position in 2 cases. In the 4 other cases, no dynamic fogging was observed. In hospital X-ray control confirmed the correct positioning of 28/32. CONCLUSION: The 2-point ultrasonographic live control of the GT position has a better sensitivity and a much higher specificity than the syringe test but similar to the xiphoid ultrasound control. However, our method allows to show the GT in the esophagus and to use the dynamic ultrasound fogging to reveal an intragastric position that was not obvious with the common techniques.

Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma.

Prehospital acute blunt thoracic trauma care remains difficult. Among then, diagnosis of atelectasis with ultrasound remains rare and unusual. We report the case of a worker who had a sharp chest pain currently after using a jackhammer. First clinical examination suspected a left tension pneumothorax but ruled out by sliding sign in left hemithorax ultrasound (US) examination. The right upper thoracic scan showed a well-defined lung point, a "hepatization" appearance with static air bronchograms, a diaphragm elevation and a dextrocardia in B mode, and a pseudobarcode with no lung pulse in Time Motion (TM) mode. A "rip's organ absent sign" excluded the hypothesis of an acute diaphragmatic rupture. An atelectasis was at once suspected and confirmed at hospital by tomodensitometry. Diaphragmatic injury can be suspected when "rip's absent organ sign," diaphragm poor movement or elevation, liver sliding sign, subphrenic effusion, or spleen or liver intrathoracic presence. Unusually, these signs can put diagnosis in a wrong track as described in our case report. Lung pulse, absent sliding sign, or hemidiaphragm standstill is highly suspect of atelectasis but cannot be established formally. However, in patients with alveolar consolidation displaying air bronchograms, the dynamic air bronchograms indicated lung contusion, distinguishing it from atelectasis. Static air bronchograms were seen in most atelectases and one-third of cases of contusion or pneumonia. Fast scan can be useful to evoke atelectasis in blunt trauma. Differential diagnoses such as diaphragmatic rupture or consolidation could be discarded. Ultrasound examination could justify a precise semiological description.

Stay and play eFAST or scoop and run eFAST? That is the question!

UNLABELLED: The concept that ultrasonography could be interesting in the prehospital setting and during the transfer of traumatized patients is not new. Paradoxically, there is a lack of description of routine use of ultrasonography in emergency ambulances. The aim of this study was to compare the feasibility and efficiency of an extended focused assessment sonography for trauma (eFAST) examination performed on-site, during the patient's transfer, or both. MATERIALS AND METHODS: From February 2010 to June 2012, 30 prehospital emergency physicians were divided randomly into 3 groups. Group 1 performed an ultrasound examination on-site; group 2, during patient transfer; and group 3, in both settings. The eFAST examination was systematically performed in all severe traumas. RESULTS: Ninety-eight patients were included. Forty-four eFAST examinations were performed on-site only; 33, only during transport; and 21, in both settings. The feasibility was 95.4%, 93.9%, and 95.2%, respectively, and efficiency, 95%, 97%, and 100%, respectively. There was no significant difference in performance or duration whether the examination was performed on-site, during the transfer, or both (w = 0.68). Last but not least, in 2 cases in group 3, the second examination carried out during transfer showed new results with the occurrence of intraperitoneal effusion in one case and a pleural effusion in the other. CONCLUSIONS: The eFAST examination can provide reliable and important information in the initial evaluation of traumatized patients. It can be completed either on-site or during patient transfer. Its feasibility and efficiency are similar to that done in intensive units, especially if the examination is repeated.

Decompression sickness in urban divers in France.

BACKGROUND: Decompression sickness (DCS) can occur in SCUBA divers. DCS is treated with oxygen, preferably given under hyperbaric conditions. Although Paris (France) is located at a distance from the sea or lakes, some injured divers require hyperbaric oxygen treatment (HBOT) in this city, sometimes within a specific time frame. Thus, this study investigated the epidemiology and outcomes of such urban divers. AIM: We conducted an observational study of SCUBA divers admitted to the Raymond Poincaré Hyperbaric centre near Paris from 1993 to 2003. MATERIALS AND METHODS: We prospectively enrolled 69 consecutive SCUBA divers presenting DCS. Common risk factors were reported, especially aeroplane flight and training dives. Symptoms are very often atypical (63%) and onset time of symptoms is often too long (59% after 2 h) due to denial of symptoms. First aid is generally inadequate, with only 23% of victims receiving oxygen, fluid loading and aspirin together. HBOT was given for 42 (61%) patients although their examination results were considered as normal. CONCLUSIONS: Diving pits and diving travel agencies should do more to warn divers of the need for treatment with normobaric oxygen and hydration pending HBOT. Moreover, hyperbaric physicians should better clarify HBOT indications for both symptoms of late onset and atypical presentations.

Ultrasound to confirm gastric tube placement in prehospital management.

BACKGROUND: In emergency medicine, the gastric tube (GT) has many purposes, however in prehospital settings, the only indication is gastric decompression. To date, there is lack of recommendation on the diagnostic methods to verify correct GT placement in prehospital. The aim of this study is to estimate diagnostic accuracy of ultrasound in confirming gastric tubes placement in a prehospital setting. METHOD: This was a prospective multicentre study conducted in two French towns (Marseille and Grasse) over a one-year period from May 2010 to May 2011. RESULTS: One hundred and thirty patients were included in the study with an M/F sex ratio of 77/53 and a mean age of 55.7±19.8 years. The GT position was confirmed by ultrasound, with direct visualization in the gastric area in 116 of the 130 patients. In 14 cases, the ultrasound failed to visualize the tip of the GT; these results were due in 2 cases to gas interposition and in 12 cases the GT was shown by final X-ray to be located in the end of the oesophagus. Direct visualization by ultrasound thus has a sensitivity of 98.3% [94-99.5] and a specificity of 100% [75.7-100], a positive predictive value of 100% and a negative predictive value of 85.7%, Youden's index of 0.98. GT size affects ultrasound visualization; the larger the GT, the easier it is to see. CONCLUSION: Bedside ultrasound thus appears to constitute an effective and reliable diagnostic procedure for confirming correct gastric tube placement in prehospital settings.

Lung ultrasound associated to capnography to verify correct endotracheal tube positioning in prehospital.

Endotracheal intubation is the "gold standard" of the control of airway patency but is associated with nonnegligible morbidity rates. A rapid detection of esophageal intubation is essential. Capnography is considered the reference technique for correct endotracheal tube (ETT) positioning confirmation. However, capnography can provide false-positive and false-negative results in some situations. Recently, the ultrasound assessment has been studied for confirming ETT placement. Despite of few trials, the ultrasound procedure may enhance physician confidence and decision making in airway management. We report the case of a 52-year-old female patient presenting cardiorespiratory failure. During cardiopulmonary resuscitation, there was a sudden absence of end-tidal CO2 capnographic detection. Correct tube positioning could not be ascertained by auscultation because the environment had become extremely noisy. However, TM-mode (Time Motion--mode) lung ultrasound revealed bilateral pleural sliding during insufflation with the self-filling balloon, thus confirming correct ETT positioning.