Effect of body position on the redistribution of regional lung aeration during invasive and non-invasive ventilation of COVID-19 patients

Severe COVID-19-related acute respiratory distress syndrome (C-ARDS) requires mechanical ventilation. While this intervention is often performed in the prone position to improve oxygenation, the underlying mechanisms responsible for the improvement in respiratory function during invasive ventilation and awake prone positioning in C-ARDS have not yet been elucidated. In this prospective observational trial, we evaluated the respiratory function of C-ARDS patients while in the supine and prone positions during invasive (n = 13) or non-invasive ventilation (n = 15). The primary endpoint was the positional change in lung regional aeration, assessed with electrical impedance tomography. Secondary endpoints included parameters of ventilation and oxygenation, volumetric capnography, respiratory system mechanics and intrapulmonary shunt fraction. In comparison to the supine position, the prone position significantly increased ventilation distribution in dorsal lung zones for patients under invasive ventilation (53.3 ± 18.3% vs. 43.8 ± 12.3%, percentage of dorsal lung aeration ± standard deviation in prone and supine positions, respectively; p = 0.014); whereas, regional aeration in both positions did not change during non-invasive ventilation (36.4 ± 11.4% vs. 33.7 ± 10.1%; p = 0.43). Prone positioning significantly improved the oxygenation both during invasive and non-invasive ventilation. For invasively ventilated patients reduced intrapulmonary shunt fraction, ventilation dead space and respiratory resistance were observed in the prone position. Oxygenation is improved during non-invasive and invasive ventilation with prone positioning in patients with C-ARDS. Different mechanisms may underly this benefit during these two ventilation modalities, driven by improved distribution of lung regional aeration, intrapulmonary shunt fraction and ventilation-perfusion matching. However, the differences in the severity of C-ARDS may have biased the sensitivity of electrical impedance tomography when comparing positional changes between the protocol groups

Prise en charge de l'infarctus du myocarde avec sus-décalage du segment ST à Genève : un registre local

Ce travail de recherche étudie les différentes étapes de la prise en charge des patients admis pour un STEMI (ST Elevation Myocardial Infarction) au Service des Urgences (SU) des Hôpitaux Universitaires de Genève. Après une année de recrutement (2004-2005), 145 patients avec STEMI ont été inclus. L'analyse de leur parcours tant préhospitalier qu'hospitalier révèle que plusieurs paramètres de prise en charge sont perfectibles. Il s'agit principalement du mode d'admission trop souvent non médicalisé, du taux d'électrocardiogramme préhospitalier insuffisant, et surtout d'un délai de reperfusion coronarienne qui est excessif. Ce constat a motivé l'élaboration d'une intervention centrée sur la réalisation systématique d'un électrocardiogramme préhospitalier par le médecin du cardiomobile qui permet, en cas de STEMI, d'activer un système visant à réduire les délais de prise en charge ultérieure. Cette intervention est en vigueur depuis le mois d'octobre 2006, ses performances sont actuellement en cours d'évaluation et feront l'objet d'une publication prochainement

Point-of-care ultrasound in internal and emergency medicine: from basics to training and implementation

Growing doubts regarding history and physician examination (HPE) value, coupled with recent advances in ultrasound technology and miniaturization offered conditions promoting the gradual advent of point of care ultrasound (POCUS). POCUS is meant to answer specific, basic and usually binary clinical questions to address specific hypotheses in a timely manner in order to immediately guide treatment and/or orientation at bedside. In internal and emergency medicine, POCUS is used for simple diagnostic purposes. Indeed, in complement to HPE, POCUS allows identification of cardiac, pleuro-pulmonary, abdominal and vessel abnormalities leading to a straightforward diagnosis. In addition, multimodal POCUS examination is performed in acute distress syndromes (e.g. acute respiratory and/or circulatory failure, cardiac arrest, multiple trauma) where it narrows differential diagnosis and shortens time to diagnosis and/or treatment according to recent evidence. Moreover, insertion of POCUS guided central and peripheral venous catheters has been extensively proven to be safer than historical non US guided procedures. Other semi-invasive procedures such as ascites and pleural fluid punctures, and more recently lumbar puncture have also shown to be safer with US guidance. The added clinical value of POCUS intimately depends on the quality of POCUS training and implementation. Usual training structure comprises three distinct steps: POCUS initiation, POCUS practical training and POCUS certification. POCUS initiation consists in theory acquisition through didactic lessons or growing more efficient Web-based content and practical ultrasound “hands on” sessions (healthy volunteers and/or patients), aiming at proper image acquisition. This initiation should be as early and as accessible as possible, automatically integrated in regular Emergency Medicine and Internal Medicine postgraduate education. POCUS supervised practical training follows; it is very demanding for trainers and trainees, but stands as a determinant factor to concretely build competency and to rigorously anchor POCUS in bedside evaluation. Successful POCUS implementation needs overt and regularly repeated clarification of its scope of practice, thus offering a delineated frame of practice to its users and a reassuring message to other institutional ultrasound providers. Besides that, current developments towards improved device simplicity and maneuverability contribute to POCUS efficient implementation. In addition, it is crucial to rely on enough well-trained referents in the process of POCUS integration. They are essential to promote, teach and honestly assume POCUS activity. Material, teaching, supporting and supervising resources are progressively available to ground POCUS as an additional truly reliable pillar of HPE. Its humble though determined implementation, alongside HPE and other imaging procedures, should be supported without restriction

Gestes invasifs et patients sous anticoagulants oraux : to bridge or not to bridge ?

Long-term oral anticoagulation is prescribed to 1% of the population to lower thrombotic risk associated with venous thromboembolic disease (VTD), atrial fibrillation (AF), and cardiac mechanical valve. Annually, 10% of patients with at least one of these conditions undergo an invasive procedure. In such case, bridging anticoagulation with short half-life parenteral molecules is frequently performed to lower the peri-procedural thrombotic risk. Nevertheless, available evidence suggests an increase bleeding risk is associated with the bridging procedure and recommendations regarding bridging are followed in less than one third of cases. Bridging should be considered only if the thromboembolic risk is high such as recent VTD (< 3 months), AF with past history of stroke or transient ischemic attack, and cardiac mechanical valve

Surprescription des inhibiteurs de la pompe à protons

Overutilization of proton pump inhibitors (PPI) is obvious despite available recommendations, with clinical and economical issues. This overuse is due to abusive stress ulcer prophylaxis and to automatic represcription, particularly during transitions from intensive care unit to other inhospital units and at hospital discharge. Withdrawal symptoms may contribute to the difficulty of PPI interruption. It is mandatory to limit initiation of PPI treatment outside of appropriate indications and to regularly reassess the need of this treatment

Les accidents d'électrisation

Electrical injuries can have serious multisystemic consequences and have to be evaluated regardless of the extent of skin injuries. Emergency department treatment is complex with simultaneous use of ACLS (Advanced Cardiac Life Support) and ATLS (Advanced Trauma Life Support) algorithms, and with particular attention given to fluid resuscitation and musculoskeletal damage management. Beyond the recognized intensive care admission criteria like polytrauma or severe bums, documented arrhythmia or abnormal ECG on initial evaluation, loss of consciousness and high voltage electrical injuries (> 1000 V) each prompt a minimum of 24 hours cardiac monitoring. In addition, severely burned patients should be promptly transferred to specialized facilities

Comment reduire le délai de reperfusion dans l'infarctus du myocarde avec sus-décalage du segment ST?

For patients with ST elevation myocardial infarction (STEMI), most hospitals do not achieve recommended reperfusion time delay. The goal of this article is to discuss the several strategies allowing to reduce delay to reperfusion (e.g., pre-hospital ECG, early activation of catheterisation laboratory), in order to help each institution to develop its own protocol

Beta-bloquants et obstruction bronchique: un si mauvais menage ?

Chronic obstructive pulmonary disease is a frequent medical condition, mainly triggered by smoking. COPD patients often suffer from heart diseases that can benefit from beta-blocker therapy. However, fear from triggering latent bronchospasm, or from worsening it, leads to under-prescription of these agents. Adequate patient selection is, thus, crucial. Prescription of a cardio-selective beta-blocker is not only reasonably safe in stable COPD patients but it is also beneficial in terms of mortality in those patients with comorbid cardiac diseases. Use of beta-blockers is contra-indicated in the case of decompensated COPD with severe bronchospasm or in poorly controlled asthma. In all cases, close clinical and, sometimes, functional monitoring is mandatory

Patients leaving the emergency department without being seen by a physician: a retrospective database analysis

To describe characteristics of patients leaving the emergency department (ED) before being seen by a physician and to identify factors associated with a greater risk of leaving the ED too early