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Abstract: Objective: The aim of this study was to assess airway management by emergency physicians in case of a simulated situation where intubation and ventilation were both impossible. Study design: Observational manikin study. Methods: A manikin (Airman®; Laerdal) allowing simulating difficult airway situations was used. The scenario assessed concerned a patient needing tracheal intubation for severe traumatic brain injury. The manikin was settled to make tracheal intubation under direct laryngoscopy impossible at the first attempt and to make facemask ventilation impossible after the second attempt. Manikin could initially be ventilated through the intubating laryngeal mask Airway (ILMA) but became impossible few seconds after its insertion. With impossible ventilation through the ILMA, arterial oxygen saturation decreased during 2minutes before an hypoxic cardiac arrest occurred. Physicians could use classic laryngoscope with Macinthosh blade, a Gum Elastic Bougie, an ILMA and a cricothyrotomy set. Adhesion to the national airway management algorithm was assessed. Time to cricothyroidotomy decision after ventilation through ILMA became impossible was measured. Results: Twenty-five emergency physicians were assessed. For 14 of them, national expert conference algorithm was perfectly followed. For ten physicians, cricothyroidotomy decision was taken after hypoxic cardiac arrest occurred. Conclusion: Simulation with a manikin is useful to assess the adhesion rate to difficult intubation algorithms. Our study shows that the decision making process for cricothyrotomy is too often delayed as soon as ventilation became impossible and oxygenation compromized. [Copyright &y& Elsevier]

BACKGROUND: Difficult intubation management algorithms have proven efficacy in operating rooms but have rarely been assessed in a prehospital emergency setting. We undertook a prospective evaluation of a simple prehospital difficult intubation algorithm. METHODS: All of our prehospital emergency physicians and nurse anesthetists were asked to adhere to a simple algorithm in all cases of impossible laryngoscope-assisted tracheal intubation. They received a short refresher course and training in the use of the gum elastic bougie (GEB) and the intubating laryngeal mask airway (ILMA), which were techniques to be used as a first and a second step, respectively. In cases of difficult ventilation with arterial desaturation, IMLA was to be used first. Cricothyroidotomy was the ultimate rescue technique when ventilation through ILMA failed. Patient characteristics, adherence to the algorithm, management efficacy, and early complications were recorded (August 2005-December 2009). RESULTS: An alternative technique to secure the airway was needed in 160 of 2,674 (6%) patients undergoing intubation. Three instances of nonadherence to the algorithm were recorded. GEB was used first in 152 patients and was successful in 115. ILMA was used first in 8 patients and second in the 37 GEB-assisted intubation failures. Forty-five patients were successfully mask-ventilated, and 42 were blindly intubated before reaching the hospital. Cricothyroidotomy was used successfully in a patient with severe upper airway obstruction as a result of pharyngeal neoplasia. Early intubation-related complications occurred in 52% difficult cases. CONCLUSION: Adherence to a simple algorithm using GEB, ILMA, and cricothyroidotomy solved all difficult intubation cases occurring in a prehospital emergency setting. [ABSTRACT FROM AUTHOR]

Abstract: The law number 2005-370 of April 22, 2005 concerning the patients’ rights at the end of life imposes from now the refusal of futility of care, a shared decision-making in unconscious patients and the duty of a palliative strategy. Our observation underlines the feasibility to withhold or withdraw life-sustaining treatments in prehospital area, in following the different steps of the legal decision-making process. However, this case also shows the major difficulty to decide, because of a lack of traceability. Finally, this case illustrates the current difficulty to identify or to join the consultant, provided by the law. [Copyright &y& Elsevier]

Background and objective: Assuming the hypothesis that the general practitioner (GP) can and should be a key player in making end-of-life decisions for hospitalized patients, perceptions of GP's role assigned to them by hospital doctors in making withdrawal decisions for such patients were surveyed. Design: Questionnaire survey. Setting: Urban (districts located near Paris) and rural (southern France) areas. Participants: GP's. Results: The response rate was 32.2% (161/500), and it was observed that 70.8% of respondents believed that their participation in withdrawal decisions for their hospitalised patients was essential, whereas 42.1% believed that the hospital doctors were sufficiently skilled to make withdrawal decisions without input from the GPs. Most respondents were found to believe that they had the necessary skills (91.9%) and enough time (87.6%) to participate in withdrawal decisions. The last case of treatment withdrawal in hospital for one of their patients was described by 40% (65/161 ) of respondents, of whom only 40.0% (26/65) believed that they had participated actively in the decision process. The major factors in the multivariate analysis were the GP's strong belief that his or her participation was essential (p = 0.01 ), information on admission of the patient given to the GP by the hospital department (p = 0.007), rural practice (p = 0.03), visit to the patient dying in hospital (p=0.02) and a request by the family to be kept informed about the patient (p = 0.003). Conclusion: Strong interest was evinced among GPs regarding end-of-life issues, as well as considerable experience of patients dying at home. As GPs are more closely corrected to patients' families, they may be a goad choice for third-party intervention in making end-of-life decisions for hospitalised patients. [ABSTRACT FROM AUTHOR]

To estimate, for the first time, overweight prevalence and associated characteristics in a representative sample of prepubertal children in Beirut, Lebanon's capital.A cross-sectional study with a home interview including measurements of weight and height and a structured questionnaire.A total of 234 children aged 6–8 years in Beirut: 131 boys, 103 girls.Prevalence of overweight and obesity was based on the international cut-off points for body mass index (BMI) by age and gender proposed by the International Obesity Task Force. The characteristics of overweight examined were: age, gender, household and family size, single- vs. two-parent family, parents’ level of education and profession, physical activity and dietary intake of children.Prevalence of overweight and obesity was 26% and 7% respectively in boys, 25% and 6% in girls. Overweight was significantly associated with low physical activity (P < 0.05) and mother's BMI (P < 0.05).This study identified a high proportion of overweight in 6- to 8-year-old children in Beirut. Reduced physical activity was the most significant factor associated with childhood overweight. Further studies in different regions in Lebanon are necessary to identify national characteristics; prevention efforts will be designed accordingly. [ABSTRACT FROM AUTHOR]

Abstract: We report two cases of emergency cricothyrotomies performed in patients with severe neoplasic upper airway obstruction. Airway control was rapidly performed using a wire guided technique of cricothyrotomy and allow adequate ventilation in the two cases. The indications and the realization conditions of this procedure in the emergency context are discussed. [Copyright &y& Elsevier]

A response by Patricia Jabre and colleagues to letters to the editor about their study "Etomide Versus Ketamine for Rapid Sequence Intubation in Acutely Ill Patients: A Multicentre Randomized Controlled Trial," published in a 2009 issue is presented.

Abstract: Objectives: Assessment of prehospital management difficulties in morbid obese patients. Registration in several emergency departments for medical devices usable for morbid obese patients. Study design: Descriptive clinical study and regional survey. Patients and methods: During one year, all morbid obese patients managed by the prehospital emergency mobile unit (PEMU) were recorded. Pre hospital medical management and hospital admission difficulties were systematically recorded and analyzed. A regional survey was also performed in clinical and radiological departments, which are likely to receive these patients in emergency situations. Results: During the period of study, 92 patients were managed by the PEMU. Medical difficulties were numerous: impossibility to measure arterial pressure in 8 patients, difficulties in peripheral line placement for 12 patients, difficult airway management in 5 of 25 (20%) patients requiring tracheal intubation. The handling of obese patients needed additional rescuer in 27 (33%) patients transported to hospital. The regional survey showed that many obese patients could not profit from several specialized diagnostic and therapeutics devices because of their weight restriction. Conclusion: Management of morbid obese patients in the context of the out-of-hospital emergency medicine is frequently associated with specific and major technical difficulties. Numerous diagnostic and therapeutic devices are not currently adapted to the most severe overweight patients. [Copyright &y& Elsevier]

Abstract: Objectives: Assessment of the intubating Laryngeal Mask Airway™ in a prehospital emergency mobile unit (PEMU). Study design: Observational study. Methods: All the emergency physicians and nurses of the PEMU were trained with the intubating laryngeal mask (ILMA) handling on manikin and a learning curve was carried out. One year after the initial formation, a reassessment of the operators was performed. Following the initial formation, all the vehicles of the PEMU were equipped with ILMA and during 15 months all cases of ILMA use were recorded. The success rate and the difficulties met were analysed. Results: Initial formation on manikin showed that at least 8 handling of the device were mandatory to achieve a 100% success rate. A significant reduction of tracheal tube insertion delay was observed up to the eight manipulations. One year after the initial formation, a significant loss of performance was observed. Over the clinical study period 20 ILMA were used with adequate ventilation through the mask in all cases and a possible intubation in 80% of the patients. Conclusion: The ILMA is a potential useful device in the prehospital setting. Initial formation and maintenance of the skill acquired with this technique are essential. [Copyright &y& Elsevier]

La mort subite de l'adulte, mode de décès correspondant le plus souvent à un trouble du rythme cardiaque ventriculaire, est un problème majeur de santé publique. Bien que la maladie coronaire soit la principale cause de mort subite cardiaque, d'autres étiologies doivent être systématiquement envisagées et recherchées. Un bilan étiologique exhaustif et standardisé est nécessaire pour optimiser la prise en charge du patient et de sa famille dans le cas d'une maladie cardiaque héréditaire. L'identification d'une anomalie cardiaque et la question de son imputabilité pouvant être délicates, la prise en charge par une équipe pluridisciplinaire expérimentée se justifie pleinement. Sudden cardiac death, mostly related to ventricular arrhythmia, is a major public health issue, with still very poor survival at hospital discharge. Although coronary artery disease remains the leading cause, other etiologies should be systematically investigated. Exhaustive and standardized exploration is required to eventually offer specific therapeutics and management to the patient as well as his/her family members in case of inherited cardiac disease. Identification and establishing direct causality of the detected cardiac anomaly may remain challenging, underlying the need for a multidisciplinary and experimented team. [ABSTRACT FROM AUTHOR]

Background Out-of-hospital refractory cardiac arrest patients can be transported to a hospital for extracorporeal life support ( ECLS), which can be either therapeutic or performed for organ donation. Early initiation is of vital importance and the main limitation when considering ECLS. This explains that all reported series of cardiac arrest patients referred for ECLS were urban ones. We report a series of rural out-of-hospital non-heart-beating patients transported by helicopter. Methods This observational study was performed in two rural districts in France. Data on patients with pre-hospital criteria for ECLS who were transported to the hospital by helicopter, maintained by mechanical chest compression, were recorded over a 2-year period. Results During the study period, 27 patients were referred for ECLS, of which 14 for therapeutic ECLS and 13 for organ preservation. The median transport distance was 37 km (25th and 75th percentiles: 31-58; range 25 to 94 km). Among the therapeutic ECLS patients, one survived to discharge from the hospital. Liver and kidneys were retrieved in another patient after brain death was ascertained. In the 13 patients referred for organ donation, four were excluded for medical reasons; 18 kidneys were retrieved in nine patients, of which six kidneys were successfully transplanted. Conclusion In this preliminary study, we report the feasibility and the interest of helicopter transport of refractory cardiac arrest patients maintained by mechanical chest compression. Patients with refractory cardiac arrest occurring in rural areas, even at distance from a referral centre, can be candidates for ECLS. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: We have prospectively compared simulated-difficult tracheal intubation characteristics of four glottiscopes: Airtraq™, GlideScope™, McGrath™, LMA CTrach™ with that of the conventional Macintosh laryngoscope. Study design: prospective with the airway devices proposed in a randomly assigned order. Materials and method: Forty-two physicians, naïve to glottiscope handling accepted participating this study after the learning curve of each airway device was completed. Participants were requested to perform two series of five tracheal intubations on the manikin Airman™, the first in standard situation and the second in difficult tracheal intubation simulation. The airway devices were chosen in a randomly assigned order. For each airway tool, the following tracheal intubation characteristics were recorded: laryngeal exposure quality, tracheal intubation and apnea durations. A performance index was calculated and a tracheal intubation difficulty was measured during simulation. Results: More than 1600 supervised tracheal intubations were performed, including 1000 for the learning process of the glottiscopes, which was completed after 10 uses on the manikin. During standard situation, laryngeal exposure quality was similar with the five airway devices. As compared to the Macintosh laryngoscope, GlideScope™, McGrath™, tracheal intubation duration was shorter (p <0.05) with the Airtraq™ and longer (p <0.01) with the LMA CTrach™. During difficult tracheal intubation simulation, laryngeal exposure and tracheal intubation duration was of better quality and shorter with the four glottiscopes as compared to that of LM, respectively. Performance index during difficult tracheal intubation simulation simulation was significantly more important (p <0.01) with the Airtraq™ and the LMA CTrach™. Airtraq™ and Macintosh laryngoscope were respectively the simplest (p <0.01) and the most difficult (p <0.01) airway devices to manage a simulated difficult tracheal intubation. Conclusion: When difficult airway was simulated on the manikin, the four glottiscopes were superior to the Macintosh laryngoscope to improve laryngeal exposure quality and to reduce duration of tracheal intubation. Airtraq™ and the LMA CTrach™ both demonstrated remarkable advantage over GlideScope™ and McGrath™ for simulated difficult intubation management. [Copyright &y& Elsevier]

Abstract: Objectives: Difficult intubation rate is higher in the prehospital setting than in the operating room. Goal of this survey was to assess compliance of the French prehospital mobile emergency unit (Smur) to the recent French guidelines for the difficult airway management. Study design: National phone survey. Methods: A phone questionnaire was proposed to one senior emergency physician of all 380 French Smur. Seven questions were asked about intubation devices used, availability of a written difficult intubation algorithm and intubation training of the Smur''s physicians. Results: Guidelines of the recent French consensus conference on difficult intubation are only partly followed by the Smur. Only 60% of the Smur perform systematic rapid intubation sequence, plastic laryngoscope blades are used by more than 50% of the Smur and less than 50% of the Smur have a written difficult intubation management algorithm available. The Gum elastic Bougie is available in 58% of the Smur and the intubating laryngeal mask airway in 71%, whereas initial formation for difficult intubation devices used is provided to the emergency physicians in only 58% of the Smur. Conclusion: This survey shows that the French guidelines for the difficult airway management are only partially followed by the French Smur. An effort should be made for a larger diffusion of these guidelines towards the emergency physicians working in the Smur. [Copyright &y& Elsevier]