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Riassunto Non appena e posta la diagnosi di embolia polmonare, il medico deve valutare la gravita stratificando i pazienti in base al rischio di complicanze e mortalita. Sono stati sviluppati algoritmi per guidare il clinico in queste scelte terapeutiche, dei luoghi di cura (settore ospedaliero o ambulatoriale) e di monitoraggio (unita classica o unita intensiva). Questa analisi del rischio e fondamentale. Il principale criterio di gravita (che definisce l’embolia polmonare ad alto rischio) e la ripercussione emodinamica sul ventricolo destro dell’embolia polmonare che causa ipotensione arteriosa. Sono stati sviluppati strumenti di assistenza alla stratificazione a partire da elementi clinici (pulmonary embolism severity score) o paraclinici (dilatazione del ventricolo destro, troponina, BNP [brain natriuretic peptide], ecc.). Da questa stratificazione del rischio derivano le strategie terapeutiche, che vanno da un trattamento invasivo con ricovero in rianimazione a un trattamento orale domiciliare. Una delle sfide e lo sviluppo di un sistema di assistenza ambulatoriale per i pazienti con embolia polmonare non grave, che consenta un follow-up ravvicinato dopo il trattamento in Pronto Soccorso.

The Haldane M constant represents the ratio of oxygen/carbon monoxide affinity to hemoglobin. Findings on M values appear to be quite variable among studies. A systematic review and a meta-analysis were conducted to set a reference of human M values according to experimental conditions. The searched included all the relevant articles published from 1985 to January 2016 and extracted from the major electronic libraries database (PubMed/Embase/JSTOR). For each article, the following items were collected: age, temperature, pH, atmospheric pressure, 2,3-diphosphoglycerate (2,3-DPG) or methemoglobin levels, and hemoglobin type. Statistical analyses were performed using JMP®Pro12 software. Among the 1.683 articles analyzed, 15 were selected, which included 111 individual data, 21 mean values related to human adult hemoglobin (HbA) and 57 mean values for fetal hemoglobin (HbF) at known temperature and pH. The median M value at physiological conditions was 218 [191–257] (n = 19) for HbA and 175 [158–192] for HbF. There was a negative correlation between temperature and M value (p < 0.001), but no correlation between M and pH for HbA (p = 0.33), conversely to HbF (p = 0.044). Data were insufficient to perform a meta-analysis on the dependence between M and 2,3-DPG concentration, atmospheric pressure, pregnancy, methemoglobin, and sickle Hb. Our analysis confirmed that the M value in humans at physiological conditions is 218 for HbA and 175 for HbF. Temperature influences M, but further studies are required to clarify pH influence.

The Haldane M-value is the ratio of half-saturation pressures for O2 and CO (PO2/PCO) and is a key value of physiological and pathological models exploring CO metabolism or exposure to CO. Nevertheless, the M-values obtained from different studies and different species appear to be inconsistent. A better estimation of M-values and a consideration of interspecies variation will ensure the accuracy of CO study results and allow reliable models to be constructed. We performed a systematic review and meta-analysis in order to determine and compare M-values according to species and experimental conditions. We used electronic libraries (PubMed/Embase/JSTORE) from 1895 to January 2016. For each article, we collected the following parameters: species, age, temperature, pH, atmospheric pressure, concentration of 2,3-diphosphoglycerate (2,3-DPG) or methemoglobin, and type of hemoglobin. The systematic review found 25 articles addressing the M constant, including 135 with individual data and 51 with mean values concerning mammals, laboratory animals, fish, fetal hemoglobin and invertebrates. M-values at a physiological temperature and pH were assessed only for adult (137 [119–153]) and fetal (135 [112–168]) sheep, dogs (215 [193–218]), mice (194 [118–278]) and rats (191 [177–200]). A correlation between M-values and temperature was confirmed for sheep and horses. A correlation between M-values and pH could not be inferred because there was a lack of data. M-values varied according to species. Only the influence of temperature was confirmed. A formal measurement of the M constant in the given experimental conditions should be performed for each animal model study of CO. Further homogeneous studies are necessary to compare the M-values of different animals.

Summary Background The ability of the pulmonary embolism rule-out criteria (PERC) to exclude pulmonary embolism without further testing remains debated outside the USA, especially in the population with suspected pulmonary embolism who have a high prevalence of the condition. Our main objective was to prospectively assess the predictive value of negative PERC to rule out pulmonary embolism among European patients with low implicit clinical probability. Methods We did a multicentre, prospective, observational study in 12 emergency departments in France and Belgium. We included consecutive patients aged 18 years or older with suspected pulmonary embolism. Patients were excluded if they had already been hospitalised for more than 2 days, had curative anticoagulant therapy in progress for more than 48 h, or had a diagnosis of thromboembolic disease documented before admission to emergency department. Physicians completed a standardised case report form comprising implicit clinical probability assessment (low, moderate, or high) and a list of risk factors including criteria of the PERC rule. They were asked to follow international recommendations for diagnostic strategy, masked to PERC assessment. The primary endpoint was the proportion of patients with low implicit clinical probability and negative PERC who had venous thromboembolic events, diagnosed during initial diagnostic work-up or during 3-month follow-up, as externally adjudicated by an independent committee masked to the PERC and clinical probability assessment. The upper limit of the 95% CI around the 3-month thromboembolic risk was set at 3%. We did all analyses by intention to treat, including all patients with complete follow-up. This trial is registered with ClinicalTrials.gov, number NCT02360540. Findings Between May 1, 2015, and April 30, 2016, 1773 consecutive patients with suspected pulmonary embolism were prospectively assessed for inclusion, of whom 1757 were included. 1052 (60%) patients were classed as having low clinical probability, 49 (4·7%, 95% CI 3·5–6·1) of whom had a venous thromboembolic event. In patients with a low implicit clinical probability, 337 (32%) patients had negative PERC, of whom four (1·2%; 95% CI 0·4–2·9) went on to have a pulmonary embolism. Interpretation In European patients with low implicit clinical probability, PERC can exclude pulmonary embolism with a low percentage of false-negative results. The results of our prospective, observational study allow and justify an implementation study of the PERC rule in Europe. Funding French Ministry of Health.

INTRODUCTION: In an experimental study on carbon monoxide (CO) exposure in swine, we aimed to compare the influence of oxygen therapy using a non-rebreathing mask (NRM) to continuous positive airway pressure (CPAP) and two pressure support ventilation (PSV) devices on the decrease of the terminal elimination half-life of carboxyhemoglobin (COHb t(1/2)). This was the primary outcome. METHODS: Eight spontaneously breathing pigs were sedated by propofol and exposed to 940 ppm CO several times (n = 25) to obtain COHb levels of 30%. CPAPb (high flow open system, CPAP Boussignac® [7.5 cmH(2)O]), PSV-Vy (open system, Vylife Boussignac®), and PSV-Leg (closed system, Legendair® [inspiratory/expiratory airway pressure 12/4 cmH(2)O]) devices were used in a randomized order and compared to NRM (O(2) at 15 l min(−1)) and atmospheric air (AA). The primary outcome was COHb t(1/2). Multiple comparisons were performed using Dunn’s tests. RESULTS: Median FiO(2) and minute ventilation were significantly higher in the PSV-Leg group than the NRM group (p

L’embolia polmonare (EP) rimane nel 2014 una sfida per il medico. Dal momento che la patologia e potenzialmente mortale e i segni e i sintomi sono poco specifici, la prima difficolta consiste nel sapere in chi sospettare un’EP e, quindi, in chi iniziare un iter diagnostico. Di fronte a un sospetto di EP, il medico inizia una strategia diagnostica basata su tre elementi principali: la valutazione della probabilita clinica, i D-dimeri e l’angio-TC toracica. La prima fase, la valutazione della probabilita clinica, e la chiave di volta di tutto l’iter diagnostico e terapeutico. Non esiste alcun elemento formale per preferire una metodica di valutazione di probabilita clinica a un’altra. I D-dimeri sono inaffidabili quando la probabilita clinica e forte. Un test di D-dimeri negativo permette di escludere un’EP quando la probabilita clinica e bassa o, per alcune tecniche di dosaggio, quando e bassa o intermedia. L’angio-TC e considerata l’esame di riferimento. Essa ha, tuttavia, dei limiti notevoli, poiche il rischio di errore e aumentato in caso di discordanza tra l’interpretazione della TC e la probabilita clinica. Infine, questa strategia deve essere adattata in contesti particolari (stato di shock, donna gravida, persona anziana, insufficienza renale, ecc.) e fare ricorso ad altre indagini (ecoDoppler venoso, ecocardiografia, scintigrafia, ecc.). Un protocollo che precisi l’iter diagnostico da seguire o, anche, uno strumento informatizzato di aiuto alla decisione migliorano la qualita delle decisioni prese in Pronto Soccorso in occasione di un sospetto di EP.

Objective We present the case of a 52-year-old patient, 108 kg, admitted to the Emergency Department (ED) of New Caledonia Hospital Center in August 2018 for confusional syndrome and major agitation requiring the establishment of an important chemical restraint. Case history In terms of medical history, the patient, a bricklayer with chronic cough in a context of diffuse interstitial pneumonitis related to chronic cement inhalation treated with long-term oxygen therapy and an association of micophenolate mofetil and prednisone, presented a month earlier a respiratory decompensation of infectious origin. On the morning of his new admission, he was perfectly fine. Then, he progressively presented coughing fits as well as neurological disorders. Medical examination in ED found tachycardia with heart rate = 92, confusional state associated with non-reactive bilateral mydriasis, language disorder, obsession and severe agitation, no fever. A mucocutaneous dryness was also noted. Blood and CSF biological investigations, cerebral CT with injection performed under midazolam sedation, revealed no abnormality. Patient was transferred to ICU for further sedation in front of persistent agitation, despite cyamemazine, haloperidol and clorazepate administrations. EEG found well-organised activity without seizure or paroxysm. From the interview with the family, it finally emerged that, if the patient did not consume any intoxicant, he was treated in addition to his immunosuppressive treatment with Lercanidipine, Esomeprazole, Allopurinol and Amitryptiline. Furthermore, he has been self-medicating for a week by plant decoctions for an episode of ichthyosarcotoxism of the ciguatera type. In front of the characteristic symptomatology of an anticholinergic syndrome, a poisoning by plants of the genus Datura or Brugmensia was considered. Methods Blood and urine samples were taken 4 h after the appearance of the disorders for toxicological analysis using LC-UV-DAD (Acquity® Waters® system) and LC-MS/MS (Alliance® and QuatroMicro® Waters® system). Results LC-UV-DAD urine analysis showed the presence of scopolamine and signed an acute intoxication by a probable tropical datura. Quantification, performed a posteriori by LC-MS/MS, confirmed the intoxication. Atropine concentrations were: undetected and 6.2 ng/mL in blood and urine, respectively; scopolamine concentrations were: 1.6 ng/mL and 643 ng/mL in blood and urine, respectively. Taking into account an elimination half-life of scopolamine between 1 h and 3 h, these concentrations are compatible with the clinical signs observed. It is likely that the patient has mistaken the leaves of “octopus bush” (Heliotropium foertherianum, Boraginaceae), a reputed traditional medicine plant to treat ciguatera fish poisoning, with leaves of a Brugmensia spp (Solanaceae). Conclusions Given the heavy medical history of this patient, the questioning of his entourage has been crucial in the rapid orientation of the investigations in search of poisoning by plant and, taking into account the toxidrome presented in a tropical context, to look more specifically for the presence of scopolamine in the patient's urine. Subsequently, evolution was gradually favourable with normal neurological examination and hospital discharge at day 7.

Smoke inhalation is a common cause of cyanide poisoning during fires, resulting in injury and even death. In many cases of smoke inhalation, cyanide has increasingly been recognized as a significant toxicant. The diagnosis of cyanide poisoning remains very difficult, and failure to recognize it may result in inadequate or inappropriate treatment. Findings suggesting cyanide toxicity include the following: (a) a history of enclosed-space fire; (b) any alteration in the level of consciousness; (c) any cardiovascular changes (particularly inexplicable hypotension); and (d) elevated plasma lactate. The feasibility and safety of empiric treatment with hydroxocobalamin for fire smoke victims have been reported in the literature. On the basis of a literature review and a panel discussion, a group of European experts has proposed emergency management protocols for cyanide toxicity in fire smoke victims.

Resume L’embolie pulmonaire est une cause frequente de deces. Ce diagnostic doit etre evoque chez les patients presentant une dyspnee inhabituelle, une douleur thoracique ou un malaise sans explication probante. Grâce a l’estimation de la probabilite clinique, au dosage des D-dimeres et a l’angioscanner thoracique spirale, la demarche diagnostique semble notablement simplifiee. La premiere etape est de determiner si le patient appartient a un groupe de prevalence forte, faible ou intermediaire. En cas de faible probabilite clinique, un test D-dimere negatif ecarte le diagnostic. De meme en cas de probabilite intermediaire avec un test D-dimere ELISA. Si la probabilite clinique est forte, le dosage des D-dimeres n’est pas indique et un traitement anticoagulant doit etre initie immediatement sans attendre le resultat des tests diagnostiques. Un angioscanner permet alors d’affirmer ou d’infirmer le diagnostic dans la majorite des situations. Si le resultat est indecis ou qu’un angioscanner est contre-indique, le recours a d’autres examens comme l’echographie veineuse ou la scintigraphie pulmonaire peuvent permettre de prendre une decision fiable. La decision therapeutique repose sur une analyse de la gravite aidee par l’utilisation d’un score clinique specifique (Pulmonary Embolism Severity Index) et, si besoin, de marqueurs biologiques ou morphologiques de souffrance cardiaque. Chez les patients en etat de choc, il existe un consensus pour initier une fibrinolyse suivie d’une heparinotherapie par voie intraveineuse. Chez les patients normotendus mais presentant des criteres cliniques ou paracliniques de gravite, la fibrinolyse est controversee mais le traitement initial est preferentiellement l’heparine par voie intraveineuse. Chez les patients sans signe de gravite, le traitement repose sur une heparine de bas poids moleculaire ou le fondaparinux avec un debut des le premier jour d’un antivitamine K et d’une contention veineuse. Une mobilisation precoce est souhaitable.

International audience; Summary: Background: Age-adjusted D-dimer cut-off has recently been proposed to increase D-dimer usefulness in older patients suspected of pulmonary embolism (PE). Objective: We externally validated this age-adjusted D-dimer cut-off using different D-dimer assays in a multicenter sample of emergency department patients. Methods: Secondary analysis of three prospectively collected databases (two European, one American) of patients suspected of having PE. D-dimer performance for ruling out PE was assessed by calculating negative likelihood ratio (nLR) for D-dimer with age-adjusted D-dimer cut-off ( 75 years: NTT halved from 8.1 to 3.6. The proportion of patients over 75 years with normal D-dimer was doubled (27.9% vs. 12.3%). Conclusions: Our study shows that age-adjusted D-dimer had low nLR, allowing its use as a rule-out PE strategy in non-high pretest clinical probability patients, as well as using Vidas(®) , Liatest(®) or MDA(®) assays. This age-adjusted cut-off increased clinical usefulness of D-dimer in older patients. A large prospective study is required to confirm these results.

OBJECTIVES: Point of care testing and multimarker panels are rapidly expanding in emergency departments. We determined the reliability of Short-of-Breath SOB panel in patients admitted for acute dyspnea and/or chest pain. DESIGN AND METHODS: SOB D-dimer, BNP, cTnI, CK-MB and myoglobin assays were compared with references in 97 outpatients. RESULTS: The correlation between SOB and references methods was acceptable, but with limited precision and accuracy. CONCLUSIONS: Diagnostic performances and cut-off values should be further validated before clinicians replace traditional cardio-respiratory biomarkers by the new SOB panel.

In this observation, we report a novel use of noninvasive positive pressure ventilation in the operating room to support ventilation in an acidotic hypercapnic patient with severe acute chronic respiratory failure refuted for general anaesthesia, operated under spinal anaesthesia for a femoral fracture. The feasibility of noninvasive ventilatory assistance during surgery performed under regional anaesthesia is reported here. In selected cases, noninvasive ventilation can be used in the management of patients with acute or chronic respiratory failure requiring an urgent surgical intervention but in whom the respiratory status excluded a general anaesthesia.

Continuous positive airway pressure (CPAP) is frequently used in patients attending emergency units. Its combination with nebulization is sometimes necessary in those patients presenting with a CPAP dependency. STUDY OBJECTIVE: To compare lung deposition of amikacin delivered by a classical jet nebulizer (SideStream; Medic-Aid; West Sussex, UK) used alone (SST) or coupled to a CPAP device (Boussignac; Vygon; Belgium). METHOD: Amikacin (1g) was nebulized with both devices in six healthy subjects during 5 min on spontaneous breathing. A 1-week wash-out period between each nebulization was applied. Lung deposition was indirectly assessed by urinary monitoring of excreted amount of amikacin. RESULTS: Total daily amount of amikacin excreted in the urine was significantly lower with CPAP than with SST (1.97% initial dose versus 4.88% initial dose, p

Most fire-related deaths are attributable to smoke inhalation rather than burns. The inhalation of fire smoke, which contains not only carbon monoxide but also a complex mixture of gases, seems to be the major cause of morbidity and mortality in fire victims, mainly in enclosed spaces. Cyanide gas exposure is quite common during smoke inhalation, and cyanide is present in the blood of fire victims in most cases and may play an important role in death by smoke inhalation. Cyanide poisoning may, however, be difficult to diagnose and treat. In these children, hydrogen cyanide seems to be a major source of concern, and the rapid administration of the antidote, hydroxocobalamin, may be critical for these children.European experts recently met to formulate an algorithm for prehospital and hospital management of adult patients with acute cyanide poisoning. Subsequently, a group of European pediatric experts met to evaluate and adopt that algorithm for use in the pediatric population.