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1. Oxygen therapy in acute hypoxemic respiratory failure: guidelines from the SRLF-SFMU consensus conference

Author

Julie Helms, Pierre Catoire, Laure Abensur Vuillaume, Héloise Bannelier, Delphine Douillet, Claire Dupuis, Laura Federici, Melissa Jezequel, Mathieu Jozwiak, Khaldoun Kuteifan, Guylaine Labro, Gwendoline Latournerie, Fabrice Michelet, Xavier Monnet, Romain Persichini, Fabien Polge, Dominique Savary, Amélie Vromant, Imane Adda, and Sami Hraiech

Subjects
Acute respiratory failure, Acute respiratory distress, Oxygen therapy, Conference consensus, Guidelines, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Introduction Although largely used, the place of oxygen therapy and its devices in patients with acute hypoxemic respiratory failure (ARF) deserves to be clarified. The French Intensive Care Society (Société de Réanimation de Langue Française, SRLF) and the French Emergency Medicine Society (Société Française de Médecine d’Urgence, SFMU) organized a consensus conference on oxygen therapy in ARF (excluding acute cardiogenic pulmonary oedema and hypercapnic exacerbation of chronic obstructive diseases) in December 2023. Methods A committee without any conflict of interest (CoI) with the subject defined 7 generic questions and drew up a list of sub questions according to the population, intervention, comparison and outcomes (PICO) model. An independent work group reviewed the literature using predefined keywords. The quality of the data was assessed using the GRADE methodology. Fifteen experts in the field from both societies proposed their own answers in a public session and answered questions from the jury (a panel of 16 critical-care and emergency medicine physicians, nurses and physiotherapists without any CoI) and the public. The jury then met alone for 48 h to write its recommendations. Results The jury provided 22 statements answering 11 questions: in patients with ARF (1) What are the criteria for initiating oxygen therapy? (2) What are the targets of oxygen saturation? (3) What is the role of blood gas analysis? (4) When should an arterial catheter be inserted? (5) Should standard oxygen therapy, high-flow nasal cannula oxygen therapy (HFNC) or continuous positive airway pressure (CPAP) be preferred? (6) What are the indications for non-invasive ventilation (NIV)? (7) What are the indications for invasive mechanical ventilation? (8) Should awake prone position be used? (9) What is the role of physiotherapy? (10) Which criteria necessarily lead to ICU admission? (11) Which oxygenation device should be preferred for patients for whom a do-not-intubate decision has been made? Conclusion These recommendations should optimize the use of oxygen during ARF.

Published
2024
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2. A new physiological manikin to test and compare ventilation devices during cardiopulmonary resuscitation

Author

François Morin, Laura Polard, Emeline Fresnel, Mathéo Richard, Hugo Schmit, Clarisse Martin-Houitte, Ricardo Luiz Cordioli, Marius Lebret, Alain Mercat, François Beloncle, Dominique Savary, Jean-Christophe Richard, and Arnaud Lesimple

Subjects
Cardiopulmonary resuscitation, Cardiac arrest, Manikin, Ventilation, Functional residual capacity, Intrathoracic airway closure, Specialties of internal medicine, RC581-951
Abstract

Background: There is a lack of bench systems permitting to evaluate ventilation devices in the specific context of cardiac arrest. Objectives: The objective of the study is to assess if a new physiological manikin may permit to evaluate the performances of medical devices dedicated to ventilation during cardiopulmonary resuscitation (CPR). Methods: Specific CPR-related features required to reproduce realistic ventilation were implemented into the SAM (Sarthe Anjou Mayenne) manikin. In the first place, the manikin ability to mimic ventilation during CPR was assessed and compared to real-life tracings of airway pressure, flow and capnogram from three out of hospital cardiac arrest (OHCA) patients. In addition, to illustrate the interest of this manikin, ventilation was evaluated during mechanical continuous chest compressions with two devices dedicated to CPR: the Boussignac cardiac arrest device (B-card − Vygon; Ecouen France) and the Impedance Threshold Device (ITD − Zoll; Chelmsford, MA). Results: The SAM manikin enabled precise replication of ventilation tracings as observed in three OHCA patients during CPR, and it allowed for comparison between two distinct ventilation devices. B-card generated a mean, maximum and minimum intrathoracic pressure of 6.3 (±0.1) cmH2O, 18.9 (±1.1) cmH2O and −0.3 (±0.2) cmH2O respectively; while ITD generated a mean, maximum and minimum intrathoracic pressure of −1.6 (±0.0) cmH2O, 5.7 (±0.1) cmH2O and −4.8 (±0.1) cmH2O respectively during CPR. B-card allowed to increase passive ventilation compared to the ITD which resulted in a dramatic limitation of passive ventilation. Conclusion: The SAM manikin is an innovative model integrating specific physiological features that permit to accurately evaluate and compare ventilation devices during CPR.

Published
2024
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3. A new reservoir-based CPAP with low oxygen consumption: the Bag-CPAP

Author

Eloïse de Beaufort, Guillaume Carteaux, François Morin, Arnaud Lesimple, Anne-Fleur Haudebourg, Emeline Fresnel, Damien Duval, Alexandre Broc, Alain Mercat, Laurent Brochard, Dominique Savary, François Beloncle, Armand Mekontso Dessap, and Jean-Christophe Richard

Subjects
Oxygen consumption, Acute hypoxemic respiratory failure, Continuous positive airway pressure, Frugal innovation, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Background Several noninvasive ventilatory supports rely in their design on high oxygen consumption which may precipitate oxygen shortage, as experienced during the COVID-19 pandemic. In this bench-to-bedside study, we assessed the performance of a new continuous positive airway pressure (CPAP) device integrating a large reservoir (“Bag-CPAP”) designed to minimize oxygen consumption, and compared it with other CPAP devices. Methods First, a bench study compared the performances of Bag-CPAP and four CPAP devices with an intensive care unit ventilator. Two FiO2 targets (40–60% and 80–100%) at a predefined positive end expiratory pressure (PEEP) level between 5 and 10 cm H2O were tested and fraction of inspired oxygen (FiO2) and oxygen consumption were measured. Device-imposed work of breathing (WOB) was also evaluated. Second, an observational clinical study evaluated the new CPAP in 20 adult patients with acute respiratory failure in two hospitals in France. Actual FiO2, PEEP, peripheral oxygen saturation, respiratory rate, and dyspnea score were assessed. Results All six systems tested in the bench study reached the minimal FiO2 target of 40% and four reached at least 80% FiO2 while maintaining PEEP in the predefined range. Device-delivered FiO2/consumed oxygen ratio was the highest with the new reservoir-based CPAP irrespective of FiO2 target. WOB induced by the device was higher with Bag-CPAP. In the clinical study, Bag-CPAP was well tolerated and could reach high (> 90%) and moderate (> 50%) FiO2 with an oxygen flow rate of 15 [15–16] and 8 [7–9] L/min, respectively. Dyspnea score improved significantly after introduction of Bag-CPAP, and SpO2 increased. Conclusions In vitro, Bag-CPAP exhibited the highest oxygen saving properties albeit had increased WOB. It was well accepted clinically and reduced dyspnea. Bag-CPAP may be useful to treat patients with acute respiratory failure in the field, especially when facing constraints in oxygen delivery.

Published
2023
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4. Cardiac Arrest Management in the Workplace: Improving but Not Enough?

Author

Alexis Descatha, François Morin, Marc Fadel, Thomas Bizouard, Romain Mermillod-Blondin, Julien Turk, Alexandre Armaingaud, Hélène Duhem, and Dominique Savary

Subjects
cardiac arrest, location, occupational, public health, work, Public aspects of medicine, RA1-1270
Abstract

The aim was to describe out-of-hospital cardiac arrest (OHCA) occurring in the workplace of a large emergency network, and compare the evolution of their management in the last 15 years. A retrospective study based on data from the Northern Alps Emergency Network compared characteristics of OHCA between cases in and out the workplace, and between cases occurring from January 2004 to December 2010 and from January 2011 to December 2017. Among the 15,320 OHCA cases included, 320 occurred in the workplace (2.1%). They were more often in younger men, and happened more frequently in an area with access to public defibrillation, had more often a shockable rhythm, had a cardiopulmonary resuscitation started by a bystander more frequently, and had a better outcome. Cardiopulmonary resuscitation started by a bystander was the only chain of survival link that improved for cases occurring after December 2010. Workplace OHCA seems to be managed more effectively than others; however, only a slight survival improvement was observed, suggesting that progress is still needed.

Published
2023
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5. A novel capnogram analysis to guide ventilation during cardiopulmonary resuscitation: clinical and experimental observations

Author

Arnaud Lesimple, Caroline Fritz, Alice Hutin, Emmanuel Charbonney, Dominique Savary, Stéphane Delisle, Paul Ouellet, Gilles Bronchti, Fanny Lidouren, Thomas Piraino, François Beloncle, Nathan Prouvez, Alexandre Broc, Alain Mercat, Laurent Brochard, Renaud Tissier, Jean-Christophe Richard, and the CAVIAR (Cardiac Arrest, Ventilation International Association for Research) Group

Subjects
Cardiopulmonary resuscitation, Thoracic distension, Intrathoracic airway closure, CO2 pattern, Cardiac arrest, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Background Cardiopulmonary resuscitation (CPR) decreases lung volume below the functional residual capacity and can generate intrathoracic airway closure. Conversely, large insufflations can induce thoracic distension and jeopardize circulation. The capnogram (CO2 signal) obtained during continuous chest compressions can reflect intrathoracic airway closure, and we hypothesized here that it can also indicate thoracic distension. Objectives To test whether a specific capnogram may identify thoracic distension during CPR and to assess the impact of thoracic distension on gas exchange and hemodynamics. Methods (1) In out-of-hospital cardiac arrest patients, we identified on capnograms three patterns: intrathoracic airway closure, thoracic distension or regular pattern. An algorithm was designed to identify them automatically. (2) To link CO2 patterns with ventilation, we conducted three experiments: (i) reproducing the CO2 patterns in human cadavers, (ii) assessing the influence of tidal volume and respiratory mechanics on thoracic distension using a mechanical lung model and (iii) exploring the impact of thoracic distension patterns on different circulation parameters during CPR on a pig model. Measurements and main results (1) Clinical data: 202 capnograms were collected. Intrathoracic airway closure was present in 35%, thoracic distension in 22% and regular pattern in 43%. (2) Experiments: (i) Higher insufflated volumes reproduced thoracic distension CO2 patterns in 5 cadavers. (ii) In the mechanical lung model, thoracic distension patterns were associated with higher volumes and longer time constants. (iii) In six pigs during CPR with various tidal volumes, a CO2 pattern of thoracic distension, but not tidal volume per se, was associated with a significant decrease in blood pressure and cerebral perfusion. Conclusions During CPR, capnograms reflecting intrathoracic airway closure, thoracic distension or regular pattern can be identified. In the animal experiment, a thoracic distension pattern on the capnogram is associated with a negative impact of ventilation on blood pressure and cerebral perfusion during CPR, not predicted by tidal volume per se.

Published
2022
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6. Prevalence and characterization of forgoing care: comparison of two prospective multicentre cohorts between pre-COVID-19 era and a lockdown period

Author

Delphine Douillet, Clémence Dupont, Noémie Leloup, Grégory Ménager, Maud Delori, Caroline Soulie, François Morin, Thomas Moumneh, Dominique Savary, Pierre-Marie Roy, and Aurore Armand

Subjects
Forgoing care, healthcare renunciation, Emergency care, COVID-19, Coronavirus, Public aspects of medicine, RA1-1270
Abstract

Abstract Background Little is known about patients who forego healthcare, although it is an important provider of unfavorable health-related outcomes. Forgoing healthcare characterizes situations in which people do not initiate or interrupt a care process, even though they perceive the need for it, whether or not this need is medically proven. The aims of this study were to assess the prevalence and the determinants of patients who forego healthcare. The second aim was to compare the characteristics of patients who gave up healthcare during the French lockdown due to COVID-19. Methods We conducted two multicenter cross-sectional studies in 2017 and 2020 carried out in French patients presenting to the emergency departments. Patients who gave their consent to participate were interviewed with a standardized questionnaire. It consisted of two parts: epidemiological characteristics and health care refusal. A third part concerning the renunciation of care during the COVID-19 period was added to the second study period. Results A total of 1878 patients had completed the questionnaire during the interview with the physicians, 900 during the first period in 2017 (47.9%) and 978 (52.1%) during the second period. A total of 401/1878 patients reported not seeking care in the last 12 months (21.4% [95%CI: 19.5–23.3%]). In 2020, patients forewent care more during the confinement period than outside with different characteristics of the foregoing care populations. Conclusion Forgoing care is common in a universal health care system such as France’s and increased during the pandemic. Key public health messages targeted at the reasons for not seeking care must now be disseminated in order to combat this.

Published
2022
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7. Point-of-care ultrasonography for risk stratification of non-critical suspected COVID-19 patients on admission (POCUSCO): A prospective binational study.

Author

François Morin, Delphine Douillet, Jean François Hamel, Dominique Savary, Christophe Aubé, Karim Tazarourte, Kamélia Marouf, Florence Dupriez, Phillipe Le Conte, Thomas Flament, Thomas Delomas, Mehdi Taalba, Nicolas Marjanovic, Francis Couturaud, Nicolas Peschanski, Thomas Boishardy, Jérémie Riou, Vincent Dubée, and Pierre-Marie Roy

Subjects
Medicine, Science
Abstract

BackgroundLung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may allow early identification of patients who are likely to develop an acute respiratory distress syndrome (ARDS). We hypothesized that L-POCUS performed within the first 48 hours of non-critical patients with suspected COVID-19 would identify those with a high-risk of worsening.MethodsPOCUSCO was a prospective, multicenter study. Non-critical adult patients who presented to the emergency department (ED) for suspected or confirmed COVID-19 were included and had L-POCUS performed within 48 hours following ED presentation. The lung damage severity was assessed using a previously developed score reflecting both the extension and the intensity of lung damage. The primary outcome was the rate of patients requiring intubation or who died within 14 days following inclusion.ResultsAmong 296 patients, 8 (2.7%) met the primary outcome. The area under the curve (AUC) of L-POCUS was 0.80 [95%CI:0.60-0.94]. The score values which achieved a sensibility >95% in defining low-risk patients and a specificity >95% in defining high-risk patients were ConclusionL-POCUS performed within the first 48 hours following ED presentation allows risk-stratification of patients with non-severe COVID-19.

Published
2023
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8. Interhospital transfer of COVID-19 patients treated with high-flow nasal oxygen therapy

Author

Elophe Dubie, François Morin, Dominique Savary, Amaury Serruys, and Pascal Usseglio

Subjects
COVID-19, Interhospital, Transfer, High-flow, Nasal, Oxygen, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract At the start of the COVID-19 pandemic, early intubation was recommended on the basis of worldwide observations of severe hypoxemia. However, some patients were ultimately able to benefit from high-flow nasal cannula (HFNC) and thus avoid intubation. During the “second wave” (September to December 2020 in France), some emergency departments implemented HFNC in patients with severe COVID-19. The question then arose regarding the transfer of these most serious patients to intensive care units (ICU) and of the respiratory modalities to be used during this transfer. To assess the feasibility of interhospital transfers of COVID-19 patients needing HFNC, we conducted a bi-centric prospective observational study of all medical transfers of patients needing HFNC with the Chambéry and Angers (France) mobile emergency and intensive care service (SMUR) during the “second wave” of the COVID-19 pandemic in France. Analysis of these 42 patients showed no significant variation in the respiratory requirements during the transfer. Overall, 52% of patients were intubated during their stay in ICU, including three patients intubated before or during transfer. Interhospital transfer with HFNC is very high-risk, and intubation remains indicated in the most unstable patients. However, 48% of patients benefited from HFNC and were thus able to avoid intubation during their transfer and ICU stay; for these patients, intubation would probably have been indicated in the absence of available HFNC techniques.

Published
2021
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9. Continuous positive airway pressure for respiratory support during COVID-19 pandemic: a frugal approach from bench to bedside

Author

Guillaume Carteaux, Manuella Pons, François Morin, Samuel Tuffet, Arnaud Lesimple, Bilal Badat, Anne-Fleur Haudebourg, François Perier, Yvon Deplante, Constance Guillaud, Frédéric Schlemmer, Elena Fois, Nicolas Mongardon, Mehdi Khellaf, Karim Jaffal, Camille Deguillard, Philippe Grimbert, Raphaëlle Huguet, Keyvan Razazi, Nicolas de Prost, François Templier, François Beloncle, Alain Mercat, Laurent Brochard, Vincent Audard, Pascal Lim, Jean-Christophe Richard, Dominique Savary, and Armand Mekontso Dessap

Subjects
COVID-19, Acute hypoxemic respiratory failure, Continuous positive airway pressure, Frugal innovation, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Background We describe a frugal approach (focusing on needs, performance, and costs) to manage a massive influx of COVID-19 patients with acute hypoxemic respiratory failure (AHRF) using the Boussignac valve protected by a filter (“Filter Frugal CPAP”, FF-CPAP) in and out the ICU. Methods (1) A bench study measured the impact of two filters with different mechanical properties on CPAP performances, and pressures were also measured in patients. (2) Non-ICU healthcare staff working in COVID-19 intermediate care units were trained with a video tutorial posted on a massive open online course. (3) A clinical study assessed the feasibility and safety of using FF-CPAP to maintain oxygenation and manage patients out of the ICU during a massive outbreak. Results Bench assessments showed that adding a filter did not affect the effective pressure delivered to the patient. The resistive load induced by the filter variably increased the simulated patient’s work of breathing (6–34%) needed to sustain the tidal volume, depending on the filter’s resistance, respiratory mechanics and basal inspiratory effort. In patients, FF-CPAP achieved pressures similar to those obtained on the bench. The massive training tool provided precious information on the use of Boussignac FF-CPAP on COVID-19 patients. Then 85 COVID-19 patients with ICU admission criteria over a 1-month period were studied upon FF-CPAP initiation for AHRF. FF-CPAP significantly decreased respiratory rate and increased SpO2. Thirty-six (43%) patients presented with respiratory indications for intubation prior to FF-CPAP initiation, and 13 (36%) of them improved without intubation. Overall, 31 patients (36%) improved with FF-CPAP alone and 17 patients (20%) did not require ICU admission. Patients with a respiratory rate > 32 breaths/min upon FF-CPAP initiation had a higher cumulative probability of intubation (p

Published
2021
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10. Reliability and limits of transport-ventilators to safely ventilate severe patients in special surge situations

Author

Dominique Savary, Arnaud Lesimple, François Beloncle, François Morin, François Templier, Alexandre Broc, Laurent Brochard, Jean-Christophe Richard, and Alain Mercat

Subjects
COVID-19, Acute Respiratory Distress Syndrome, Respiratory failure, Mechanical ventilation, Respiratory mechanics, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Background Intensive Care Units (ICU) have sometimes been overwhelmed by the surge of COVID-19 patients. Extending ICU capacity can be limited by the lack of air and oxygen pressure sources available. Transport ventilators requiring only one O2 source may be used in such places. Objective To evaluate the performances of four transport ventilators and an ICU ventilator in simulated severe respiratory conditions. Materials and methods Two pneumatic transport ventilators, (Oxylog 3000, Draeger; Osiris 3, Air Liquide Medical Systems), two turbine transport ventilators (Elisee 350, ResMed; Monnal T60, Air Liquide Medical Systems) and an ICU ventilator (Engström Carestation—GE Healthcare) were evaluated on a Michigan test lung. We tested each ventilator with different set volumes (Vtset = 350, 450, 550 ml) and compliances (20 or 50 ml/cmH2O) and a resistance of 15 cmH2O/l/s based on values described in COVID-19 Acute Respiratory Distress Syndrome. Volume error (percentage of Vtset) with P0.1 of 4 cmH2O and trigger delay during assist-control ventilation simulating spontaneous breathing activity with P0.1 of 4 cmH2O and 8 cmH2O were measured. Results Grouping all conditions, the volume error was 2.9 ± 2.2% for Engström Carestation; 3.6 ± 3.9% for Osiris 3; 2.5 ± 2.1% for Oxylog 3000; 5.4 ± 2.7% for Monnal T60 and 8.8 ± 4.8% for Elisee 350. Grouping all conditions (P0.1 of 4 cmH2O and 8 cmH2O), trigger delay was 50 ± 11 ms, 71 ± 8 ms, 132 ± 22 ms, 60 ± 12 and 67 ± 6 ms for Engström Carestation, Osiris 3, Oxylog 3000, Monnal T60 and Elisee 350, respectively. Conclusions In surge situations such as COVID-19 pandemic, transport ventilators may be used to accurately control delivered volumes in locations, where only oxygen pressure supply is available. Performances regarding triggering function are acceptable for three out of the four transport ventilators tested.

Published
2020
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11. Association of helicopter transportation and improved mortality for patients with major trauma in the northern French Alps trauma system: an observational study based on the TRENAU registry

Author

Francois-Xavier Ageron, Guillaume Debaty, Dominique Savary, Frederic Champly, Francois Albasini, Pascal Usseglio, Cécile Vallot, Samuel Galvagno, Pierre Bouzat, and for the TRENAU Group

Subjects
Emergency medical services, Helicopter, Mortality, Trauma, Triage, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Background Prompt prehospital triage and transportation are essential in an organised trauma system. The benefits of helicopter transportation on mortality in a physician-staffed pre-hospital trauma system remains unknown. The aim of the study was to assess the impact of helicopter transportation on mortality and prehospital triage. Methods Data collection was based on trauma registry for all consecutive major trauma patients transported by helicopter or ground ambulance in the Northern French Alps Trauma system between 2009 and 2017. The primary endpoint was in-hospital death. We performed multivariate logistic regression to compare death between helicopter and ground ambulance. Results Overall, 9458 major trauma patients were included. 37% (n = 3524) were transported by helicopter, and 56% (n = 5253) by ground ambulance. Prehospital time from the first call to the arrival at hospital was longer in the helicopter group compared to the ground ambulance group, respectively median time 95 [72–124] minutes and 85 [63–113] minutes (P

Published
2020
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12. Early inter-hospital transfer of patients with myocardial infarction without a doctor, paramedic or nurse on board: results from a French regional emergency care network

Author

Sebastien Cassan, Mihaela Rata, Claire Vallenet, Philippe Fromage, Frederic Champly, Patrick Broin, Guillaume Peribois, Valerie Sierra, Cedric Lutz, Lionel Mangin, Dominique Savary, François-Xavier Ageron, Loic Belle, and for the SCA-Alp Investigators

Subjects
SCA-Alp protocol, Myocardial infarction, Percutaneous coronary intervention, Transfer, France, Special situations and conditions, RC952-1245, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Background In France, patients with acute coronary syndromes (ACS) are usually transferred from remote hospitals to percutaneous coronary intervention (PCI) centres in mobile intensive care units (MICUs) with on-board medical staff. They are then returned to the remote hospitals by MICU 48 h after PCI. However, MICU transportation and beds in a PCI centre are in short supply. Therefore, we investigated clinical outcomes among intermediate-risk ACS patients who were transferred in private ambulances without an on-board medic or paramedic; and returned to the remote hospital sooner after PCI. Methods In the French Alps, the RESURCOR network manages ‘SCA-Alp’ transfers using strict management protocols in ambulances with trained drivers and automatic external defibrillators, but without heart rhythm monitoring. We conducted an observational retrospective study that assessed outcomes (death and emergency return to the PCI centre within 48 h) in patients transferred using SCA-Alp. Our population comprised stabilized patients with ST-segment elevation myocardial infarction (STEMI) who returned to the remote hospital within 24–48 h of PCI, and uncomplicated patients with non-ST-segment elevation myocardial infarction (NSTEMI) within 24–72 h of symptom onset who come from and returned to (‘round-trip’) the remote hospital on the day of PCI (return

Published
2019
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14. Hypothermia in trauma victims at first arrival of ambulance personnel: an observational study with assessment of risk factors

Author

Frédéric Lapostolle, James Couvreur, François Xavier Koch, Dominique Savary, Armelle Alhéritière, Michel Galinski, Jean-Luc Sebbah, Karim Tazarourte, and Frédéric Adnet

Subjects
Trauma, Body temperature, Prehospital settings, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Background Hypothermia is common in trauma victims and is associated with increased mortality, however its causes are little known. The objective of this study was to identify the risk factors associated with hypothermia in prehospital management of trauma victims. Methods This was an ancillary analysis of data recorded in the HypoTraum study, a prospective multicenter study conducted by the emergency medical services (EMS) of 8 hospitals in France. Inclusion criteria were: trauma victim, age over 18 years, and victim receiving prehospital care from an EMS team and transported to hospital by the EMS team in a medically equipped mobile intensive care unit. The following data were recorded: victim demographics, circumstances of the trauma, environmental factors, patient presentation, clinical data and time from accident to EMS arrival. Independent risk factors for hypothermia were analyzed in a multivariate logistic regression model. Results A total of 461 trauma patients were included in the study. Road traffic accidents (N = 261; 57%) and falls (N = 65; 14%) were the main causes of trauma. Hypothermia (

Published
2017
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16. Choix du soluté pour le remplissage vasculaire en situation critique

Author

Olivier Joannes Boyau, Philippe Le Conte, Marie Pierre Bonnet, Eric Cesareo, Benjamin Chousterman, Djamila Chaiba, Benedicte Douay, Emmanuel Futier, Anatole Harrois, Catherine Huraux, Carole Ichai, Eric Meaudre, Olivier Mimoz, Laurent Muller, Mathieu Oberlin, Nicolas Peschanski, Hervé Quintard, Geoffroy Rousseau, Dominique Savary, Alexy Tran-Dinh, Barbara Villoing, Anthony Chauvin, and Emmanuel Weiss

Subjects
Anesthesiology and Pain Medicine
Published
2022

18. Impact of Specific Emergency Measures on Survival in Out-of-Hospital Traumatic Cardiac Arrest

Author

Dominique Savary, François Morin, Delphine Douillet, Adrien Drouet, François Xavier Ageron, Romain Charvet, Bruno Carneiro, Pierre Metton, Marc Fadel, Alexis Descatha, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Centre Hospitalier Annecy-Genevois [Saint-Julien-en-Genevois], Centre Hospitalier Universitaire Vaudois [Lausanne] (CHUV), Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique )-Institut National de la Santé et de la Recherche Médicale (INSERM)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Université de Rennes 1 (UR1), and Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-Université d'Angers (UA)

Subjects
Emergency Medical Services, [SDV]Life Sciences [q-bio], 030208 emergency & critical care medicine, cardiac arrest, 030204 cardiovascular system & hematology, Emergency Nursing, Cardiopulmonary Resuscitation, Hospitals, 3. Good health, 03 medical and health sciences, trauma, 0302 clinical medicine, Emergency Medicine, Humans, Advanced Life Support, Out-of-Hospital Cardiac Arrest, Retrospective Studies
Abstract

Introduction:The management of out-of-hospital traumatic cardiac arrest (TCA) for professional rescuers entails Advanced Life Support (ALS) with specific actions to treat the potential reversible causes of the arrest: hypovolemia, hypoxemia, tension pneumothorax (TPx), and tamponade. The aim of this study was to assess the impact of specific rescue measures on short-term outcomes in the context of resuscitating patients with a TCA.Methods:This retrospective study concerns all TCA patients treated in two emergency medical units, which are part of the Northern French Alps Emergency Network (RENAU), from January 2004 through December 2017. Utstein variables and specific rescue measures in TCA were compiled: fluid expansion, pelvic stabilization, tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at Day 30 with good neurological status (Cerebral Performance Category [CPC] score CPC 1 and CPC 2).Results:In total, 287 resuscitation attempts in TCA were included and 279 specific interventions were identified: 262 fluid expansions, 41 pelvic stabilizations, five tourniquets, and 175 bilateral thoracostomies (including 44 with TPx).Conclusion:Among the standard resuscitation measures to treat the reversible causes of cardiac arrest, this study found that bilateral thoracostomy and tourniquet application on a limb hemorrhage improve survival in TCA. A larger sample for pelvic stabilization is needed.

Published
2021

19. What is the true place of the SARS‐CoV‐2 rapid point‐of‐care antigen test in the hospital setting? Lessons learned from real life

Author

Steven Roger, Caroline Lefeuvre, Adeline Pivert, Alexandra Ducancelle, Dominique Savary, Élise Bouthry, and Hélène Le Guillou‐Guillemette

Subjects
Adult, Aged, 80 and over, Male, Time Factors, Adolescent, SARS-CoV-2, COVID-19, Middle Aged, Sensitivity and Specificity, Hospitals, COVID-19 Serological Testing, Young Adult, Infectious Diseases, Point-of-Care Testing, COVID-19 Nucleic Acid Testing, Virology, Humans, Female, Antigens, Viral, Aged
Abstract

To assist in the clinical management of patients and to support infection control, we tested the use of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) point-of-care antigen test (AgPOC) for unplanned hospitalization, coupled with a nucleic acid amplification test (NAAT) using specimens collected at the same time upon arrival. The aim of this study was to assess the performance of the AgPOC in this specific use compared to NAAT for SARS-CoV-2 diagnosis, in the context of the low prevalence of infection. For 5 months (between two peaks in France of the SARS-CoV-2 pandemic), all patients admitted who undertook the AgPOC/NAAT paired tests were included in the study. AgPOC performances were determined considering the clinical status and the delay of symptoms onset. NAAT and AgPOC results were available for 4425 subjects. AgPOC results showed a homogeneous specificity (97%) but a low sensitivity at 45.8%. Considering the national guidelines, sensitivity dropped to 32.5% in cases of symptomatic patients with symptoms older than 5 days or more. This study shows the poor performance of AgPOC for entry screening of patients in hospitals. AgPOC may represent a useful tool in the hospital setting only if the use is restricted to patients with consistent symptoms less than 4 days old.

Published
2021

20. Prehospital predictors for return of spontaneous circulation in traumatic cardiac arrest

Author

Eric Mercier, Carlos El Khoury, Dominique Savary, Axel Benhamed, Valentine Canon, Hervé Hubert, Matthieu Heidet, Pierre-Yves Gueugniaud, Karim Tazarourte, and Amaury Gossiome

Subjects
Male, Emergency Medical Services, Resuscitation, Traumatic cardiac arrest, Return of spontaneous circulation, Critical Care and Intensive Care Medicine, Logistic regression, Humans, Medicine, Registries, Organ donation, Asystole, Retrospective Studies, business.industry, Retrospective cohort study, Prognosis, medicine.disease, Survival Analysis, Cardiopulmonary Resuscitation, Advanced life support, Anesthesia, Female, Surgery, France, Return of Spontaneous Circulation, business, Out-of-Hospital Cardiac Arrest
Abstract

Traumatic cardiac arrests (TCAs) are associated with high mortality and the majority of deaths occur at the prehospital scene. The aim of the present study was to assess, in a prehospital physician-led emergency medical system, the factors associated with sustained return of spontaneous circulation (ROSC) in TCA, including advanced life procedures. The secondary objectives were to assess factors associated with 30-day survival in TCA, evaluate neurological recovery in survivors, and describe the frequency of organ donation among patients experiencing a TCA.We conducted a retrospective study of all TCA patients included in the French nationwide cardiac arrest registry from July 2011 to November 2020. Multivariable logistic regression analysis was used to identify factors independently associated with ROSC.A total of 120,045 out-of-hospital cardiac arrests were included in the registry, among which 4,922 TCA were eligible for analysis. Return of spontaneous circulation was sustained on-scene in 21.1% (n = 1,037) patients. Factors significantly associated with sustained ROSC were not-asystolic initial rhythms (pulseless electric activity (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.40-2.35; p0.001), shockable rhythm (OR, 1.83; 95% CI, 1.12-2.98; p = 0.016), spontaneous activity (OR, 3.66; 95% CI, 2.70-4.96; p0.001), and gasping at the mobile medical team (MMT) arrival (OR, 1.40; 95% CI, 1.02-1.94; p = 0.042). The MMT interventions significantly associated with ROSC were as follows: intravenous fluid resuscitation (OR, 3.19; 95% CI, 2.69-3.78; p0.001), packed red cells transfusion (OR, 2.54; 95% CI, 1.84-3.51; p0.001), and external hemorrhage control (OR, 1.74; 95% CI, 1.31-2.30; p0.001). Among patients who survived (n = 67), neurological outcome at Day 30 was favorable (cerebral performance categories 1-2) in 72.2% cases (n = 39/54) and 1.4% (n = 67/4,855) of deceased patients donated one or more organ.Sustained ROSC was frequently achieved in patients not in asystole at MMT arrival, and higher ROSC rates were achieved in patients benefiting from specific advanced life support interventions. Organ donation was somewhat possible in TCA patients undergoing on-scene resuscitation.Prognostic and epidemiologic, Level III.

Published
2021

21. Risk of symptomatic venous thromboembolism in mild and moderate COVID-19: A comparison of two prospective European cohorts

Author

Jérémie Riou, Rafael Mahieu, Dominique Savary, Pierre-Marie Roy, Caroline Soulie, Delphine Douillet, Francois Morin, A Penaloza, Thomas Moumneh, UCL - SSS/IREC/EPID - Pôle d'épidémiologie et biostatistique, UCL - (SLuc) Service des urgences, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), F-CRIN, Innovative clinical research network in vaccinology (I-REIVAC), Université d'Angers (UA), Université Catholique de Louvain = Catholic University of Louvain (UCL), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), École des Hautes Études en Santé Publique [EHESP] (EHESP), Plate-forme de Recherche en Imagerie et Spectroscopie Multi-modales [SFR ICAT - UA] (PRISM), SFR UA 4208 Interactions Cellulaires et Applications Thérapeutiques (ICAT), Université d'Angers (UA)-Université d'Angers (UA), Centre de Recherche en Cancérologie et Immunologie Nantes-Angers (CRCINA), Université d'Angers (UA)-Université de Nantes (UN)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Centre hospitalier universitaire de Nantes (CHU Nantes), French Clinical Research Infrastructure Network on Venous Thromboembolism (FCRIN INNOVTE), Chard-Hutchinson, Xavier, Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Plate-forme de Recherche en Imagerie et Spectroscopie Multi-modales (PRISM [SFR ICAT - UA]), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Nantes - UFR de Médecine et des Techniques Médicales (UFR MEDECINE), and Université de Nantes (UN)-Université de Nantes (UN)-Centre hospitalier universitaire de Nantes (CHU Nantes)-Centre National de la Recherche Scientifique (CNRS)-Université d'Angers (UA)

Subjects
medicine.medical_specialty, Deep vein, [SDV]Life Sciences [q-bio], VTE risk, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Full Length Article, medicine, Humans, Prospective Studies, cardiovascular diseases, Prospective cohort study, 030304 developmental biology, Aged, Retrospective Studies, 0303 health sciences, business.industry, SARS-CoV-2, Incidence (epidemiology), SARS-CoV-2 infection, COVID-19, Hematology, Emergency department, Venous Thromboembolism, medicine.disease, Thrombosis, 3. Good health, Pulmonary embolism, [SDV] Life Sciences [q-bio], medicine.anatomical_structure, Cohort, Propensity score matching, business, Venous thromboembolism
Abstract

International audience; Background: Severely ill patients with SARS-CoV-2 have an increased risk of venous thromboembolism (VTE) i.e., deep vein thrombosis and pulmonary embolism. However, the VTE risk in patients with mild and moderate COVID-19, hospitalized or managed at home, remain uncertain. The aims of this study were to assess the rate and the risk factors symptomatic VTE, in patients with mild and moderate COVID-19 and to compare them to a cohort of similar patients without COVID-19. Methods: Patients presenting to the emergency department (ED) of participating centers for confirmed or probable mild or moderate COVID-19 and not having acute VTE were included. This COVID-19 cohort was retrospectively compared to a prospective cohort of similar ED patients using propensity score matching. The main outcome was the rate of symptomatic VTE within the 28 days after ED presentation. Results: A total of 2292 patients were included in the COVID-19 cohort. The 28-day incidence of symptomatic VTE was 1.3% (n = 29/2292, 95%CI: 0.9 to 1.8), 2.3% (n = 20/866, 95%CI: 1.5 to 3.5) in moderate COVID-19 patients and 0.6% (n = 9/1426; 95%CI: 0.3 to 1.2) in mild COVID-19 patients managed as outpatients. An age over 65 years and hospitalization were independent risk factors of VTE. After adjustment, patients in the COVID19 cohort had an absolute increase in over symptomatic VTE risk of +1.69% (95%CI, 0.88 to 2.51) versus patients in the comparison cohort (n = 1539). Conclusions: Patients with moderate COVID-19 presenting to the ED had a high risk of subsequent VTE. Trial registration: Ethics committee of the CHU of Angers (N degrees 2020/87).

Published
2021

22. Use of troponin assay after electrical injuries: a 15-year multicentre retrospective cohort in emergency departments

Author

Yara Amro, Quentin Le Bastard, Benjamin Gicquel, Idriss Arnaudet, Dominique Savary, Delphine Douillet, François Javaudin, Stéphanie Kalwant, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Centre hospitalier universitaire de Nantes (CHU Nantes), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Microbiotes, Hôtes, Antibiotiques et Résistances bactériennes (MiHAR) (MiHAR), Université de Nantes - UFR de Médecine et des Techniques Médicales (UFR MEDECINE), Université de Nantes (UN)-Université de Nantes (UN), Université de Nantes (UN), Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), and Chard-Hutchinson, Xavier

Subjects
Adult, Cardiac arrhythmias, Chest Pain, medicine.medical_specialty, [SDV]Life Sciences [q-bio], MACE, 030204 cardiovascular system & hematology, Electric injuries, Critical Care and Intensive Care Medicine, Likelihood ratios in diagnostic testing, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, medicine, Clinical endpoint, Humans, ST segment, Prospective Studies, 030212 general & internal medicine, Child, Retrospective Studies, Original Research, Predictive marker, biology, business.industry, RC86-88.9, Correction, Retrospective cohort study, Medical emergencies. Critical care. Intensive care. First aid, Emergency department, Emergency Department, Troponin, 3. Good health, [SDV] Life Sciences [q-bio], Emergency Medicine, biology.protein, Emergency Service, Hospital, business, Biomarkers, Mace
Abstract

Background Patients with electrical injury are considered to be at risk of cardiac arrhythmia. Assessing the risk of developing a major adverse cardiac event (MACE) is the cornerstone of patient management. The aim of this study was to assess the performance of initial troponin and troponin rise to predict Major Adverse Cardiac Events (MACEs) in all patients with electrical injuries admitted to the Emergency Department. Methods This is a multicentre retrospective study in which consecutive patients with electrical injuries admitted to the Emergency Departments (ED) (adult and paediatric) of five French Hospitals were included between 2005 and 2019. The threshold for troponin elevation is based on the European Society of Cardiology guidelines for patients presenting without persistent ST segment elevation. The primary endpoint was the rate of MACE. Results A total of 785 included patients were admitted to ED with a first diagnosis of electrical injury during the study period. Troponin assays were performed in 533 patients (67.9%), including 465 of 663 adults (70.1%) and 68 of 122 children (55.7%) and 17/533 (3.2%) of patients had an initial elevated troponin. If none of the clinical criteria for MACE were present (i.e., previous known heart disease, exposure to a high voltage of ≥ 1000 Volts, initial loss of consciousness, or an abnormal initial ECG), this defined a low-risk subgroup (n = 573, 76.0%) that could be safely discharged. The initial positive troponin assay had a sensitivity of 83.3 (95% CI 35.9–99.6%), a specificity of 97.7 (95% CI 96.1–98.8%), a positive likelihood ratio 36.6 (95% CI 18.8–71.1%) and a negative predictive value of 99.9 (95% CI 99.2–99.9%) in predicting a MACE. Conclusions Troponin assay appears to be a predictive marker of MACE risk and should be considered in high-risk patients.

Published
2021

23. Acting on the potentially reversible causes of traumatic cardiac arrest: Possible but not sufficient

Author

Adrien Drouet, Thomas Moumned, Francois Morin, Pierre Metton, Marc Fadel, Bruno Carneiro, Dominique Savary, Delphine Douillet, Alexis Descatha, École des Hautes Études en Santé Publique [EHESP] (EHESP), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), CHU Annecy, Université d'Angers (UA)-Université de Rennes 1 (UR1), and Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique )

Subjects
Emergency Medical Services, Resuscitation, medicine.medical_specialty, [SDV]Life Sciences [q-bio], Traumatic cardiac arrest, Thoracostomy, 030204 cardiovascular system & hematology, Emergency Nursing, Trauma, 03 medical and health sciences, 0302 clinical medicine, Clinical endpoint, Humans, Medicine, Survival rate, Retrospective Studies, business.industry, 030208 emergency & critical care medicine, Retrospective cohort study, Cardiac arrest, medicine.disease, Cardiopulmonary Resuscitation, Heart Arrest, 3. Good health, Advanced life support, Emergency medicine, Emergency Medicine, Cardiology and Cardiovascular Medicine, business, Advanced airway management, Out-of-Hospital Cardiac Arrest
Abstract

International audience; INTRODUCTION: Traumatic cardiac arrest (TCA) guidelines emphasize specific actions that aim to treat the potential reversible causes of the arrest. The aim of this study was to measure the impact of these recommendations on specific rescue measures carried out in the field, and their influence on short-term outcomes in the resuscitation of TCA patients. METHODS: We conducted a retrospective study of all TCA patients treated in two emergency medical units, which are part of the Northern Alps Emergency Network, from January 2004 to December 2017. We categorised cases into three periods: pre-guidelines (from January 2004 to December 2007), during guidelines (from January 2008 to December 2011), and post-guidelines (from January 2012 to December 2017). Local guidelines, a physician education programme, and specific training were set up during the post-guidelines period to increase adherence to recommendations. Utstein variables, and specific rescue measures were collected: advanced airway management, fluid administration, pelvic stabilisation or tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at day 30 with good neurological status (cerebral performance category scores 1 and 2) in each period, considering the pre-guidelines period as the reference. RESULTS: There were 287 resuscitation attempts in the TCA cases included, and 279 specific interventions were identified with a significant increase in the number of fluid expansions (+16%), bilateral thoracostomies (+75%), and pelvic stabilisations (+25%) from the pre- to post-guidelines periods. However, no improvement in survival over time was found. CONCLUSION: Reversible measures were applied but to a varying degree, and may not adequately capture pre-hospital performance on overall TCA survival.

Published
2021

24. A novel capnogram analysis to guide ventilation during continuous chest compressions resuscitation. From clinical to experimental observations

Author

Arnaud Lesimple, Caroline Fritz, Alice Hutin, Emmanuel Charbonney, Dominique Savary, Stéphane Delisle, Paul Ouellet, Gilles Bronchti, Fanny Lidouren, Thomas Piraino, François Beloncle, Nathan Prouvez, Alexandre Broc, Alain Mercat, Laurent Brochard, Renaud Tissier, Jean-Christophe Richard, and Cardiac Arrest and Ventilation International Association for CAVIAR

Abstract

Background: Cardio-Pulmonary Resuscitation (CPR) decreases lung volume below the functional residual capacity and can generate intrathoracic airway closure. Conversely, large insufflations can induce thoracic distension and jeopardize circulation. The capnogram (CO2 signal) obtained during continuous chest compressions can reflect intrathoracic airway closure and we hypothesized here that it can also indicate thoracic distension. Objectives: to test whether a specific capnogram may identify thoracic distension during CPR and assess its impact on gas exchange and hemodynamics. Methods: 1. In out-of-hospital cardiac arrest patients, we identified on capnograms three patterns: intrathoracic airway closure, thoracic distension or regular pattern. An algorithm was designed to identify them automatically.2. To link CO2 patterns with ventilation, we conducted three experiments:i) Reproducing the CO2 patterns in human cadavers. ii) Assessing the influence of tidal volume and respiratory mechanics on thoracic distension using a mechanical lung model. iii) Exploring the impact of thoracic distension patterns on different circulation parameters during CPR on a pig model. Measurements and main results: Clinical data: 202 patients were included. Intrathoracic airway closure was present in 35%, thoracic distension in 22% and regular pattern in 43%. Experiments:i) Higher insufflated volumes reproduced thoracic distension CO2 patterns in 5 cadavers. ii) In the mechanical lung model, thoracic distension patterns were associated with higher volumes and longer time constants. iii) In six pigs during CPR with various tidal volumes, a CO2 pattern of thoracic distension, but not tidal volume per se, was associated with a significant decrease in blood pressure and cerebral perfusion. Conclusions: During CPR, intrathoracic airway closure, thoracic distension or regular pattern can be identified by capnogram analysis. A thoracic distension pattern on the capnogram may indicate a negative impact of ventilation on blood pressure and cerebral perfusion during CPR, not predicted by tidal volume per se.

Published
2022

25. Cardiac arrest: work on global prevention, global at prevention at work?

Author

Alexis Descatha, Marc Fadel, Dominique Savary, École des Hautes Études en Santé Publique [EHESP] (EHESP), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), and Chard-Hutchinson, Xavier

Subjects
[SDV] Life Sciences [q-bio], [SDV]Life Sciences [q-bio], Emergency Medicine, Humans, Emergency Nursing, Cardiology and Cardiovascular Medicine, Out-of-Hospital Cardiac Arrest, ComputingMilieux_MISCELLANEOUS
Abstract

International audience

Published
2022

26. Gas Exchange and Respiratory Mechanics after a Cardiac Arrest: A Clinical Description of Cardiopulmonary Resuscitation-associated Lung Edema

Author

François M. Beloncle, Hamid Merdji, Arnaud Lesimple, Bertrand Pavlovsky, Elise Yvin, Dominique Savary, Alain Mercat, Ferhat Meziani, and Jean-Christophe Richard

Subjects
Pulmonary and Respiratory Medicine, Respiratory Mechanics, Edema, Humans, Pulmonary Edema, Critical Care and Intensive Care Medicine, Lung, Cardiopulmonary Resuscitation, Heart Arrest
Published
2022

27. Retour d’expérience sur les transports Smur des patients Covid-19

Author

Francois Morin, Dominique Savary, A. Ricard Hibon, Delphine Douillet, and Nicolas Peschanski

Subjects
03 medical and health sciences, 0302 clinical medicine, 010102 general mathematics, Emergency Medicine, 030212 general & internal medicine, 0101 mathematics, 01 natural sciences
Abstract

Dès la fin du mois de février 2020, les urgentistes français ont été confrontés à une situation inédite et complexe dans la gestion des cas les plus sévères d’infections pulmonaires associées au nouveau coronavirus (SARSCoV- 2). Les informations en provenance de Chine et les recommandations initiales de l’Organisation mondiale de la santé ont rapidement amené à considérer l’intubation et la ventilation mécanique précoce des malades atteints par la pneumonie de la Covid-19. Or, dès la fin du mois de mars 2020, grâce aux retours d’expérience et de prise en charge, d’abord de la part des réanimateurs et urgentistes italiens, puis espagnols, les pratiques et les recommandations concernant les modalités d’oxygénation et de ventilation des patients Covid-19 ont évolué. Le caractère exceptionnel de cette pandémie et la grande adaptabilité des services de Samu/Smur de France, en l’espace de quelques semaines, pour prendre en charge ces patients oxygénodépendants, justifient que nous en fassions le retour d’expérience, et ce, d’autant plus que nous sommes exposés à un risque de recrudescence d’infections respiratoires graves associées au SARS-CoV-2 à court terme, risquant de saturer une nouvelle fois notre système de santé. Nous détaillons donc ici le retour d’expérience des prises en charge médicales préhospitalières concernant principalement les supports d’oxygénation et de ventilation mécanique.

Published
2020

28. Emergency care for a worker with a possible infection to COVID-19

Author

Dominique Savary, Alexis Descatha, P. Havette, M. Fadel, M. Baer, Corinne Letheux, Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), SAMU 92 [Garches], Hôpital Raymond Poincaré [AP-HP], La poste, and Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique )

Subjects
03 medical and health sciences, 0302 clinical medicine, [SDV]Life Sciences [q-bio], Public Health, Environmental and Occupational Health, 030212 general & internal medicine, 030210 environmental & occupational health, ComputingMilieux_MISCELLANEOUS
Abstract

National audience

Published
2020

29. Deployment of 'super lay-rescuers' equipped with AED to improve OHCA survival: An innovative partnership between emergency medical service, city hall and a mobile application in France

Author

François Morin, Delphine Douillet, Lionel Lamhaut, Marc Fadel, Dominique Savary, Chard-Hutchinson, Xavier, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Gastro-Entérologie, Hépatologie et Nutrition pédiatriques (CHU Necker - Enfants Malades [AP-HP]), CHU Necker - Enfants Malades [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Paris-Centre de Recherche Cardiovasculaire (PARCC (UMR_S 970/ U970)), Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), École des Hautes Études en Santé Publique [EHESP] (EHESP), Institut de recherche en santé, environnement et travail (Irset), and Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique )

Subjects
Emergency Medical Services, [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, [SDV]Life Sciences [q-bio], Emergency Nursing, Mobile Applications, Cardiopulmonary Resuscitation, [SDV] Life Sciences [q-bio], Emergency Medicine, Humans, France, Cardiology and Cardiovascular Medicine, Out-of-Hospital Cardiac Arrest, ComputingMilieux_MISCELLANEOUS, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, Defibrillators
Abstract

International audience

Published
2022

30. Do Not Throw Out the Baby With the Bathwater

Author

Thomas Moumneh, Delphine Douillet, Dominique Savary, Pierre-Marie Roy, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), École des Hautes Études en Santé Publique [EHESP] (EHESP), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Chard-Hutchinson, Xavier, Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique )-Institut National de la Santé et de la Recherche Médicale (INSERM)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Université de Rennes 1 (UR1), and Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-Université d'Angers (UA)

Subjects
[SDV] Life Sciences [q-bio], 03 medical and health sciences, 0302 clinical medicine, [SDV]Life Sciences [q-bio], 010102 general mathematics, Emergency Medicine, 030212 general & internal medicine, 0101 mathematics, 01 natural sciences, ComputingMilieux_MISCELLANEOUS
Abstract

International audience

Published
2022

31. Continuous positive airway pressure for respiratory support during COVID-19 pandemic: a frugal approach from bench to bedside

Author

Bilal Badat, Nicolas Mongardon, Keyvan Razazi, C. Deguillard, Frédéric Schlemmer, Mehdi Khellaf, Raphaëlle Huguet, Pascal Lim, Nicolas de Prost, François Templier, Karim Jaffal, Dominique Savary, Francois Morin, Elena Fois, Yvon Deplante, François Beloncle, François Perier, Constance Guillaud, Laurent Brochard, Philippe Grimbert, Armand Mekontso Dessap, Anne-Fleur Haudebourg, Jean-Christophe Richard, Samuel Tuffet, Manuella Pons, Vincent Audard, Arnaud Lesimple, Alain Mercat, Guillaume Carteaux, Institut Mondor de Recherche Biomédicale (IMRB), Institut National de la Santé et de la Recherche Médicale (INSERM)-IFR10-Université Paris-Est Créteil Val-de-Marne - Paris 12 (UPEC UP12), CHU Henri Mondor [Créteil], Université Paris-Est Créteil Val-de-Marne - Paris 12 (UPEC UP12), Centre Hospitalier Universitaire [Grenoble] (CHU), Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Département de neurosciences (CHU Henri Mondor), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Henri Mondor, University of Toronto, Keenan Research Centre of the Li Ka Shing Knowledge Institute [Toronto], Centre de Recherche en Acquisition et Traitement de l'Image pour la Santé (CREATIS), Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon-Institut National des Sciences Appliquées de Lyon (INSA Lyon), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Modeling & analysis for medical imaging and Diagnosis (MYRIAD), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), CHU Henri Mondor, Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet [Saint-Étienne] (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet [Saint-Étienne] (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL), Chard-Hutchinson, Xavier, Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), and Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL)

Subjects
medicine.medical_specialty, medicine.medical_treatment, Continuous positive airway pressure, Context (language use), Respiratory physiology, Critical Care and Intensive Care Medicine, [SDV.MHEP.PSR]Life Sciences [q-bio]/Human health and pathology/Pulmonology and respiratory tract, 03 medical and health sciences, Work of breathing, 0302 clinical medicine, [SDV.MHEP.MI]Life Sciences [q-bio]/Human health and pathology/Infectious diseases, Anesthesiology, medicine, Intubation, Tidal volume, Acute hypoxemic respiratory failure, Frugal innovation, [SDV.MHEP.ME] Life Sciences [q-bio]/Human health and pathology/Emerging diseases, [SDV.MHEP.ME]Life Sciences [q-bio]/Human health and pathology/Emerging diseases, business.industry, Research, lcsh:Medical emergencies. Critical care. Intensive care. First aid, COVID-19, 030208 emergency & critical care medicine, lcsh:RC86-88.9, Oxygenation, 3. Good health, respiratory tract diseases, 030228 respiratory system, Emergency medicine, [SDV.MHEP.MI] Life Sciences [q-bio]/Human health and pathology/Infectious diseases, [SDV.MHEP.PSR] Life Sciences [q-bio]/Human health and pathology/Pulmonology and respiratory tract, business
Abstract

Background We describe a frugal approach (focusing on needs, performance, and costs) to manage a massive influx of COVID-19 patients with acute hypoxemic respiratory failure (AHRF) using the Boussignac valve protected by a filter (“Filter Frugal CPAP”, FF-CPAP) in and out the ICU. Methods (1) A bench study measured the impact of two filters with different mechanical properties on CPAP performances, and pressures were also measured in patients. (2) Non-ICU healthcare staff working in COVID-19 intermediate care units were trained with a video tutorial posted on a massive open online course. (3) A clinical study assessed the feasibility and safety of using FF-CPAP to maintain oxygenation and manage patients out of the ICU during a massive outbreak. Results Bench assessments showed that adding a filter did not affect the effective pressure delivered to the patient. The resistive load induced by the filter variably increased the simulated patient’s work of breathing (6–34%) needed to sustain the tidal volume, depending on the filter’s resistance, respiratory mechanics and basal inspiratory effort. In patients, FF-CPAP achieved pressures similar to those obtained on the bench. The massive training tool provided precious information on the use of Boussignac FF-CPAP on COVID-19 patients. Then 85 COVID-19 patients with ICU admission criteria over a 1-month period were studied upon FF-CPAP initiation for AHRF. FF-CPAP significantly decreased respiratory rate and increased SpO2. Thirty-six (43%) patients presented with respiratory indications for intubation prior to FF-CPAP initiation, and 13 (36%) of them improved without intubation. Overall, 31 patients (36%) improved with FF-CPAP alone and 17 patients (20%) did not require ICU admission. Patients with a respiratory rate > 32 breaths/min upon FF-CPAP initiation had a higher cumulative probability of intubation (p Conclusion Adding a filter to the Boussignac valve does not affect the delivered pressure but may variably increase the resistive load depending on the filter used. Clinical assessment suggests that FF-CPAP is a frugal solution to provide a ventilatory support and improve oxygenation to numerous patients suffering from AHRF in the context of a massive outbreak.

Published
2021

32. Adaptation of ED design layout during the COVID-19 pandemic: a national cross-sectional survey

Author

Pauline Ravon, Thomas Saloux, Francois Morin, Bruno Carneiro, Dominique Savary, Pierre-Marie Roy, Delphine Douillet, Thomas Moumneh, Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), École des Hautes Études en Santé Publique [EHESP] (EHESP), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), and Chard-Hutchinson, Xavier

Subjects
emergency department, Cross-sectional study, [SDV]Life Sciences [q-bio], emergency care systems, Context (language use), Computer-assisted web interviewing, Critical Care and Intensive Care Medicine, emergency departments, 03 medical and health sciences, 0302 clinical medicine, Pandemic, medicine, Humans, Hospital Design and Construction, 030212 general & internal medicine, Pandemics, Original Research, Health Services Needs and Demand, SARS-CoV-2, business.industry, Staff management, COVID-19, 030208 emergency & critical care medicine, Workload, General Medicine, Emergency department, medicine.disease, Triage, [SDV] Life Sciences [q-bio], Cross-Sectional Studies, efficiency, Health Care Surveys, Emergency Medicine, France, Medical emergency, Emergency Service, Hospital, business
Abstract

BackgroundThe aim was to describe the organisational changes in French EDs in response to the COVID-19 pandemic with regard to architectural constraints and compare with the recommendations of the various bodies concerning the structural adjustments to be made in this context.MethodsAs part of this cross-sectional study, all heads of emergency services or their deputies were contacted to complete an electronic survey. This was a standardised online questionnaire consisting of four parts: characteristics of the responding centre, creation of the COVID-19 zone and activation of the hospital’s emergency operations plan, flow and circulation of patients and, finally, staff management. Each centre was classified according to its workload related to COVID-19 and its size (university hospital centre, high-capacity hospital centre and low-capacity hospital centre). The main endpoint was the frequency of implementation of international guidelines for ED organisation.ResultsBetween 11 May and 20 June 2020, 57 French EDs completed the online questionnaire and were included in the analysis. Twenty-eight EDs were able to separate patient flows into two zones: high and low viral density (n=28/57, 49.1%). Of the centres included, 52.6% set up a specific triage area for patients with suspected COVID-19 (n=30/57). Whereas, in 15 of the EDs (26.3%), the architecture made it impossible to increase the surface area of the ED.ConclusionAll EDs have adapted, but many of the changes recommended for the organisation of ED could not be implemented. ED architecture constrains adaptive capacities in the context of COVID-19.

Published
2021

33. Interhospital transfer of COVID-19 patients treated with high-flow nasal oxygen therapy

Author

Francois Morin, Elophe Dubie, Dominique Savary, Pascal Usseglio, Amaury Serruys, Centre Hospitalier Métropole Savoie [Chambéry], Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Université d'Angers (UA)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), and Chard-Hutchinson, Xavier

Subjects
medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), medicine.medical_treatment, [SDV]Life Sciences [q-bio], medicine.disease_cause, 03 medical and health sciences, 0302 clinical medicine, Intensive care, Oxygen therapy, medicine, Intubation, In patient, High-flow, business.industry, RC86-88.9, Nasal, Interhospital, COVID-19, 030208 emergency & critical care medicine, Medical emergencies. Critical care. Intensive care. First aid, Brief Research Report, 3. Good health, [SDV] Life Sciences [q-bio], Transfer, Oxygen, 030228 respiratory system, Emergency medicine, Emergency Medicine, Observational study, High flow, business, Nasal cannula
Abstract

At the start of the COVID-19 pandemic, early intubation was recommended on the basis of worldwide observations of severe hypoxemia. However, some patients were ultimately able to benefit from high-flow nasal cannula (HFNC) and thus avoid intubation. During the “second wave” (September to December 2020 in France), some emergency departments implemented HFNC in patients with severe COVID-19. The question then arose regarding the transfer of these most serious patients to intensive care units (ICU) and of the respiratory modalities to be used during this transfer. To assess the feasibility of interhospital transfers of COVID-19 patients needing HFNC, we conducted a bi-centric prospective observational study of all medical transfers of patients needing HFNC with the Chambéry and Angers (France) mobile emergency and intensive care service (SMUR) during the “second wave” of the COVID-19 pandemic in France. Analysis of these 42 patients showed no significant variation in the respiratory requirements during the transfer. Overall, 52% of patients were intubated during their stay in ICU, including three patients intubated before or during transfer. Interhospital transfer with HFNC is very high-risk, and intubation remains indicated in the most unstable patients. However, 48% of patients benefited from HFNC and were thus able to avoid intubation during their transfer and ICU stay; for these patients, intubation would probably have been indicated in the absence of available HFNC techniques.

Published
2021

34. Basic life support training in out-of-hospital cardiac arrest: From the youth to a special 'Senior Force Against Cardiac Arrest'

Author

Alexis Descatha, Thomas Bizouard, Dominique Savary, Francois Morin, Delphine Douillet, Delphine Plard, Suzanne Schunder-Tatzber, Marc Fadel, Pascal Cassan, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), École des Hautes Études en Santé Publique [EHESP] (EHESP), OMV [Vienne], Fédération internationale des Sociétés de la Croix-Rouge et du Croissant-Rouge (IFIRC Global First Aid Reference Centre), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Chard-Hutchinson, Xavier, Université d'Angers (UA)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), and Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC)

Subjects
medicine.medical_specialty, Emergency Medical Services, Occupational Medicine, Adolescent, [SDV]Life Sciences [q-bio], 030204 cardiovascular system & hematology, Emergency Nursing, Out of hospital cardiac arrest, Occupational medicine, 03 medical and health sciences, 0302 clinical medicine, medicine, Humans, ComputingMilieux_MISCELLANEOUS, Out-of-hospital cardiac arrest, business.industry, Basic life support, 030208 emergency & critical care medicine, Basic life support training, medicine.disease, Cardiopulmonary Resuscitation, [SDV] Life Sciences [q-bio], Emergency Medicine, Medical emergency, Cardiology and Cardiovascular Medicine, business
Abstract

International audience

Published
2021

35. Assessment of physicians’ resilience level during the COVID-19 pandemic

Author

E Riquin, P.-M. Roy, Delphine Douillet, Olivier Hugli, P Miroux, Francois Morin, Thomas Moumneh, Rafael Mahieu, Maxime Léger, M Noizet, F Javaudin, M Oberlin, Dominique Savary, E Thibaud, Jérémie Riou, A Caillaud, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Micro et Nanomédecines Translationnelles (MINT), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut de Chimie du CNRS (INC)-Centre National de la Recherche Scientifique (CNRS), Hôpital pasteur [Colmar], Centre Hospitalier de Mulhouse, site du Hasenrain (Mulhouse), Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg (UNISTRA), Nanomédecine Régénérative (NanoRegMed), Université de Strasbourg (UNISTRA)-Institut National de la Santé et de la Recherche Médicale (INSERM), Centre de Recherche en Cancérologie et Immunologie Nantes-Angers (CRCINA), Université d'Angers (UA)-Université de Nantes (UN)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Centre hospitalier universitaire de Nantes (CHU Nantes), Centre hospitalier universitaire de Nantes (CHU Nantes), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Lausanne University Hospital, Chard-Hutchinson, Xavier, Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Nantes - UFR de Médecine et des Techniques Médicales (UFR MEDECINE), Université de Nantes (UN)-Université de Nantes (UN)-Centre hospitalier universitaire de Nantes (CHU Nantes)-Centre National de la Recherche Scientifique (CNRS)-Université d'Angers (UA), Université d'Angers (UA)-Université de Rennes 1 (UR1), and Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique )

Subjects
Adult, Male, medicine.medical_specialty, [SDV.MHEP.PSM] Life Sciences [q-bio]/Human health and pathology/Psychiatrics and mental health, Specialty, Neurosciences. Biological psychiatry. Neuropsychiatry, Anxiety, Molecular neuroscience, Article, law.invention, 03 medical and health sciences, Cellular and Molecular Neuroscience, 0302 clinical medicine, law, Intensive care, Anesthesiology, Physicians, Genetics, Medicine, Humans, 030212 general & internal medicine, Resilience (network), Pandemics, Biological Psychiatry, Depression (differential diagnoses), business.industry, SARS-CoV-2, COVID-19, Emergency department, Middle Aged, Resilience, Psychological, Intensive care unit, 3. Good health, Psychiatry and Mental health, [SDV.SPEE] Life Sciences [q-bio]/Santé publique et épidémiologie, Family medicine, [SDV.MHEP.PSM]Life Sciences [q-bio]/Human health and pathology/Psychiatrics and mental health, Female, [SDV.SPEE]Life Sciences [q-bio]/Santé publique et épidémiologie, medicine.symptom, business, 030217 neurology & neurosurgery, RC321-571
Abstract

We aim to assess physicians’ level of resilience and define factors that improve or decrease the resilience level during the COVID-19 pandemic. Physicians from hospitals located in areas with different COVID-19 caseload levels, were invited to participate in a national e-survey between April and May 2020. Study participants were mainly emergency physicians, and anaesthesiologists, infectious disease consultants, and intensive care. The survey assessed participant’s characteristics, factors potentially associated with resilience, and resilience using the Connor-Davidson Resilience Scale (RISC-25), with higher scores indicative of greater resilience. Factors associated with the resilience score were assessed using a multivariable linear regression. Of 451 responding physicians involved in the care of COVID-19 patients, 442 were included (98%). Age was 36.1 ± 10.3 years and 51.8% were male; 63% worked in the emergency department (n = 282), 10.4% in anesthesiology (n = 46), 9.9% in infectious disease department (n = 44), 4.8% in intensive care unit (n = 21) or other specialties (n = 49). The median RISC-25 score was at 69 (IQR 62–75). Factors associated with higher RISC scores were anesthesia as a specialty, parenthood, no previous history of anxiety or depression and nor increased anxiety. To conclude, this study is the first to characterize levels of resilience among physicians involved in COVID-19 unit. Our data points to certain protective characteristics and some detrimental factors, such as anxiety or depression, that could be amenable to remediating or preventing strategies to promote resilience and support caregivers in a pandemic.

Published
2021

36. Intrathoracic Airway Closure Impacts CO2 Signal and Delivered Ventilation during Cardiopulmonary Resuscitation

Author

Cécile Ricard, Gilles Bronchti, Irene Telias, Jordi Mancebo, Paul Ouellet, Dominique Savary, Jean-Christophe M. Richard, Stéphane Delisle, Adrien Drouet, Alain Mercat, Rigollot Marceau, Emmanuel Charbonney, Domenico Luca Grieco, Bilal Badat, and Laurent Brochard

Subjects
Pulmonary and Respiratory Medicine, Pulmonary mechanics, Resuscitation, business.industry, medicine.medical_treatment, food and beverages, respiratory system, Critical Care and Intensive Care Medicine, Cardiac massage, respiratory tract diseases, 03 medical and health sciences, 0302 clinical medicine, 030228 respiratory system, Anesthesia, Breathing, medicine, Esophageal pressure, 030212 general & internal medicine, Cardiopulmonary resuscitation, business, Airway closure
Abstract

Rationale: End-tidal CO2 (EtCO2) is used to monitor cardiopulmonary resuscitation (CPR), but it can be affected by intrathoracic airway closure. Chest compressions induce oscillations in expired CO...

Published
2019

37. Prehospital Lyophilized Plasma Transfusion for Trauma-Induced Coagulopathy in Patients at Risk for Hemorrhagic Shock

Author

Daniel, Jost, Sabine, Lemoine, Frédéric, Lemoine, Clément, Derkenne, Sébastien, Beaume, Vincent, Lanoë, Olga, Maurin, Emilie, Louis-Delaurière, Maëlle, Delacote, Pascal, Dang-Minh, Marilyn, Franchin-Frattini, René, Bihannic, Dominique, Savary, Albrice, Levrat, Clémence, Baudouin, Julie, Trichereau, Marina, Salomé, Benoit, Frattini, Vivien Hong Tuan, Ha, Romain, Jouffroy, Edouard, Seguineau, Rudy, Titreville, Florian, Roquet, Olivier, Stibbe, Benoit, Vivien, Catherine, Verret, Michel, Bignand, Stéphane, Travers, Christophe, Martinaud, Michel, Arock, Mathieu, Raux, Bertrand, Prunet, Sylvain, Ausset, Anne, Sailliol, Jean-Pierre, Tourtier, and Alexia, Vocel

Subjects
Adult, Male, Emergency Medical Services, Plasma, Humans, Blood Component Transfusion, Blood Transfusion, Saline Solution, General Medicine, Shock, Hemorrhagic
Abstract

Blood transfusion is a mainstay of therapy for trauma-induced coagulopathy, but the optimal modalities for plasma transfusion in the prehospital setting remain to be defined.To determine whether lyophilized plasma transfusion can reduce the incidence of trauma-induced coagulopathy compared with standard care consisting of normal saline infusion.This randomized clinical trial was performed at multiple centers in France involving prehospital medical teams. Participants included 150 adults with trauma who were at risk for hemorrhagic shock and associated coagulopathy between April 1, 2016, and September 30, 2019, with a 28-day follow-up. Data were analyzed from November 1, 2019, to July 1, 2020.Patients were randomized in a 1:1 ratio to receive either plasma or standard care with normal saline infusion (control).The primary outcome was the international normalized ratio (INR) on arrival at the hospital. Secondary outcomes included the need for massive transfusion and 30-day survival. As a safety outcome, prespecified adverse events included thrombosis, transfusion-related acute lung injury, and transfusion-associated circulatory overload.Among 150 randomized patients, 134 were included in the analysis (median age, 34 [IQR, 26-49] years; 110 men [82.1%]), with 68 in the plasma group and 66 in the control group. Median INR values were 1.21 (IQR, 1.12-1.49) in the plasma group and 1.20 (IQR, 1.10-1.39) in the control group (median difference, -0.01 [IQR, -0.09 to 0.08]; P = .88). The groups did not differ significantly in the need for massive transfusion (7 [10.3%] vs 4 [6.1%]; relative risk, 1.78 [95% CI, 0.42-8.68]; P = .37) or 30-day survival (hazard ratio for death, 1.07 [95% CI, 0.44-2.61]; P = .89). In the full intention-to-treat population (n = 150), the groups did not differ in the rates of any of the prespecified adverse events.In this randomized clinical trial including severely injured patients at risk for hemorrhagic shock and associated coagulopathy, prehospital transfusion of lyophilized plasma was not associated with significant differences in INR values vs standard care with normal saline infusion. Nevertheless, these findings show that lyophilized plasma transfusion is a feasible and safe procedure for this patient population.ClinicalTrials.gov Identifier: NCT02736812.

Published
2022

38. Guidelines for the choice of intravenous fluids for vascular filling in critically ill patients, 2021

Author

Olivier Joannes-Boyau, Philippe Le Conte, Marie-Pierre Bonnet, Eric Cesareo, Benjamin Chousterman, Djamila Chaiba, Bénédicte Douay, Emmanuel Futier, Anatole Harrois, Catherine Huraux, Carole Ichai, Eric Meaudre Desgouttes, Olivier Mimoz, Laurent Muller, Mathieu Oberlin, Nicolas Peschanski, Hervé Quintard, Geoffroy Rousseau, Dominique Savary, Alexy Tran-Dinh, Barbara Villoing, Anthony Chauvin, Emmanuel Weiss, CHU Bordeaux [Bordeaux], Hôpital Haut-Lévêque - CHU de Bordeaux (Centre médico chirurgical Magellan), Centre hospitalier universitaire de Nantes (CHU Nantes), Nantes Université (Nantes Univ), CHU Trousseau [APHP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Groupe de Recherche Clinique en Anesthésie Réanimation médecine PEriopératoire (GRC 29 - ARPE), Sorbonne Université (SU), Equipe 1 : EPOPé - Épidémiologie Obstétricale, Périnatale et Pédiatrique (CRESS - U1153), Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS (U1153 / UMR_A_1125 / UMR_S_1153)), Conservatoire National des Arts et Métiers [CNAM] (CNAM), HESAM Université - Communauté d'universités et d'établissements Hautes écoles Sorbonne Arts et métiers université (HESAM)-HESAM Université - Communauté d'universités et d'établissements Hautes écoles Sorbonne Arts et métiers université (HESAM)-Université Sorbonne Paris Cité (USPC)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE)-Conservatoire National des Arts et Métiers [CNAM] (CNAM), HESAM Université - Communauté d'universités et d'établissements Hautes écoles Sorbonne Arts et métiers université (HESAM)-HESAM Université - Communauté d'universités et d'établissements Hautes écoles Sorbonne Arts et métiers université (HESAM)-Université Sorbonne Paris Cité (USPC)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Hôpital Edouard Herriot [CHU - HCL], Hospices Civils de Lyon (HCL), Marqueurs cardiovasculaires en situation de stress (MASCOT (UMR_S_942 / U942)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Groupe Hospitalier Saint Louis - Lariboisière - Fernand Widal [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Centre National de la Recherche Scientifique (CNRS)-Université Paris Cité (UPCité)-Université Sorbonne Paris Nord, Hôpital Lariboisière-Fernand-Widal [APHP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Hôpital Simone Veil [Eaubonne], Hôpital Beaujon [AP-HP], Génétique, Reproduction et Développement (GReD), Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Clermont Auvergne (UCA), CHU Clermont-Ferrand, CHU Estaing [Clermont-Ferrand], Hôpital Bicêtre, Université Paris-Saclay, Clinique des Cèdres, Hôpital Pasteur [Nice] (CHU), Hopital d'instruction des armées Sainte-Anne [Toulon] (HIA), Pharmacologie des anti-infectieux et antibiorésistance (PHAR2), Université de Poitiers-Institut National de la Santé et de la Recherche Médicale (INSERM), Centre hospitalier universitaire de Poitiers (CHU Poitiers), Hôpital Universitaire Carémeau [Nîmes] (CHU Nîmes), Centre Hospitalier Universitaire de Nîmes (CHU Nîmes), Initial MAnagement and prevention of acute orGan failures IN critically ill patiEnts (IMAGINE), Université de Montpellier (UM), Les Hôpitaux Universitaires de Strasbourg (HUS), CHU Pontchaillou [Rennes], Université de Rennes - Faculté de Médecine (UR Médecine), Université de Rennes (UR), Hôpitaux Universitaires de Genève (HUG), Centre Hospitalier Régional Universitaire de Tours (CHRU Tours), Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), AP-HP - Hôpital Bichat - Claude Bernard [Paris], Université Paris Cité (UPCité), Hôpital Cochin [AP-HP], Centre de recherche sur l'Inflammation (CRI (UMR_S_1149 / ERL_8252 / U1149)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Paris Cité (UPCité), Département Médico-Universitaire réanimation anesthésie médecine péri-opératoire [Sorbonne Université] (DMU DREAM), CHU Tenon [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-CHU Saint-Antoine [AP-HP], Université de Rennes 1 - Faculté de Médecine (UR1 Médecine), and Jonchère, Laurent

Subjects
[SDV] Life Sciences [q-bio], Anesthesiology and Pain Medicine, Fluid therapy, Haemorrhagic shock, [SDV]Life Sciences [q-bio], General Medicine, Guidelines, Acute brain failure, Critical Care and Intensive Care Medicine, Sepsis or septic shock
Abstract

International audience; PURPOSE: To provide recommendations for the appropriate choice of fluid therapy for resuscitation of critically ill patients. DESIGN: A consensus committee of 24 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d’anesthésie et de réanimation, SFAR) and the French Society of Emergency Medicine (Société française de médecine d’urgence, SFMU) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were left ungraded. METHODS: Four fields were defined: patients with sepsis or septic shock, patients with haemorrhagic shock, patients with acute brain failure, and patients during the peripartum period. For each field, the panel focused on two questions: (1) Does the use of colloids, as compared to crystalloids, reduce morbidity and mortality, and (2) Does the use of some specific crystalloids effectively reduce morbidity and mortality. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE methodology. RESULTS: The SFAR/SFMU guideline panel provided nine statements on the appropriate choice of fluid therapy for resuscitation of critically ill patients. After two rounds of rating and various amendments, strong agreement was reached for 100% of the recommendations. Out of these recommendations, two have a high level of evidence (Grade 1 +/-), six have a moderate level of evidence (Grade 2 +/-), and one is based on expert opinion. Finally, no recommendation was formulated for two questions. CONCLUSIONS: Substantial agreement among experts has been obtained to provide a sizable number of recommendations aimed at optimising the choice of fluid therapy for resuscitation of critically ill patients.

Published
2022

39. What is the motivation of young emergency physicians to pursue an academic career in Emergency Medicine?

Author

Delphine Douillet, Emmanuel Montassier, Said Laribi, Louis Soulat, Nicolas Peschanski, François Javaudin, Eric Batard, Pierre-Marie Roy, Philippe Le Conte, Emgan Querellou, and Dominique Savary

Subjects
Academic career, Medical education, Psychology
Abstract

Background The study aims were to assess the motivation behind embarking on a university hospital career in Emergency Medicine, as well as any potential motivational barriers and levers. Methods We carried out a multicenter prospective observational study. All interns from the first year to the fourth year of a residency program in Emergency Medicine as well as young emergency physicians at 5 universities in the west of France were interviewed. A questionnaire with 37 questions was developed based on the literature and in line with the Delphi method. The questionnaires were self-administered online. This questionnaire assessed 4 aspects: demographic data, overall motivational factors, specific motivational factors, and motivational barriers and levers. Results The participation rate was 70%, with 193 answers. A median of 3 (2–4) out of 6 was the result for motivation to pursue an academic career in Emergency Medicine. Twenty respondents (10%) showed a genuine motivation for an academic career, rating this item at 5 or 6 (out of 6). The most motivated students were those who had received research training (first-level master’s degree, Master 1) (OR, 3.2 [95%CI: 1.3 to 3.9]). Among them, the most important potential levers were the possibility to devote at least 50% of the time to clinical activity, the time dedicated to missions, clear recruitment prospects, and supervision/guidance in preparing for an academic career. Conclusions Ten percent of the young emergency physicians who responded to this questionnaire have a high motivation for an academic career, which suggests that there is a large potential reserve of academics in emergency medicine. There are several levels to maintain this motivation and transform it into commitment in the academic course.

Published
2021

40. Point-of-care ultrasonography for risk stratification of non-critical suspected COVID-19 patients on admission (POCUSCO): a prospective binational study

Author

Nicolas Peschanski, Florence Dupriez, Nicolas Marjanovic, Mehdi Taalba, Jérémie Riou, Francois Morin, Thomas Flament, Karim Tazarourte, Thomas Delomas, Jean Francois Hamel, Kamelia Marouf, Thomas Boishardy, Francis Couturaud, Delphine Douillet, Dominique Savary, Philippe Le Conte, Christophe Aubé, Pierre-Marie Roy, and Vincent Dubée

Subjects
ARDS, education.field_of_study, medicine.medical_specialty, Lung, Coronavirus disease 2019 (COVID-19), Receiver operating characteristic, business.industry, medicine.medical_treatment, Population, Area under the curve, Emergency department, medicine.disease, medicine.anatomical_structure, Internal medicine, medicine, Intubation, education, business
Abstract

BackgroundLung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may allow early identification of patients who are likely to develop an acute respiratory distress syndrome (ARDS). We hypothesized that L-POCUS performed during the initial examination would identify non-severe COVID-19 patients with a high risk of getting worse.MethodsPOCUSCO was a prospective, multicenter study. Non-critical adult patients who were admitted to the emergency department (ED) for suspected or confirmed COVID-19 were included and had L-POCUS performed within 48 hours following admission. The severity of lung damage was assessed using the L-POCUS score based on 36 points for ARDS. The primary outcome was the rate of patients requiring intubation or who died within 14 days following inclusion.ResultsAmong 296 participating patients, 8 (2.7%) had primary outcome. The area under the curve (AUC) of the receiver operating characteristic of L-POCUS was 0.80 [95%CI:0.60-0.94]. The score values which achieved a sensibility > 95% in defining low-risk patients and a specificity > 95% in defining high-risk patients were ConclusionsL-POCUS allows risk-stratification of patients with suspected or confirmed COVID-19. These results should be confirmed in a population with a higher risk of an unfavorable outcome.Trial registration numberNCT04338100

Published
2021

41. Point-of-care ultrasonography for risk stratification of non-critical COVID-19 patients on admission (POCUSCO): a study protocol of an international study

Author

Francois Morin, Pierre-Marie Roy, Christophe Aubé, Vincent Dubée, Delphine Douillet, Dominique Savary, Florence Dupriez, Jean-François Hamel, Josué Rakotonjanahary, Jérémie Riou, UCL - SSS/IRSS - Institut de recherche santé et société, UCL - (SLuc) Service des urgences, HAL UR1, Admin, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Cliniques Universitaires Saint-Luc [Bruxelles], Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Université d'Angers (UA), NCT04338100Ministère des Affaires Sociales et de la Santé, Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Université de Rennes 1 (UR1), and Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique )

Subjects
medicine.medical_specialty, ARDS, Adolescent, [SDV]Life Sciences [q-bio], Point-of-Care Systems, medicine.medical_treatment, Context (language use), Risk Assessment, 030218 nuclear medicine & medical imaging, respiratory infections, 03 medical and health sciences, Patient Admission, 0302 clinical medicine, accident & emergency medicine, medicine, Humans, Multicenter Studies as Topic, Intubation, Prospective Studies, 030212 general & internal medicine, Prospective cohort study, Pandemics, business.industry, COVID-19, accident and emergency medicine, ultrasonography, Emergency department, General Medicine, medicine.disease, virology, 3. Good health, [SDV] Life Sciences [q-bio], Emergency medicine, Good clinical practice, Emergency Medicine, Medicine, Emergency Service, Hospital, business, Risk assessment, Declaration of Helsinki
Abstract

IntroductionIn the context of the COVID-19 pandemic, early identification of patients who are likely to get worse is a major concern. Severity mainly depends on the development of acute respiratory distress syndrome (ARDS) with a predominance of subpleural lesions. Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may be appropriate for examining patients with COVID-19. We suggest that L-POCUS performed during the initial examination may identify patients with COVID-19 who are at a high risk of complicated treatment or unfavourable evolution.Methods and analysisPoint-of-care ultrasonography for risk stratification of non-critical COVID-19 patients on admission is a prospective, multicentre study. Adult patients visiting the emergency department (ED) of participating centres for suspected or confirmed COVID-19 are assessed for inclusion. Included patients have L-POCUS performed within 48 hours following ED admission. The severity of lung damage is assessed using the L-POCUS score based on 36 points for ARDS. Apart from the L-POCUS score assessment, patients are treated as recommended by the WHO. For hospitalised patients, a second L-POCUS is performed at day 5±3. A follow-up is carried out on day 14, and the patient’s status according to the Ordinal Scale for Clinical Improvement for COVID-19 from the WHO is recorded.The primary outcome is the rate of patients requiring intubation or who are dead from any cause during the 14 days following inclusion. We will determine the area under the ROC curve of L-POCUS.Ethics and disseminationThe protocol has been approved by the French and Belgian Ethics Committees and is carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The study is funding by a grant from the French Health Ministry, and its findings will be disseminated in peer-reviewed journals and at scientific conferences.Trial registration numberNCT04338100.

Published
2021

43. Outpatient Management of Patients With COVID-19: Multicenter Prospective Validation of the Hospitalization or Outpatient Management of Patients With SARS-CoV-2 Infection Rule to Discharge Patients Safely

Author

Delphine Douillet, Andrea Penaloza, Rafaël Mahieu, François Morin, Anthony Chauvin, Stéphane Gennai, Thibault Schotte, Emmanuel Montassier, Pierre-Clément Thiebaud, Alexandre Ghuysen François, David Dall’acqua, Kasarra Benhammouda, Pascal Bissokele, Mathieu Violeau, Luc-Marie Joly, Hery Andrianjafy, Caroline Soulie, Dominique Savary, Jérémie Riou, Pierre-Marie Roy, H. Andrianjafy, L. Baudin, K. Benhammouda, P. Bissolokele, C. Brice, C. Cayeux, E. Casalino, C. Casarin, A. Chauvin, C. Choquet, Y.-E. Claessens, Francis Couturaud, D. Dall’acqua, B. Dobanton, D. Douillet, F. Dupriez, X. Eyer, L. Ferrand, S. Gennai, A. Ghuysen, A. Greau-Chauchet, L.-M. Joly, H.-H. Karam, M. Layot, A. Leroy, R. Lopez, R. Mahieu, N. Marchant, N. Marjanovic, E. Montassier, F. Morin, Baeza A. Penaloza, G. Plantefeve, P.-M. Roy, D. Savary, J. Schmidt, T. Schotte, M. Sebbane, C. Soulie, L. Soulat, C. Steiner, P.-C. Thiebaud, E. Timsit, E. Trabattoni, M. Violeau, UCL - SSS/IREC/EPID - Pôle d'épidémiologie et biostatistique, and UCL - (SLuc) Service des urgences

Subjects
RT-PCR, reverse-transcriptase polymerase chain reaction, Pulmonary and Respiratory Medicine, Male, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), HOME-CoV, Hospitalization or Outpatient Management of Patients With SARS-CoV-2 Infection, Critical Care and Intensive Care Medicine, AUC, area under the receiver operating characteristic curve, 03 medical and health sciences, 0302 clinical medicine, Outpatients, Ambulatory Care, Medicine, Humans, 030212 general & internal medicine, Pandemics, expert consensus, Receiver operating characteristic, business.industry, SARS-CoV-2, WHO OSCI, World Health Organization Ordinal Scale for Clinical Improvement, COVID-19, Disease Management, rule validation, Middle Aged, Decision Support Systems, Clinical, Hospitals, Checklist, Patient Discharge, 3. Good health, Hospitalization, clinical support decision tool, Editorial, 030228 respiratory system, Propensity score matching, Emergency medicine, outpatient, rule-based decision-making, Very low risk, Observational study, Female, Chest Infections: Original Research, Cardiology and Cardiovascular Medicine, business, Outpatient management, hospitalization
Abstract

BACKGROUND: The Hospitalization or Outpatient Management of Patients With SARS-CoV-2 Infection (HOME-CoV) rule is a checklist of eligibility criteria for home treatment of patients with COVID-19, defined using a Delphi method. RESEARCH QUESTION: Is the HOME-CoV rule reliable for identifying a subgroup of COVID-19 patients with a low risk of adverse outcomes who can be treated at home safely? STUDY DESIGN AND METHODS: We aimed to validate the HOME-CoV rule in a prospective, multicenter study before and after trial of patients with probable or confirmed COVID-19 who sought treatment at the ED of 34 hospitals. The main outcome was an adverse evolution, that is, invasive ventilation or death, occurring within the 7 days after patient admission. The performance of the rule was assessed by the false-negative rate. The impact of the rule implementation was assessed by the absolute differences in the rate of patients who required invasive ventilation or who died and in the rate of patients treated at home, between an observational and an interventional period after implementation of the HOME-CoV rule, with propensity score adjustment. RESULTS: Among 3,000 prospectively enrolled patients, 1,239 (41.3%) demonstrated a negative HOME-CoV rule finding. The false-negative rate of the HOME-CoV rule was 4 in 1,239 (0.32%; 95% CI, 0.13%-0.84%), and its area under the receiver operating characteristic curve was 80.9 (95% CI, 76.5-85.2). On the adjusted populations, 25 of 1,274 patients (1.95%) experienced an adverse evolution during the observational period vs 12 of 1,274 patients (0.95%) during the interventional period: -1.00 (95% CI, -1.86 to -0.15). During the observational period, 858 patients (67.35%) were treated at home vs 871 patients (68.37%) during the interventional period: -1.02 (95% CI, -4.46 to 2.26). INTERPRETATION: A large proportion of patients treated in the ED with probable or confirmed COVID-19 have a negative HOME-CoV rule finding and can be treated safely at home with a very low risk of complications. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04338841; URL: www.clinicaltrials.gov.

Published
2021

44. Outcomes of Patients Treated with Prehospital Noninvasive Ventilation: Observational Retrospective Multicenter Study in the Northern French Alps

Author

Julie Pinczon, Nicolas Terzi, G. Gheno, Pascal Usseglio-Polatera, Dominique Savary, Vincent Peigne, Guillaume Debaty, Centre Hospitalier Métropole Savoie [Chambéry], Centre Hospitalier Universitaire [Grenoble] (CHU), Centre Hospitalier Annecy-Genevois [Saint-Julien-en-Genevois], Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Physiologie cardio-Respiratoire Expérimentale Théorique et Appliquée (TIMC-PRETA ), Translational Innovation in Medicine and Complexity / Recherche Translationnelle et Innovation en Médecine et Complexité - UMR 5525 (TIMC ), VetAgro Sup - Institut national d'enseignement supérieur et de recherche en alimentation, santé animale, sciences agronomiques et de l'environnement (VAS)-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP ), Université Grenoble Alpes (UGA)-VetAgro Sup - Institut national d'enseignement supérieur et de recherche en alimentation, santé animale, sciences agronomiques et de l'environnement (VAS)-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP ), Université Grenoble Alpes (UGA), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Physiologie cardio-Respiratoire Expérimentale Théorique et Appliquée (TIMC-IMAG-PRETA), Techniques de l'Ingénierie Médicale et de la Complexité - Informatique, Mathématiques et Applications Grenoble - UMR 5525 (TIMC-IMAG), and Chard-Hutchinson, Xavier

Subjects
medicine.medical_specialty, Acute exacerbation of chronic obstructive pulmonary disease, medicine.medical_treatment, lcsh:Medicine, Physical examination, [SDV.MHEP.PSR]Life Sciences [q-bio]/Human health and pathology/Pulmonology and respiratory tract, Article, 03 medical and health sciences, 0302 clinical medicine, medicine, Intubation, pneumonia, COPD, 030212 general & internal medicine, medicine.diagnostic_test, business.industry, lcsh:R, noninvasive ventilation, 030208 emergency & critical care medicine, Retrospective cohort study, General Medicine, medicine.disease, 3. Good health, Pneumonia, prehospital investigation, [SDV.SPEE] Life Sciences [q-bio]/Santé publique et épidémiologie, Emergency medicine, Etiology, [SDV.MHEP.PSR] Life Sciences [q-bio]/Human health and pathology/Pulmonology and respiratory tract, Observational study, [SDV.SPEE]Life Sciences [q-bio]/Santé publique et épidémiologie, business, acute pulmonary edema
Abstract

Noninvasive ventilation (NIV) improves the outcome of acute cardiogenic pulmonary edema (AcPE) and acute exacerbation of chronic obstructive pulmonary disease (aeCOPD) but is not recommended in pneumonia. The aim of this study was to assess the appropriateness of the use of NIV in a prehospital setting, where etiological diagnostics rely mainly on clinical examination. This observational multicenter retrospective study included all the patients treated with NIV by three mobile medical emergency teams in 2015. Prehospital diagnoses and hospital diagnoses were extracted from the medical charts. The appropriateness of NIV was determined by matching the hospital diagnosis to the current guidelines. Among the 14,067 patients screened, 172 (1.2%) were treated with NIV. The more frequent prehospital diagnoses were AcPE (n = 102, 59%), acute respiratory failure of undetermined cause (n = 46, 28%) and aeCOPD (n = 17, 10%). An accurate prehospital diagnosis was more frequent for AcPE (83/88, 94%) than for aeCOPD (14/32, 44%, p &lt, 0.01). Only two of the 25 (8%) pneumonia cases were diagnosed during prehospital management. Prehospital NIV was inappropriate for 32 (21%) patients. Patients with inappropriate NIV had a higher rate of in-hospital intubation than patients with appropriate NIV (38% vs. 8%, 0.001). This high frequency of inappropriate NIV could be reduced by an improvement in the prehospital detection of aeCOPD and pneumonia.

Published
2021

47. Reliability and limits of transport-ventilators to safely ventilate severe patients in special surge situations

Author

Francois Morin, François Beloncle, Dominique Savary, Alexandre Broc, Laurent Brochard, François Templier, Jean-Christophe M. Richard, Arnaud Lesimple, Alain Mercat, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), Institut de recherche en santé, environnement et travail (Irset), Université d'Angers (UA)-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Université de Strasbourg (UNISTRA), University of Toronto, Institut Mondor de Recherche Biomédicale (IMRB), Institut National de la Santé et de la Recherche Médicale (INSERM)-IFR10-Université Paris-Est Créteil Val-de-Marne - Paris 12 (UPEC UP12), Université d'Angers (UA)-Université de Rennes (UR)-École des Hautes Études en Santé Publique [EHESP] (EHESP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Centre de Recherche en Acquisition et Traitement de l'Image pour la Santé (CREATIS), Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon-Institut National des Sciences Appliquées de Lyon (INSA Lyon), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Modeling & analysis for medical imaging and Diagnosis (MYRIAD), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet [Saint-Étienne] (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet [Saint-Étienne] (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL), HAL UR1, Admin, Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), and Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL)

Subjects
medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), medicine.medical_treatment, Respiratory mechanics, [SDV]Life Sciences [q-bio], Respiratory physiology, Acute respiratory distress, Respiratory failure, Critical Care and Intensive Care Medicine, law.invention, 03 medical and health sciences, 0302 clinical medicine, Mechanical ventilation, law, Intensive care, Medicine, 030212 general & internal medicine, Respiratory system, Oxygen pressure, Acute Respiratory Distress Syndrome, Medical systems, business.industry, Research, lcsh:Medical emergencies. Critical care. Intensive care. First aid, COVID-19, 030208 emergency & critical care medicine, lcsh:RC86-88.9, [SDV] Life Sciences [q-bio], 030228 respiratory system, Anesthesia, Emergency medicine, Ventilation (architecture), Breathing, business
Abstract

Background Intensive Care Units (ICU) have sometimes been overwhelmed by the surge of COVID-19 patients. Extending ICU capacity can be limited by the lack of air and oxygen pressure sources available. Transport ventilators requiring only one O2 source may be used in such places. Objective To evaluate the performances of four transport ventilators and an ICU ventilator in simulated severe respiratory conditions. Materials and methods Two pneumatic transport ventilators, (Oxylog 3000, Draeger; Osiris 3, Air Liquide Medical Systems), two turbine transport ventilators (Elisee 350, ResMed; Monnal T60, Air Liquide Medical Systems) and an ICU ventilator (Engström Carestation—GE Healthcare) were evaluated on a Michigan test lung. We tested each ventilator with different set volumes (Vtset = 350, 450, 550 ml) and compliances (20 or 50 ml/cmH2O) and a resistance of 15 cmH2O/l/s based on values described in COVID-19 Acute Respiratory Distress Syndrome. Volume error (percentage of Vtset) with P0.1 of 4 cmH2O and trigger delay during assist-control ventilation simulating spontaneous breathing activity with P0.1 of 4 cmH2O and 8 cmH2O were measured. Results Grouping all conditions, the volume error was 2.9 ± 2.2% for Engström Carestation; 3.6 ± 3.9% for Osiris 3; 2.5 ± 2.1% for Oxylog 3000; 5.4 ± 2.7% for Monnal T60 and 8.8 ± 4.8% for Elisee 350. Grouping all conditions (P0.1 of 4 cmH2O and 8 cmH2O), trigger delay was 50 ± 11 ms, 71 ± 8 ms, 132 ± 22 ms, 60 ± 12 and 67 ± 6 ms for Engström Carestation, Osiris 3, Oxylog 3000, Monnal T60 and Elisee 350, respectively. Conclusions In surge situations such as COVID-19 pandemic, transport ventilators may be used to accurately control delivered volumes in locations, where only oxygen pressure supply is available. Performances regarding triggering function are acceptable for three out of the four transport ventilators tested.

Published
2020

48. Impact of specific emergency measures on survival of out of hospital traumatic cardiac arrest: data from the northern french alps cardiac arrest registry

Author

Romain Charvet, Adrien Drouet, Delphine Douillet, Alexis Descatha, Francois Morin, Marc Fadel, Francois Xavier Ageron, Dominique Savary, Thierry Roupioz, Pierre Metton, and Bruno Carneiro

Subjects
Out of hospital, medicine.medical_specialty, business.industry, Emergency medicine, Medicine, Traumatic cardiac arrest, business, medicine.disease
Abstract

The management of Out of hospital Traumatic Cardiac Arrest (TCA) for professional rescuers combines advanced life support with specifics actions to treat potential reversible causes of the arrest: hypovolemia, hypoxemia, Tension Pneumothorax (TPx) and tamponade. The aim of this study was to assess the impact of specific rescue gestures on short-term outcomes in the context of resuscitation of patients with a pre-hospital TCA.Methods: We conducted a retrospective study of all TCA treated in two emergency medical units (EM unit), which are part of the Northern Alps emergency network, from January 2004 to December 2017. Utstein variables and specific rescue actions in TCA were compiled: advanced airway management, fluid administration, pelvic stabilization or tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary end point was the survival rate at day 30 with good neurologic outcome (cerebral performance category [CPC] score 1 & 2).Results: 287 resuscitations attempt in TCA were included and 279 specific interventions were Identified: 262 Fluid expansion, 41 External Pelvic stabilizations, 5 tourniquets, 175 bilateral thoracostomies, (including 44 with TPx).Conclusion: Among standard resuscitation measures to treat reversible causes of cardiac arrest, we were able to show that bilateral thoracostomy and tourniquet application on a limb hemorrhage improves survival of TCA. A larger sample for pelvic stabilization is necessary.

Published
2020

49. Singularities of AED implementation in occupational setting and COVID-19 pandemic

Author

Marc Fadel, Francois Morin, Alexis Descatha, and Dominique Savary

Subjects
2019-20 coronavirus outbreak, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), business.industry, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), medicine.medical_treatment, MEDLINE, 030208 emergency & critical care medicine, Emergency Nursing, Out of hospital cardiac arrest, 03 medical and health sciences, 0302 clinical medicine, External defibrillators, Emergency medicine, Pandemic, Emergency Medicine, medicine, 030212 general & internal medicine, Cardiopulmonary resuscitation, Cardiology and Cardiovascular Medicine, business
Published
2021

50. Definition and Validation of a Risk-Stratification Model for Probable or Proven COVID-19 Patients in Emergency Departments: The Revised HOME-CoV Score.

Author

Delphine, Douillet, primary, Jérémie, Riou, additional, Francois, Morin, additional, Rafaël, Mahieu, additional, Anthony, Chauvin, additional, Stéphane, Gennai, additional, Lionel, Ferrant, additional, Raphaëlle, Lopez, additional, Mustapha, Sebbane, additional, Gaëtan, Plantefeve, additional, Christian, Brice, additional, Coralie, Cayeux, additional, Thomas, Moumneh, additional, Dominique, Savary, additional, Andrea, Penaloza, additional, and Pierre-Marie, Roy, additional

Published
2021
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