Effect of the implementation of a checklist in the prehospital management of a traumatised patient.

BACKGROUND: In October 2021, French acute care societies jointly published cognitive aids to standardise practices and limit cognitive biases to ensure greater safety in management of severe trauma patients. The aim of the study was to evaluate the impact of a checklist on emergency physicians' adherence to the recommendations. METHODS: This prospective before-and-after study study took place in a French mobile emergency and resuscitation service. All adults trauma patients referred to hospital were included. A checklist on trauma management inspired by the MARCHE acronym was produced. During phase I, the checklist was performed within 24 h after the end of the intervention. During phase II, the checklist was performed during the patient's transport to hospital, thus allowing potentially omitted procedures to be performed initially. The use of the checklist was systematically evaluated using an anonymous questionnaire among doctors and nurses. In phase II, doctors and nurses who did not perform checklist were systematically asked to answer a specific online questionnaire. The primary outcome was the overall omission rate of checklist items during each phase of the study. RESULTS: One hundred and sixteen patients were included, 53 in phase I and 63 in phase II. Eleven patients did not have a checklist in phase II. The overall omission rate of checklist items was significantly lower with checklist (17%) than without (25%) (p = 0.02). This trend increased in proportion to severity with an omission rate of 30% without checklist versus 15% with checklist (p = 0.03) for patients with an ISS ≥ 25. A majority of doctors and nurses who used the checklist considered that it should be made compulsory (82% and 67% respectively). Paradoxically, only 55% of doctors who did not perform the checklist thought it was useful, while the omission rate was significantly higher (17% with checklist compared with 59% without checklist, p < 0.01). CONCLUSION: This work shows a significant reduction in the number of omissions on the actions carried out during the management of a trauma patient in prehospital settings, allowing better adherence to the recommendations. Its benefit is increased in severely traumatised patients.

Healthcare-associated adverse events and readmission to the emergency departments within seven days after a first consultation.

Introduction: The use of emergency hospital service has become increasingly frequent with a rise of approximately 3.6%. in annual emergency department visits. The objective of this study was to describe the reasons for reconsultations to emergency departments and to identify the risk and protective factors of reconsultations linked to healthcare-associated adverse events. Materials and methods: A retrospective, descriptive, multicenter study was performed in the emergency department of Troyes Hospital and the Sainte Anne Army Training Hospital in Toulon, France from January 1 to December 31, 2019. Patients over 18 years of age who returned to the emergency department for a reconsultation within 7 days were included. Healthcare-associated adverse events in the univariate analysis (p < 0.10) were introduced into a multivariate logistic regression model. Model performance was examined using the Hosmer-Lemeshow test and calculated with c-statistic. Results: Weekend visits and performing radiology examinations were risk factors linked to healthcare associated adverse events. Biological examinations and the opinion of a specialist were protective factors. Discussion: Numerous studies have reported that a first consultation occurring on a weekend is a reconsultation risk factor for healthcare-associated adverse events, however, performing radiology examinations were subjected to confusion bias. Patients having radiology examinations due to trauma-related pathologies were more apt for a reconsultation. Conclusion: Our study supports the need for better emergency departments access to biological examinations and specialist second medical opinions. An appropriate patient to doctor ratio in hospital emergency departments may be necessary at all times.

Evaluation of the implementation of personal protective equipment for French military firefighters in a CBRN context.

INTRODUCTION: Military firefighters are the first responders in the event of a chemical, biological, radiation, and nuclear (CBRN) event in the Marseille area. They receive initial training to intervene safely in a CBRN context. We wanted to evaluate the use of CBRN personal protective equipment (PPE) at a distance from this training. METHOD: A prospective observational bicentric descriptive study on 20 operational firefighters operating on rescue and emergency vehicles. Two PPE dressing sessions, separated by 3 months, were evaluated and timed. A reminder of the correct procedure was given by the investigator after the first dressing. RESULTS: On average, 60.5 percent of the steps were correctly performed during the first dressing and 83 percent during the second dressing. Between the two dressings, there was a significant improvement (p < 0.01) in the team verification of the dressing and the chronological order of the dressing as well as the actions to be taken before dressing (remembering to make oneself comfortable, to urinate, to drink). The second dressing is on average 21 seconds faster than the first. Professional training and exercise experience of the firefighters in CBRN improve the success and speed of dressing in the absence of a prior reminder. CONCLUSION: Shorter and more frequent training and exercises, which simulate real-life situations for firefighters, lead to safer, more competent and faster donning of PPE.

Synthesis and characterization of a new monometallic layered double hydroxide using manganese.

This article reports for the first time the synthesis of an LDH using only manganese as the divalent and trivalent metallic ion. Analysis of the pH, redox potential, and chemical composition during the oxidation of a manganese basic salt using persulfate indicates the oxidation of 1/3 of the initial MnII ions, in agreement with the paramagnetic structure and XPS analysis. Infrared, Raman spectra and thermogravimetric analysis results were similar to the ones obtained with Fe-LDH also known as green rust. X-Ray diffractograms and Rietveld refinement were used to determine the structure of this solid. Thermodynamic considerations predict that this solid could reduce nitrate into gaseous nitrogen without further reduction to ammonium or ammonia unlike what is observed for Fe-LDH.

Ultrasonography Performed by Military Nurses in Combat Operations: A Perspective for the Future?

INTRODUCTION: In current French military operations, it is not uncommon for military nurses (MNs) alone to be required to support soldiers in isolated areas. At a time when advanced practice nurses in the civilian sector develop extended skills, we asked MNs about their willingness to be trained in pointof- care ultrasound (POCUS). METHODS: We conducted a webbased survey from 1 November 2018 to 1 December 2018, including all MNs deployed in Operation Barkhane. The questionnaire, sent by e-mail, aimed to describe the willingness of MNs to be trained in POCUS. Their opinion on the usefulness of this training, the situations, and ultrasound (US) targets that seemed most useful to them were also studied. RESULTS: Thirty of 34 questionnaires were completed. On average, MNs had 7.4 years of practice and had been deployed three times for military operations. Five MNs reported having had informal training in clinical US by the military physicians (MPs) they work with and had performed POCUS in real-life situations; 24 (96%) of the untrained MNs wanted to be trained. Twenty- nine (96%) of the MNs felt that there was added value in knowing how to perform POCUS, especially in operations and in isolated posts without an MP. Focused assessment with sonography for trauma and pleural and renal US were the targets considered most useful to them, in that order. CONCLUSION: MNs are interested in learning POCUS and say it would be beneficial for the patient. Available scientific data tend to validate their ability after a brief training course to perform reliable, targeted US examinations in the field.

S100ß protein for non-traumatic subarachnoid hemorrhage diagnosis.

INTRODUCTION: The S100ß protein (PS100ß) is a biomarker, which has demonstrated its importance in diagnoses ruling out intracranial hemorrhages in people with light head traumas This study aims to evaluate if the PS100ß presents an interest in the diagnostic strategy for subarachnoid hemorrhages (SAH). METHODS: Prospective non-randomized multicentric study in three hospitals from October 2018 to January 2020. Every patient who came into the emergency department for an intense non-traumatic headache lasting less than 3 h received an PS100ß assay and a non-injected head computed tomography (CT) scan. The primary endpoint was the number of patients with a diagnosis of SAH on the head CT scan with a PS100ß level of under 0.10 µg/L. RESULTS: 60 patients were included and five patients had a SAH. Four patients had an SAH with a PS100ß level lower than 0.10 µg/L and one patient had an SAH with a PS100ß level higher than 0.10 µg/L. The negative predictive value for the PS100ß with a discriminating threshold less than or equal to 0,10 µg/L in the diagnosis ruling out SAH was 93% [IC 95%: 0,86-1]. CONCLUSION: S100ß protein assay with a discriminating threshold of 0,10 µg/L does not demonstrate any interest in the diagnostic strategy for non-traumatic SAH.

Early packed red blood cell transfusion in major trauma patients: Evaluation and comparison of different prediction scores for massive transfusion.

BACKGROUND AND OBJECTIVES: Our study sought to evaluate and compare different prediction scores for massive transfusion in-hospital packed red blood cell (PRBC) transfusions. MATERIALS AND METHODS: Between January 2013 and December 2018, 1843 trauma patients were enrolled in the registry of a level-1 trauma centre. All prehospital and in-hospital variables needed to calculate the Shock Index and RED FLAG, Assessment of Blood Consumption (ABC) and Trauma Associated Severe Hemorrhage (TASH) scores were prospectively collected in the registry. The primary endpoint was the initiation of transfusion within the first hour of the patient's arrival at the hospital. RESULTS: A total of 1767 patients were included for analysis with a mean age of 43 years (±19) and a mean Injury Severity Score of 15 (±14). The in-hospital TASH score had the highest predictive performance overall (area under the curve [AUC] = 0.925, 95% confidence interval [CI] [0.904-0.946]), while the RED FLAG score (AUC = 0.881, 95% CI [0.854-0.908]) had the greatest prehospital predictive performance compared to the ABC score (AUC = 0.798, 95% CI [0.759-0.837]) and Shock Index (AUC = 0.795, 95% CI [0.752-0.837]). Using their standard thresholds, the RED FLAG score was the most efficient in predicting early transfusion (sensitivity: 87%, specificity: 76%, positive predictive value: 25%, negative predictive value: 99%, Youden index: 0.63). CONCLUSION: The RED FLAG score appears to outperform both the ABC score and the Shock Index in predicting early in-hospital transfusion in trauma patients managed by pre-hospital teams. If adopted, this score could be used to give advance warning to trauma centres or even to initiate early transfusion during pre-hospital care.

Long-term consequences of electrical injury without initial signs of severity: The AFTER-ELEC study.

BACKGROUND: There is no specificity of emergency or long-term management of benign electrical injuries (EI). The main objective of our work was to describe the occurrence of long-term complications of EI considered as benign. METHODS: Single-center retrospective study of a cohort of adult patients who consulted for EI without initials signs of severity in an emergency department between 2012 and 2019. All included patients were secondarily contacted by telephone at least one year after their EI to complete a questionnaire. RESULTS: 76 adult patients visited the emergency department and 48 of them could be contacted by phone. 82% of the recalled patients had at least one complication following their EI. The main long-term complications were neurological (65%), psychological (58%) and cardiological (31%). Patients recalled eight years after EI had higher rates of neuropsychological complications than those recalled one year after EI. Only the time spent in the emergency department was statistically longer in patients who developed long-term complications compared to those who did not. DISCUSSION: The occurrence of long-term neuropsychological complications predominates. The knowledge and management of these long-term consequences must be particularly well known by emergency physicians because they are often the first medical contact of the patient. Our results also seem to show a crescendo in time of the occurrence of long-term complications. CONCLUSION: all health professionals involved in the care of victims of a EI must be made widely aware of the occurrence of these long-term complications, particularly neuropsychological ones, in order to improve the long-term patient care.

Impact of the COVID-19 Pandemic on Emergency Department Use: Focus on Patients Requiring Urgent Revascularization.

BACKGROUND: The novel coronavirus (2019-nCOV) appeared in China and precipitously extended across the globe. As always, natural disasters or infectious disease outbreaks have the potential to cause emergency department (ED) volume changes. OBJECTIVE: We aimed to assess the influence of the Coronavirus Disease 2019 (COVID-19) pandemic on ED visits and the impact on the handling of patients requiring urgent revascularization. METHODS: We reviewed the charts of all patients presenting to the ED of Hospital Sainte Anne (Toulon, France) from March 23 to April 5, 2020 and compared them with those of the same period in 2019. Then we analyzed complementary data on acute coronary syndrome (ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) and neurovascular emergencies (strokes and transient ischemic attacks). RESULTS: The total number of visits decreased by 47%. The number of people assessed as triage level 2 was 8% lower in 2020. There were five fewer cases of NSTEMI in 2020, but the same number of STEMI. The number of neurovascular emergencies increased (27 cases in 2019 compared with 30 in 2020). We observed a reduction in the delay between arrival at the ED and the beginning of coronary angiography for STEMI cases (27 min in 2019 and 22 min in 2020). In 2020, 7 more stroke patients were admitted. CONCLUSION: The COVID-19 pandemic probably dissuaded "non-critical" patients from coming to the hospital, whereas the same number of patients with a critical illness attended the ED as attended prior to the pandemic. There does not seem to have been any effect of the pandemic on patients requiring reperfusion therapy (STEMI and stroke).

Think about acute shisha carbon monoxide intoxication: that's one small step for the patient, one giant leap for our society.

The number of people in the world consuming chicha is constantly increasing. However, several studies have shown that regular shisha smokers, whether active or passive, are exposed to the same risks as tobacco smokers. Shisha is also responsible for acute carbon monoxide (CO) poisoning, which is often unknown to emergency doctors, leading to under-diagnosis of this pathology and inappropriate treatment. We report in this series 3 cases of acute carbon monoxide poisoning following active or passive consumption of chicha. The prehospital percentage carboxyhemoglobin level measured by the pulse CO-oximeter is 22 and 27% for active smokers and 10% for the passively intoxicated patient. The individual and societal consequences of CO intoxication are significant. We believe it is important to make all those involved in emergency medicine aware of this pathology in order to treat it correctly from the initial phase and thus reduce its morbi-mortality and the risks of long-term complications.

Civilian prehospital transfusion - experiences from a French region.

BACKGROUND AND OBJECTIVES: Haemorrhagic shock is a leading cause of avoidable mortality in prehospital care. For several years, our centre has followed a procedure of transfusing two units of packed red blood cells outside the hospital. Our study's aim was twofold: describe the patient characteristics of those receiving prehospital blood transfusions and analyse risk factors for the 7-day mortality rate. MATERIALS AND METHODS: We performed a monocentric retrospective observational study. Demographic and physiological data were recovered from medical records. The primary outcome was mortality at seven days for all causes. All patients receiving prehospital blood transfusions between 2013 and 2018 were included. RESULTS: Out of 116 eligible patients, 56 patients received transfusions. Trauma patients (n = 18) were younger than medical patients (n = 38) (P = 0·012), had lower systolic blood pressure (P = 0·001) and had higher haemoglobin levels (P = 0·016). Mortality was higher in the trauma group than the medical group (P = 0·015). In-hospital trauma patients received more fresh-frozen plasma and platelet concentrate than medical patients (P < 0·05). Predictive factors of 7-day mortality included transfusion for trauma-related reasons, low Glasgow Coma Scale, low peripheral oxygen saturation, prehospital intensive resuscitation, existing coagulation disorders, acidosis and hyperlactataemia (P < 0·05). CONCLUSION: Current guidelines recommend early transfusion in patients with haemorrhagic shock. Prehospital blood transfusions are safe. Coagulation disorders and acidosis remain a cause of premature death in patients with prehospital transfusions.