First French and Indonesian university medical cooperation for promoting emergency medicine.

Indonesia and French Guiana share many geographic and medical concerns regarding access to care. The organisational needs in emergency management, particularly in the prehospital phase, are similar. Whereas emergency medicine (EM) is an academic and entire speciality in France, it is still under construction in Indonesia. In the framework of the French and Indonesian academic cooperation, the Medical school in Jakarta University and the French Guiana University in Cayenne signed a Memorandum of Understanding encompassing education programmes, joint research work and students' and health professionals' exchanges in EM. This partnership represented the first medical cooperation programme between the two countries. The first student class was launched in August 2022 and involved 50 Indonesian doctors who graduated in August 2023. The implementation and success of this Franco-Indonesian cooperation were supported by political and academic partners from the two sides. Given the first student class's success, we aim to continue this programme, in line with Indonesia and World Health Organization's plan to establish a multi-country training hub for health emergency operational readiness and Emergency Medical Teams.

Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription.

Background: Across the world, 25-29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit-risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon. Objective: This study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED. Methods: A 3-month prospective study with a case-control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher's exact test or the chi-squared tests. Student's t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression. Results: A total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient's epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient's initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for "self-referral" [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32-12.18, p < 0.0001] and patients' trajectories (Fisher's exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, "junior physician grade" was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09-5.25, p = 0.03), but physician gender was not. Conclusion: This bedside case-control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of "NRS-only" IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways.

Evolution of the use of intraosseous vascular access in prehospital advanced cardiopulmonary resuscitation: The IOVA-CPR study.

INTRODUCTION: Obtaining vascular access is crucial in critically ill patients. The EZ-IO® device is easy to use and has a high insertion success rate. Therefore, the use of intraosseous vascular access (IOVA) has gradually increased. AIM: We aim to determine how IOVA was integrated into management of vascular access during out-of-hospital cardiac arrest (OHCA) resuscitation. METHODS: Analysing the data from the OHCA French registry for events occurring between 1 January 2013 and 15 March 2021, we studied: demography, circumstances of occurrence and management including vascular access, delays and evolution. The primary outcome was the rate of IOVA implantation. RESULTS: Among the 7156 OHCA included in the registry, we analysed the 3964 (55%) who received cardiopulmonary resuscitation. The vascular access was peripheral in 3122 (79%) cases, intraosseous in 775 (20%) cases and central in 12 (<1%) cases. The use of IOVA has increased linearly (R2 = 0.61) during the 33 successive trimesters studied representing 7% of all vascular access in 2013 and 33% in 2021 (p = 0.001). It was significantly more frequent in traumatic cardiac arrest: 12% versus 5%; p < 0.0001. The first epinephrine bolus occurred significantly later in the IOVA group, at 6 (4-10) versus 5 (3-8) min; p < 0.0001. Survival rate in the IOVA group was significantly lower, at 1% versus 7%; p < 0.0001. CONCLUSION: The insertion rate of IOVA significantly increased over the studied period, to reach 30% of all vascular access in the management OHCA patients. The place of the intraosseous route in the strategy of venous access during the management of prehospital cardiac arrest has yet to be determined.

Evolution of REperfusion Strategies and impact on mortality in Old and Very OLD STEMI patients. The RESOVOLD-e-MUST study.

BACKGROUND: The use of myocardial reperfusion-mainly via angioplasty-has increased in our region to over 95%. We wondered whether old and very old patients have benefited from this development. METHODS: Setting: Greater Paris Area (Ile-de-France). DATA: Regional registry, prospective, including since 2003, data from 39 mobile intensive care units performing prehospital treatment of patients with ST segment elevation myocardial infarction (STEMI) (<24 h). PARAMETERS: Demographic, decision to perform reperfusion and outcome (in-hospital mortality). PRIMARY ENDPOINT: Reperfusion decision rate by decade over age 70. SECONDARY ENDPOINT: Outcome. RESULTS: We analysed the prehospital management of 27,294 patients. There were 21,311 (78%) men and 5,919 (22%) women with a median age of 61 (52-73 years). Among these patients, 8,138 (30%) were > 70 years, 3,784 (14%) > 80 years and 672 (2%) > 90 years.The reperfusion decision rate was 94%. It decreased significantly with age: 93, 90 and 76% in patients in their seventh, eighth and ninth decade, respectively. The reperfusion decision rate increased significantly over time. It increased in all age groups, especially the higher ones. Mortality was 6%. It increased significantly with age: 8, 16 and 25% in patients in their seventh, eighth and ninth decade, respectively. It significantly decreased over time in all age groups. The odds ratio of the impact of reperfusion decision on mortality reached 0.42 (0.26-0.68) in patients over 90 years. CONCLUSION: the increase in the reperfusion decision rate was the greatest in the oldest patients. It reduced mortality even in patients over 90 years of age.

[e-MUST Registry - Evaluation of prehospital medical management of STEMI in Île-de-France]. / Registre e-MUST - Évaluation de la prise en charge médicale préhospitalière du SCA ST+ en Île-de-France.

The e-MUST registry has continuously and comprehensively documented ST-segment elevation myocardial infarctions (STEMIs) managed in the prehospital setting by the 39 Mobile Emergency and Resuscitation Services (SMUR) of the 8 Emergency Medical Assistance System (SAMU) and subsequently managed in the 36 interventional cardiology services in Île-de-France since 2000. This encompasses a population of over 12 million residents. To date, nearly 44,000 patients have been enrolled. The analysis of these findings reflects the real-world management of these patients and the evolution of their care. The results are shared annually with the investigators' teams and have led to around twenty publications. The latest acquired results have demonstrated, in a series of over 630 patients aged over 90, that nonagenarians particularly benefit from prehospital coronary reperfusion decisions, resulting in a nearly 60% reduction in mortality.

Diagnosis and practical management of digoxin toxicity: a narrative review and consensus.

There are currently no universally accepted guidelines for the management of digoxin toxicity. In the absence of clinical practice guidelines, a set of consensus recommendations for management of digoxin toxicity in the clinical setting were developed through a modified Delphi approach. The recommendations highlight the importance of early recognition of signs of potentially life-threatening toxicity that requires immediate treatment with digoxin-specific antibodies. The consensus identifies a straightforward approach to dosing immune antibody fragments according to the presence or absence of signs of life-threatening toxicity. Supportive measures and management of specific signs of toxicity are also covered.

Detecting cervical esophagus with ultrasound on healthy voluntaries: learning curve.

BACKGROUND: The objective of this study was to determine the learning curve of tracheal-esophageal ultrasound by prehospital medical and paramedical staff. METHODS: A single-center prospective study was carried out at a French EMS (SAMU 92). Volunteer participants first received a short theoretical training through e-learning, followed by two separate hands-on workshops on healthy volunteers, spaced one to two months apart. Learners were timed to obtain the tracheal-esophageal ultrasound target image 10 consecutive times. The first workshop was intended to perform a learning curve, and the second was to assess unlearning. The secondary objectives were to compare performance by profession and by previous ultrasound experience. RESULTS: We included 32 participants with a mean age of 38 (± 10) years, consisting of 56% men. During the first workshop, the target image acquisition time was 20.4 [IQR: 10.6;41] seconds on the first try and 5.02 [3.72;7.5] seconds on the 10th (p < 0.0001). The image acquisition time during the second workshop was shorter compared to the first one (p = 0.016). In subgroup analyses, we found no significant difference between physicians and nurses (p = 0.055 at the first workshop and p = 0.164 at the second) or according to previous ultrasound experience (p = 0.054 at the first workshop and p = 0.176), counter to multivariate analysis (p = 0.02). CONCLUSIONS: A short web-based learning completed by a hands-on workshop made it possible to obtain the ultrasound image in less than 10 s, regardless of the profession or previous experience in ultrasound.

Digit preference and biased conclusions in cardiac arrest studies.

BACKGROUND: In cardiac arrest (CA), time is directly predictive of patients' prognosis. The increase in mortality resulting from delayed cardiopulmonary resuscitation has been quantified minute by minute. Times reported in CA management studies could reflect a timestamping bias referred to as "digit preference". This phenomenon leads to a preference for certain numerical values (such as 2, 5, or 10) over others (such as 13). Our objective was to investigate whether or not digit preference phenomenon could be observed in reported times of the day related to CA management, as noted in a national registry. METHODS: We analyzed data from the French National Electronic Registry of Cardiac Arrests. We analyzed twelve times-of-the-day corresponding to each of the main steps of CA management reported by the emergency physicians who managed the patients in prehospital settings. We postulated that if CA occurred at random times throughout the day, then we could expect to see events related to CA management occurring at a similar rate each minute of each hour of the day, at a fraction of 1/60. We compared the fraction of times reported as multiples of 15 (0, 15, 30, and 45 - on the hour, quarters, half hour) with the expected fraction of 4/60 (i.e. 4 × 1/60). MAIN RESULTS: A total of 47,211 times-of-the-day in relation to 6131 CA were analyzed. The most overrepresented numbers were: 0, with 3737 occurrences (8% vs 2% expected, p < 0.0001) and 30, with 2807 occurrences (6% vs 2% expected, p < 0.0001). Times-of-the-day as multiples of 15 were overrepresented (22% vs 7% expected, p < 0.0001). CONCLUSION: Prospectively collected times were considerably influenced by digit preference phenomenon. Studies that are not based on automatic time recordings and that have not evaluated and considered this bias should be interpretated with caution.

Prehospital treatment with zalunfiban (RUC-4) in patients with ST- elevation myocardial infarction undergoing primary percutaneous coronary intervention: Rationale and design of the CELEBRATE trial.

BACKGROUND: Early and complete restoration of target vessel patency in ST-elevation myocardial infarction (STEMI) is associated with improved outcomes. Oral P2Y12 inhibitors have failed to demonstrate either improved patency or reduced mortality when administered in the prehospital setting. Thus, there is a need for antiplatelet agents that achieve prompt and potent platelet inhibition, and that restore patency in the prehospital setting. Zalunfiban, a novel subcutaneously administered glycoprotein IIb/IIIa inhibitor designed for prehospital administration, has shown to achieve rapid, high-grade platelet inhibition that exceeds that of P2Y12 inhibitors. Whether prehospital administration of zalunfiban can improve clinical outcome is unknown. HYPOTHESIS: The present study is designed to assess the hypothesis that a single, prehospital injection of zalunfiban given in the ambulance, in addition to standard-of-care in patients with STEMI with intent to undergo primary percutaneous coronary intervention (PCI) will improve clinical outcome compared to standard-of-care with placebo. STUDY DESIGN: The ongoing CELEBRATE trial (NCT04825743) is a phase 3, randomized, double-blinded, placebo-controlled, international trial. Patients with STEMI intended to undergo primary PCI will receive treatment with a single subcutaneous injection containing either zalunfiban dose 1 (0.110 mg/kg), zalunfiban dose 2 (0.130 mg/kg) or placebo, and the study drug will be administered in the ambulance before transportation to the hospital. A target of 2499 patients will be randomly assigned to one of the treatment groups in a 1:1:1 ratio, ie, to have approximately 833 evaluable patients per group. The primary efficacy outcome is a ranked 7-point scale on clinical outcomes. The primary safety outcome is severe or life-threatening bleeding according to the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) criteria. SUMMARY: The CELEBRATE trial will assess whether a single prehospital subcutaneous injection of zalunfiban in addition to standard-of-care in patients with STEMI with intent to undergo primary PCI will result in improved clinical outcome.

[Prehospital ultrasound and cardiological emergencies]. / Échographie préhospitalière et urgences cardiologiques.

Technological advances over the past two decades have paved the way for the prehospital use of ultrasound. This practice was first developed in traumatology and then in a multitude of other indications, including cardiology. The development of pulmonary ultrasound is certainly the most visible illustration of this. Firstly, because it is an extra-cardiac examination that provides the answer to a cardiac question. Secondly because from a theoretical point of view this ultrasound indication was a bad indication for the use of ultrasound due to the air contained in the thorax. Thirdly, because this indication has become a 'standard of care' when caring for a patient with dyspnea - a practice that has become widespread during the COVID epidemic. In patients with heart failure, ultrasound has a high diagnostic power (including for alternative diagnoses) which is all the more precise since the technique is non-invasive, the response is obtained quickly, the examination can be repeated at desire to follow the evolution of the patient. The main other indications for prehospital ultrasound are cardiac arrest to search for a curable cause, identification of residual mechanical cardiac activity, monitoring of cerebral perfusion; chest pain, for both positive and negative diagnoses; shock for the search for an etiology and therapeutic follow-up or even pulmonary embolism or ultrasound for the search for dilation of the right ventricle which is now at the forefront of the recommendation algorithm.

A national population-based study of patients, bystanders and contextual factors associated with resuscitation in witnessed cardiac arrest: insight from the french RéAC registry.

BACKGROUND: In out-of-hospital cardiac arrest (OHCA), bystander initiated cardiopulmonary resuscitation (CPR) increases the chance of return of spontaneous circulation and survival with a favourable neurological status. Socioeconomic disparities have been highlighted in OHCA field. In areas with the lowest average socioeconomic status, OHCA incidence increased, and bystander CPR decreased. Evaluations were performed on restricted geographical area, and European evaluation is lacking. We aimed to analyse, at a national level, the impact of area-level social deprivation on the initiation of CPR in case of a witnessed OHCA. METHODS: We included all witnessed OHCA cases with age over 18 years from July 2011 to July 2018 form the OHCA French national registry. We excluded OHCA occurred in front of rescue teams or in nursing home, and patients with incomplete address or partial geocoding. We collected data from context, bystander and patient. The area-level social deprivation was estimated by the French version of the European Deprivation Index (in quintile) associated with the place where OHCA occurred. We assessed the associations between Utstein variables and social deprivation level using a mixed-effect logit model with bystander-initiated CPR. RESULTS: We included 23,979 witnessed OHCA of which 12,299 (51%) had a bystander-initiated CPR. More than one third of the OHCA (8,326 (35%)) occurred in an area from the highest quintile of social deprivation. The higher the area-level deprivation, the less the proportion of bystander-initiated CPR (56% in Quintile 1 versus 48% in Quintile 5). The In the multivariable analysis, bystander less often began CPR in areas with the highest deprivation level, compared to those with the lowest deprivation level (OR=0.69, IC95%: 0.63-0.75). CONCLUSIONS: The level of social deprivation of the area where OHCA occurred was associated with bystander-initiated CPR. It decreased in the more deprived areas although these areas also concentrate more younger patients.

Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices.

Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on "real" reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to "Pain reassessment" (61.0%) and/or "alternative treatment prioritization" (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of "simulated" prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.

[Managing STEMI before the hospital : let's identify our enemies!] / Prise en charge de l'infarctus avant l'hôpital : identifions nos ennemis !

Managing a patient with chest pain suspected to be a ST segment elevation myocardial infarction is a race against time. This management is based on a chain, like what is presented for cardiac arrest. Three phases follow one another, with potential loss of time successively attributable to the patient, the emergency physician and then the cardiologist. It would be tempting to consider that the main culprit in the event of delayed treatment is the patient. This review is the opportunity to show that it is not the case. The emergency physician, the cardiologist and their interconnection are the main providers of delay and, as such, the main enemies of myocardial reperfusion.

Efficacy of emergency medical center use of a protocol during telephone calls to give medical advice related to fever or gastroenteritis: a cluster randomized controlled trial. / Eficacia de un protocolo de asesoramiento médico telefónico formalizado para consultas por fiebre o gastroenteritis en centros de comunicación médica de emergencia. Ensayo clínico AMTF.

OBJECTIVES: To determine the efficacy of emergency medical center physicians' use of a protocol to guide their management of telephone consultations for fever and gastroenteritis. MATERIAL AND METHODS: Cluster randomized controlled trial. Participating centers were randomized to use the telephone protocol or provide usual telephone assistance. Six emergency centers in France included calls from patients needing advice on fever or gastroenteritis. Centers assigned to the protocol followed specific guidelines on managing the call and giving advice on treatment. Primary endpoints were the number of in-person visits and hospital admissions required within 15 days of the call. Secondary endpoints were patient satisfaction and costs. RESULTS: A total of 2498 calls were included. Use of the assigned protocol while attending 1234 calls was associated with a relative risk for hospitalization or an unscheduled in-person visit for care of 0.70 (95% CI, 0.58-0.85) versus usual practice. Ambulance use, admission to an intensive care unit, mortality, morbidity, and symptom improvement did not differ significantly between centers using the protocol and those following usual practice. Ninety percent of the patients were satisfied. The cost of care was €91 in centers applying the protocol and €150 in the other centers (P .01). CONCLUSION: Use of the protocol was associated with fewer unscheduled in-person visits for care and fewer hospital admissions. The protocol is safe and less costly than the centers' usual approaches to giving telephone advice.

OBJETIVO: Determinar la eficacia de un protocolo de asesoramiento médico telefónico formalizado (AMTF), realizado por un médico para consultas, para fiebre o gastroenteritis en centros de comunicación médica de emergencia. METODO: Ensayo clínico por conglomerado, controlado. Los pacientes fueron aleatorizados al grupo AMTF o al grupo de atención habitual. Participaron 6 centros de comunicación médica de emergencia franceses. Se incluyeron pacientes que solicitaban asistencia telefónica por fiebre o gastroenteritis. El grupo ATMF realizó recomendaciones protocolizadas sobre el manejo terapéutico. Se valoró el número de consultas presenciales o ingreso hospitalario durante los 15 días siguientes a la consulta. También se evaluó la satisfacción del paciente y el coste económico. RESULTADOS: Se incluyeron 2.498 llamadas. El grupo ATMF (n = 1.234) tuvo un riesgo relativo de 0,70 (CI 95% 0,58 a 0,85) de requerir un ingreso hospitalario o de realizar una consulta no programada durante el seguimiento. No hubo diferencias entre los dos grupos en cuanto al uso de ambulancia, el ingreso en cuidados intensivos, la mortalidad o morbilidad y la mejoría de los síntomas. La satisfacción de los pacientes fue del 90%. El coste total fue de 91 euros en el grupo de la ATMF y de 150 euros en el grupo de atención habitual (p 0,01). CONCLUSIONES: El grupo ATMF se asoció con una disminución de las consultas presenciales no programadas o del ingreso en el hospital. Este procedimiento es seguro y comporta un menor coste que la atención que se realiza habitualmente en la actualidad.