Choice of Initial Brain Imaging in Patients with Suspected Acute Stroke: STROKE69, a Population-Based Study.

BACKGROUND: In patients with suspected stroke, brain imaging is recommended in the acute phase for appropriate management and treatment. Both computed tomography (CT) and magnetic resonance imaging (MRI) are considered reasonable choices for initial brain imaging. When both techniques are available, choosing one or the other might be associated with specific factors related either to patients, stroke symptoms, and severity or management organization. METHODS: The study was performed within the STROKE 69 database, a population-based cohort of all adult patients with suspected stroke admitted in one of the emergency departments (ED), primary stroke center, or stroke center of the Rhône County, from November 2015 to December 2016. Patients were included if they were admitted within 24 h following either symptom onset or last known normal. To identify factors potentially associated with the choice of initial brain imaging, a multivariate logistic regression was performed. RESULTS: Among the 3,244 patients with suspected stroke enrolled in the STROKE69 cohort, 3,107 (95.8%) underwent brain imaging within the first 24 h after admission. Among those 74.6% underwent CT as initial imaging while 25.4% had an MRI. In multivariate analyses, several factors were associated with a lower probability of having an MRI as initial brain imaging versus CT. These were either patient characteristics: older age (>80 years old, OR 0.39 [95% CI 0.28-0.54]), preexisting disability (OR 0.55 [95% CI 0.36-0.84]), use of anticoagulants (OR 0.52 [95% CI 0.33-0.81]), stroke characteristics: stroke of unknown onset (OR 0.42 [95% CI 0.31-0.58]) or factors associated with overall management: onset-to-door time (>6 h, OR 0.38 [95% CI 0.23-0.60]), initial admission to ED (OR 0.02 [95% CI 0.02-0.04]) or intensive care unit (OR 0.01 [95% CI 0.001-0.08]), personal transport (OR 0.66 [95% CI 0.45-0.96]), and admission during working hours (OR 0.65 [95% CI 0.51-0.84]). CONCLUSIONS: Besides CT or MRI availability, a number of other parameters could influence the choice of first imaging in case of stroke suspicion. These are related to patient characteristics, type of stroke symptoms, and type of organization.

A Time-Dependent Propensity Score Matching Approach to Assess Epinephrine Use on Patients Survival Within Out-of-Hospital Cardiac Arrest Care.

BACKGROUND: Epinephrine effectiveness and safety are still questioned. It is well known that the effect of epinephrine varies depending on patients' rhythm and time to injection. OBJECTIVE: We aimed to assess the association between epinephrine use during out-of-hospital cardiac arrest (OHCA) care and patient 30-day (D30) survival. METHODS: Between 2011 and 2017, 27,008 OHCA patients were included from the French OHCA registry. We adjusted populations using a time-dependent propensity score matching. Analyses were stratified according to patient's first rhythm. After matching, 2837 pairs of patients with a shockable rhythm were created and 20,950 with a nonshockable rhythm. RESULTS: Whatever the patient's rhythm (shockable or nonshockable), epinephrine use was associated with less D30 survival (odds ratio [OR] 0.508; 95% confidence interval [CI] 0.440-0.586] and OR 0.645; 95% CI 0.549-0.759, respectively). In shockable rhythms, on all outcomes, epinephrine use was deleterious. In nonshockable rhythms, no difference was observed regarding return of spontaneous circulation and survival at hospital admission. However, epinephrine use was associated with worse neurological prognosis (OR 0.646; 95% CI 0.549-0.759). CONCLUSIONS: In shockable and nonshockable rhythms, epinephrine does not seem to have any benefit on D30 survival. These results underscore the need to perform further studies to define the optimal conditions for using epinephrine in patients with OHCA.

Improving Access to Thrombolysis and Inhospital Management Times in Ischemic Stroke: A Stepped-Wedge Randomized Trial.

BACKGROUND AND PURPOSE: A suboptimal number of ischemic stroke patients eligible for thrombolysis actually receive it, partly because of extended inhospital delays. We developed a comprehensive program designed for emergency unit staff and evaluated its effectiveness for reducing intrahospital times and improving access to thrombolysis. METHODS: We conducted a randomized stepped-wedge controlled trial in 18 emergency unit. The sequentially implemented training intervention, targeting emergency physicians and nurses, was based on specifically designed videos and interactive simulation workshops on intrahospital management optimization. The effectiveness was assessed on intrahospital times and thrombolysis proportion. During the study period, all consecutive patients with confirmed ischemic stroke and no contraindications to thrombolysis were included. RESULTS: A total of 328 patients were enrolled in the control group and 363 in the intervention group. Mean age was 73.6 years. Overall thrombolysis proportion was 34.2% in the intervention group versus 25.6% in the control group (adjusted odds ratio, 1.42; 95% confidence interval, 1.01-2.01), thrombolysis proportion within 4 hours 30 minutes almost doubled (adjusted odds ratio, 1.9; 95% confidence interval, 1.32-2.73). Although imaging-to-stroke unit time was significantly decreased in the intervention group (39 versus 53 minutes; P=0.03), median door-to-imaging and door-to-needle times were not different between groups (P=0.70 and P=0.40, respectively). CONCLUSIONS: An interactive and multifaceted training program targeting emergency professionals was significantly associated with an increased access to thrombolysis, especially within 4 hours and 30 minutes. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02814760.

Evolution of Survival in Cardiac Arrest with Age in Elderly Patients: Is Resuscitation a Dead End?

BACKGROUND: Even if age is not considered the key prognostic factor for survival in cardiac arrest (CA), some studies question whether cardiopulmonary resuscitation (CPR) in the elderly could be futile. OBJECTIVE: The aim of this study was to describe differences in out-of-hospital CA survival rates according to age stratification based on the French National CA registry (RéAC). The second objective was to analyze the differences in resuscitation interventions according to age. METHODS: We performed a retrospective cohort study based on data extracted from the RéAC. All 18,249 elderly patients (>65 years old) with non-traumatic CA recorded between July 2011 and March 2015 were included. Patients' ages were stratified into 5-year increments. RESULTS: Cardiopulmonary resuscitation (CPR) was started significantly more often in younger patients (p = 0.019). Ventilation and automated external defibrillation by bystanders were started without any difference between age subgroups (p = 0.147 and p = 0.123, respectively). No difference in terms of rate of external chest compressions or ventilation initiation was found between the subgroups (p = 0.357 and p = 0.131, respectively). Advanced cardiac life support was started significantly more often in younger patients (p = 0.023). Total CPR duration, return of spontaneous circulation, and survival at hospital admission and at 30 days or hospital discharge decreased significantly with age (p < 10-3). The survival decrease was linear, with a loss of 3% survival chances each 5-year interval. CONCLUSIONS: This study found that survival in older persons decreased linearly by 3% every 5 years. However, this diminished rate of survival could be the consequence of a shorter duration and less advanced life support.

Endovascular Versus External Targeted Temperature Management for Patients With Out-of-Hospital Cardiac Arrest: A Randomized, Controlled Study.

BACKGROUND: Targeted temperature management is recommended after out-of-hospital cardiac arrest. Whether advanced internal cooling is superior to basic external cooling remains unknown. The aim of this multicenter, controlled trial was to evaluate the benefit of endovascular versus basic surface cooling. METHODS AND RESULTS: Inclusion criteria were the following: age of 18 to 79 years, out-of-hospital cardiac arrest related to a presumed cardiac cause, time to return of spontaneous circulation <60 minutes, delay between return of spontaneous circulation and inclusion <240 minutes, and unconscious patient after return of spontaneous circulation and before the start of cooling. Exclusion criteria were terminal disease, pregnancy, known coagulopathy, uncontrolled bleeding, temperature on admission <30°C, in-hospital cardiac arrest, immediate need for extracorporeal life support or hemodialysis. Patients were randomized between 2 cooling strategies: endovascular femoral devices (Icy catheter, Coolgard, Zoll, formerly Alsius; n=203) or basic external cooling using fans, a homemade tent, and ice packs (n=197). The primary end point, that is, favorable outcome evaluated by survival without major neurological damage (Cerebral Performance Categories 1-2) at day 28, was not significantly different between groups (odds ratio, 1.41; 95% confidence interval, 0.93-2.16; P=0.107). Improvement in favorable outcome at day 90 in favor of the endovascular group did not reach significance (odds ratio, 1.51; 95% confidence interval, 0.96-2.35; P=0.07). Time to target temperature (33°C) was significantly shorter and target hypothermia was more strictly maintained in the endovascular than in the surface group (P<0.001). Minor side effects directly related to the cooling method were observed more frequently in the endovascular group (P=0.009). CONCLUSION: Despite better hypothermia induction and maintenance, endovascular cooling was not significantly superior to basic external cooling in terms of favorable outcome. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00392639.

[Emergency nurse faced with death in pre-hospital situations]. / L'infirmier urgentiste face à la mort en pré-hospitalier.

The occurrence of a death in the out-of-hospital environment is often brutal and the reactions of the deceased's family and friends, unprepared for this event, can be unpredictable. After the technical procedures have been carried out and within a limited period of intervention, the caregivers, and in particular the nurse of the mobile emergency and intensive care service, must provide the family and friends with support enabling them to begin the grieving process. To help the caregivers in this mission, a pedagogical tool remains to be developed.

Rationale, methodology, implementation, and first results of the French out-of-hospital cardiac arrest registry.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is an important public health issue with an estimated incidence of 50,000 cases per year in France. Community survival rates for OHCA are still low (approximately 5%). An effective, recognized way to study, assess, and improve OHCA care is to create a standard-format database. OBJECTIVE: The aim of this work is to present the French OHCA registry (RéAC). METHODS: RéAC is a secure, web-based data management system that was initiated in 2009 and deployed nationally in June 2012. The main goal of this registry is to improve the care and survival rate of OHCA patients. The survey form is in compliance with the requirements of French organizations and is organized in accordance with the Utstein universal style. RéAC provides real-time statistical analyses and enables all French mobile emergency and resuscitation services (MERS) to assess and improve their professional OHCA care practices. RESULTS: In June 2012, the RéAC was nationally opened for all French MERSs. In June 2013, 221 of a possible 320 MERS participated in the RéAC. A total of 15,944 OHCA have been collected (14,939 cases closed with follow-up monitoring). The current rate of inclusion is approximately 1,500 cases per month. Since August 2012, the inclusion rate has increased by 9.5% per month, while the participation rate has increased by 9% per month. The first results show that the population is mainly male (65.4%) and the mean age is 65 ± 19 years. On MERS arrival, 73.5% of the patients were in asystole. The rates of return of spontaneous circulation, survival to hospital admission, and 30-day survival are low (respectively 21.1%, 17.2%, 4.6%). Of those who survived 30 days, 84.0% had a good neurological recovery. CONCLUSIONS: The RéAC registry is a reliable observation tool to improve public health management of OHCA. It provides relevant information to adapt or to develop diagnosis, treatments, and prognostic resources. Moreover, it enables the development of targeted awareness programs for the unique purpose of increasing the survival rates of OHCA patients.

Comparative effectiveness of inhospital trauma resuscitation at a French trauma center and matched patients treated in the United States.

OBJECTIVE: The objective of this paper is to compare mortality outcomes between patients treated at a trauma center in France and matched patients in the United States. BACKGROUND: Although trauma systems in France and the United States differ significantly in prehospital and inhospital management, previous comparisons have been challenged by the lack of comparable data. METHODS: Coarsened exact matching identified matching patients between a single center trauma database from Lyon, France, and the National Trauma Data Bank (NTDB) of the United States. Moderate to severely injured [injury severity score (ISS) > 8] adult patients (age ≥ 16) presenting alive to level 1 trauma centers from 2002 to 2005 with blunt or penetrating injuries were included. After matching patients, multivariate regression analyses were performed to determine difference in mortality between patients in Lyon and the NTDB. RESULTS: A total of 1043 significantly injured patients were presented to the Lyon center. Matching eligible patients with complete records were sought from 219,985 patients in the NTDB. The unadjusted odds of mortality at the Lyon center was 2.5 times higher than that of the NTDB [95% confidence interval (CI) = 2.18-2.98]. However, the Lyon center received patients with higher ISS, lower Glasgow Coma Score (GCS), and lower systolic blood pressure (SBP) (all P < 0.001). After 1:1 matching, 858 patient pairs were produced, and the odds of mortality became equivalent [odds ratio (OR) = 1.3, 95% CI = 0.91-1.73]. Similar results were found in multiple subset analyses. CONCLUSIONS: Trauma patients admitted to a single French trauma center had an equal chance of survival compared with similarly injured patients treated at US trauma centers.

Evaluation of a training program for emergency medical service physician dispatchers to reduce emergency departments visits.

BACKGROUND: Emergency Departments (ED) have seen an increasing number of older patients who are mostly referred following a call to the Emergency Medical Services (EMS). Long waiting times in settings, which are not designed to meet older patients' needs, may increase the risk of hospital-acquired complications. Unnecessary visits should therefore be avoided as much as possible. The objective of the study was to evaluate whether a program to provide geriatric knowledge and tools to the dispatching physicians of the EMS could decrease ED referrals of older patients. METHODS: Design: Before-and-after study with two 6-month periods before and after intervention. PARTICIPANTS: All calls received by a dispatching physician of the Rhône EMS from 8 am to 6 pm concerning patients aged 75 years or above during the study period. INTERVENTION: A program consisting of training dispatching physicians in the specific care of older patients and the developing, with a multidisciplinary team, of specific tools for dispatching physicians. OUTCOME: Proportion of ED referrals of patients aged 75 years or above after a call to the EMS. RESULTS: A total of 2671 calls to the Rhône EMS were included corresponding to 1307 and 1364 patients in the pre-and post-intervention phases, respectively. There was no significant difference in the proportion of referrals to the ED between the pre-intervention (61.7%) and the post-intervention (62.8%) phases (p = 0.57). Contact of the patients with their General Practitioner (GP) in the month preceding the call was associated with a 22% reduced probability of being referred to an ED. CONCLUSIONS: No beneficial effect of the intervention was demonstrated. This strategy of intervention is probably not effective enough in such time-constraint environment. Other strategies with a specific parallel dispatching of geriatric calls by geriatricians should be tested to avoid these unnecessary ED referrals. TRIAL REGISTRATION: ClinicalTrials NCT02712450.