Procedural Sedation and Analgesia in Trauma Patients in an Out-of-Hospital Emergency Setting: A Prospective Multicenter Observational Study.

BACKGROUND: The quality of procedural analgesia and sedation among trauma patients has not been studied much in the prehospital setting. The main objective of this study was to characterize the quality of procedural analgesia sedation practices in prehospital settings in trauma patients. METHODS: This was an open-label observational prospective multicenter study (January 01, 2012-December 31, 2013). We included all consecutive trauma victims undergoing a potentially painful procedure on the accident scene. The primary endpoint was the procedural pain intensity. RESULTS: Data for 210 patients aged 11 to 98 years were analyzed. The most common lesions were limb fractures or dislocations. The most common procedures were limb realignment and splinting. Overall, 25 different drug combinations [with paracetamol [acetaminophen], non-steroidal anti-inflammatory drugs, nefopam, opioids, loco-regional anesthesia, Equimolar Mixture of Oxygen/Nitrous Oxide (EMONO), sedative drugs] were used by the emergency medical services (EMS). One hundred seventeen patients (55%) received either one or two sedative drugs (among ketamine, propofol, and midazolam), 171 patients (81%) received morphine that was combined with a sedative drug in 54% of cases. During the procedure, 95 patients, 45% [95% Confidence Interval (CI) 39-52] experienced intense to severe pain. Among patients who received sedative drugs, 27% (32/117) had intense to severe pain vs. 68% (63/93) in patients who did not, that is, 40% difference [95% CI 33.8-47.0]. Seventeen patients (8%) experienced 18 adverse events of which 6 were respiratory adverse events. A deep sedation occurred in 17 patients. No center had any specific protocols for procedural sedation analgesia. CONCLUSION: Procedural sedation-analgesia was inadequate in almost half of the trauma patients in the out-of-hospital setting. The reasons of these failures were probably multiple. The non-administration of a sedative drug despite an indication or non-adapted doses, in the context of a lack of specific protocols, was certainly one of them.

Chest pain in an out-of-hospital emergency setting: no relationship between pain severity and diagnosis of acute myocardial infarction.

BACKGROUND: Chest pain frequently prompts emergency medical services (EMS) call-outs. Early management of acute coronary syndrome (ACS) cases is crucial, but there is still controversy over the relevance of pain severity as a diagnostic criterion. STUDY OBJECTIVE: The aim of this study was to determine whether there is a relationship between the severity of chest pain at the time of out-of-hospital emergency care and diagnosis of acute myocardial infarction (AMI). METHODS: This was a subsidiary analysis of prehospital data collated prospectively by EMS in a large suburb. It concerned patients with chest pain taken to hospital by a mobile intensive care unit. Pain was rated on EMS arrival using a visual analog, numeric or verbal rating scale and classified on severe or not severe according to the pain score. A diagnosis of AMI was confirmed or ruled out on the basis of 2 plasma troponin measurements and/or coronary angiography results. RESULTS: Among the cohort of 2,279 patients included, 234 were suitable for analysis, of which 109 (47%) were diagnosed with AMI. The rate of severe pain on EMS arrival was not significantly different between AMI patients and no myocardial infarction patients (49% [95% CI 40 to 58] and 43% [34 to 52], respectively; P = 0.3; odds ratio 1.3 [0.8 - 2.3] after adjustment for age and gender). CONCLUSION: In our out-of-hospital emergency setting, the severity of chest pain was not a useful diagnostic criterion for AMI.

Risk factors for failed first intubation attempt in an out-of-hospital setting: a multicenter prospective study.

This study was performed to identify variables potentially associated with failure of the first intubation attempt in an out-of-hospital emergency setting, considering all aspects of tracheal intubation. This observational prospective multicenter study was performed over 17 months and involved 10 prehospital emergency medical units. After each tracheal intubation, the operator was required to provide information concerning operator and patient characteristics, as well as the environmental conditions during intubation, by completing a data collection form. The primary endpoint was failure of the first intubation attempt. During the study period, 1546 patients were analyzed, of whom 59% were in cardiac arrest; 486 intubations failed on the first attempt (31.4% [95% confidence interval = 30.2-32.6]). Multivariate analysis revealed that the following 7 of 28 factors were associated with an increased risk of a failed first intubation attempt: operator with fewer than 50 prior intubations (odds ratio [OR] = 1.8 [1.4-2.4]), small inter-incisor space (OR = 2.3 [1.7-3.2]), limited extension of the head (OR = 1.6 [1.1-2.1]), macroglossia (OR = 2.3 [1.6-3.2]), ear/nose/throat (ENT) tumor (OR = 4.4 [1.4-13.4]), cardiac arrest (OR = 1.8 [1.3-2.6]), and vomiting (OR = 1.7 [1.3-2.3]). The frequency of adverse events among non-cardiac arrest patients was 17.6%; it increased with each additional intubation attempt. The first intubation attempt failed in more than 30% of cases, and seven variables were associated with increased risk of failure. Most of these factors could not be predicted.

Out-of-hospital tracheal intubation with single-use versus reusable metal laryngoscope blades: a multicenter randomized controlled trial.

STUDY OBJECTIVE: Emergency tracheal intubation is reported to be more difficult with single-use plastic than with reusable metal laryngoscope blades in both inhospital and out-of-hospital settings. Single-use metal blades have been developed but have not been compared with conventional metal blades. This controlled trial compares the efficacy and safety of single-use metal blades with reusable metal blades in out-of-hospital emergency tracheal intubation. METHODS: This randomized controlled trial was carried out in France with out-of-hospital emergency medical units (Services de Médecine d'Urgence et de Réanimation). This was a multicenter prospective noninferiority randomized controlled trial in adult out-of-hospital patients requiring emergency tracheal intubation. Patients were randomly assigned to either single-use or reusable metal laryngoscope blades and intubated by a senior physician or a nurse anesthetist. The primary outcome was first-pass intubation success. Secondary outcomes were incidence of difficult intubation, need for alternate airway devices, and early intubation-related complications (esophageal intubation, mainstem intubation, vomiting, pulmonary aspiration, dental trauma, bronchospasm or laryngospasm, ventricular tachycardia, arterial desaturation, hypotension, or cardiac arrest). RESULTS: The study included 817 patients, including 409 intubated with single-use blades and 408 with a reusable blade. First-pass intubation success was similar in both groups: 292 (71.4%) for single-use blades, 290 (71.1%) for reusable blades. The 95% confidence interval (CI) for the difference in treatments (0.3%; 95% CI -5.9% to 6.5%) did not include the prespecified inferiority margin of -7%. There was no difference in rate of difficult intubation (difference 3%; 95% CI -7% to 2%), need for alternate airway (difference 4%; 95% CI -8% to 1%), or early complication rate (difference 3%; 95% CI -3% to 8%). CONCLUSION: First-pass out-of-hospital tracheal intubation success with single-use metal laryngoscopy blades was noninferior to first-pass success with reusable metal laryngoscope blades.

Out-of-hospital use of an automated chest compression device: facilitating access to extracorporeal life support or non-heart-beating organ procurement.

OBJECTIVE: The aim of the study was to assess the ease-of-use, safety, and usefulness of an automated external chest compression device for cardiopulmonary resuscitation. METHODS: Adults with out-of-hospital cardiac arrest (OHCA) were included prospectively. The emergency medical services (EMS) in a large suburb northeast of Paris (France) recorded data for standard criteria for EMS care for CA and specific criteria on device use-application time, ease of application and use (visual analog scale score: 0, impossible; 5, very easy), technical incidents, and clinical complications. RESULTS: We attended 4868 OHCA patients (January 2005 to April 2010) and used the device in 285 patients (6%) (212 males [74%], 73 females [26%]; median age, 56 [43-70] years). Results (medians with 25-75 percentiles) were as follows: time to apply device, 30 seconds (20-60); ease of application and activation, 5 (4-5) and 5 (5-5), respectively; duration of use, 30 (20-41) minutes; return to spontaneous circulation (ROSC), 76 patients (27%); and time to ROSC, 19 (12-32) minutes after placement. Twenty-seven patients (9%) with refractory CA benefited from extracorporeal life support. Overall, 32 patients were alive after 24 hours, 11 at 7 days, and 3 at 1 month. An additional 23 patients (8%) with refractory CA were selected for non-heart-beating kidney procurement. Ten patients were used to harvest kidneys and 15 were transplanted. There were 21 technical incidents (7%) and 19 clinical complications (7%). CONCLUSION: The device was easy to use in routine emergency practice and of particular value in facilitating access to extracorporeal life support or non-heart-beating organ procurement. These uses should be itemized in all OHCA studies.

Prevalence and management of acute pain in prehospital emergency medicine.

BACKGROUND: Less is known about the prevalence of pain in prehospital emergency medicine than about pain in the emergency department. Objectives. To estimate the prehospital prevalence of pain and to identify the factors associated with oligoanalgesia. METHODS: The mobile intensive care units of the emergency services of a Paris suburb conducted this prospective study. All consecutive patients aged 16 years or older who were able to self-assess pain were included around the clock over a period of 11 months in 2007. RESULTS: Among the 2,279 included patients, 947 had acute pain (42% [95% confidence interval (CI) 40-44]). Pain was intense to severe in 64% of patients. Factors associated with acute pain were trauma (odds ratio [OR] = 2.9 [1.9-4.3]) and age under 75 years (OR = 2.2 [1.7-2.8]). Intense pain was significantly associated with pain of cardiac or traumatic origin. Among the 1,364 patients transported by the mobile units, 48% experienced acute pain (71% had intense to severe pain). An analgesic agent was administered to 73%. According to multivariate analysis, only gynecologic/obstetric emergencies were associated with inadequate treatment (OR = 0.2 [95% CI 0.1-0.6]). Overall, 51% of patients [46-56] experienced pain relief. The rate of pain relief was lowest in patients suffering from trauma or a gynecologic/obstetric disorder. CONCLUSION: In our studied population, pain in prehospital emergency medicine affects 42% of patients. However, the rate varies widely according to the origin of the pain. Pain management is inadequate, as only one in two patients experiences relief.

[General practitioners' perceptions of medical information from hospitals]. / Information médicale: de l'hôpital à la ville. Que perçoit le médecin traitant?

BACKGROUND: The communication and circulation of medical information between hospitals and GPs play a central role in the quality of care. Numerous statutes, regulations, and clinical practice guidelines stress the need for such communication. We assessed how it really works. METHODS: We conducted face-to-face interviews based on a standardized questionnaire with 50 GPs in the districts of Paris and Seine-Saint-Denis, to explore different aspects of their communication with hospitals: the communication channels, and the amount, content, and quality of the information received. RESULTS: It appears that the overall quantity of communication is satisfactory but its quality and content vary according to the reasons for which the GP sent the patient to the hospital. GPs have a deep feeling that hospital staff physicians do not collaborate with them. CONCLUSION: The proposed personal medical file may help resolve logistic obstacles to the circulation of medical information but it will not bridge the cultural gap that exists between the two pillars of the system of care: the hospital and the GP.