RELATIONSHIP BETWEEN SHOCK INDEX, MODIFIED SHOCK INDEX, AND AGE SHOCK INDEX AND 28-DAY MORTALITY AMONG PATIENTS WITH PREHOSPITAL SEPTIC SHOCK.

BACKGROUND: A relative hypovolemia occurs during septic shock (SS); the early phase is clinically reflected by tachycardia and low blood pressure. In the prehospital setting, simple objective tools to assess hypovolemia severity are needed to optimize triaging. OBJECTIVE: The aim of this study was to evaluate the relationship between shock index (SI), diastolic SI (DSI), modified SI (MSI), and age SI (ASI) and 28-day mortality of patients with SS initially cared for in a prehospital setting of a mobile intensive care unit (MICU). METHODS: From April 6, 2016 through December 31, 2021, 530 patients with SS cared for at a prehospital MICU were analyzed retrospectively. Initial SI, MSI, DSI, and ASI values, that is, first measurement after MICU arrival to the scene were calculated. A propensity score analysis with inverse probability of treatment weighting (IPTW) method was used to assess the relationship between SI, DSI, MSI, and ASI and 28-day mortality. RESULTS: SS resulted mainly from pulmonary, digestive, and urinary infections in 44%, 25%, and 17% of patients. The 28-day overall mortality was 31%. IPTW propensity score analysis indicated a significant relationship between 28-day mortality and SI (adjusted odds ratio [aOR] 1.13; 95% CI 1.01-1.26; p = 0.04), DSI (aOR 1.16; 95% CI 1.06-1.34; p = 0.03), MSI (aOR 1.03; 95% CI 1.01-1.17; p = 0.03), and ASI (aOR 3.62; 95% CI 2.63-5.38; p < 10-6). CONCLUSIONS: SI, DSI, MSI, and ASI were significantly associated with 28-day mortality among patients with SS cared for at a prehospital MICU. Further studies are needed to confirm the usefulness of SI and SI derivates for prehospital SS optimal triaging.

The prehospital NEW score to assess septic shock in-hospital, 30-day and 90-day mortality.

BACKGROUND: The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). METHODS: Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports. RESULTS: Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39-3.95], 2.08 [1.33-3.25] and 2.22 [1.38-3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively. CONCLUSION: A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.

Influence of antibiotic therapy with hemodynamic optimization on 30-day mortality among septic shock patients cared for in the prehospital setting.

BACKGROUND: In order to reduce septic shock mortality, international guidelines recommend early treatment implementation, antibiotic therapy (ABT) and hemodynamic optimisation, within 1-h. This retrospective multicentric study aims to investigate the relationship between prehospital ABT delivered within 1st hour and mean blood pressure (MAP) ≥ 65 mmHg at the end of the prehospital stage, and 30-day mortality among patients with septic shock. METHODS: From May 2016 to December 2021, patients with septic shock requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To assess the relationship between 30-day mortality and prehospital ABT delivered within 1st hour and/or MAP ≥ 65 mmHg at the end of the prehospital stage, Inverse Probability Treatment Weighting (IPTW) propensity score method was performed. RESULTS: Among the 530 patients included, 341 were male gender (64%) with a mean age of 69 ± 15 years. One-hundred and thirty-two patients (25%) patients received prehospital ABT, among which 98 patients (74%) were treated with 3rd generation cephalosporin. Suspected pulmonary, urinary and digestive infections were the cause of sepsis in respectively 43%, 25% and 17%. The 30-day overall mortality was 31%. A significant association was observed between 30-day mortality rate and (i) ABT administration within the first hour: RRa = 0.14 [0.04-0.55], (ii) ABT administration within the first hour associated with a MAP ≥ 65 mmHg: RRa = 0.08 [0.02-0.37] and (iii) ABT administration within the first hour in the prehospital setting associated with a MAP < 65 mmHg at the end of the prehospital stage: RRa = 0.75 [0.45-0.85]. Patients who received prehospital ABT after the first hour have also a 30-day mortality rate decrease: RRa = 0.87 [0.57-0.99], whereas patients who did not received ABT had an increased 30-day mortality rate: RRa = 2.36 [1.89-2.95]. CONCLUSION: In this study, we showed that pre-hospital ABT within the first hour and MAP≥65 mmHg at the end of prehospital stage are both associated with 30-day mortality decrease among patients suffering from septic shock cared for by a MICU. Further prospective studies are needed to confirm these preliminary results.

Exploring Population Characteristics and Recruitment Challenges in Older People Experiencing Falls at Home without Hospitalization or with an Emergency Department Visit: Insights from the RISING-DOM Experience.

Background: An increasing number of falls among community-living older adults are reported in emergency calls. Data on evidence of appropriate fall prevention interventions are limited and challenges in recruiting this population in randomized trials are acknowledged. Purpose: The main aim of this study was to provide demographic data, circumstance and fall-related outcomes of the population in the RISING-DOM study [Impact d'une évaluation des facteurs de RISque de chute et d'une prise en charge personnalisée, sur la mortalité et l'institutionnalisation, après INtervention du SAMU chez la personne âGée à DOMicile], a multicenter, randomized interventional trial involving community-dwelling older adults who have experienced a fall at home and were not hospitalized. Additionally, the challenges of remote recruitment in this population were discussed. Patients and Methods: Participants were identified through the Occitania Emergency Observatory database. Participant recruitment and data collection were performed through telephone interviews (October 2019-March 2022). Additionally, a sample survey of Emergency Medical Services calls was carried out. Results: Out of the 1151 individuals screened, a total of 951 participants were included in the trial follow-up, resulting in an acceptance rate of 82.62%. The screening delay was extended due to the COVID-19 pandemic. Recruiting difficulties were mainly related to identifying potential participants, unavailable contact information and unreachability. Participants' mean age was 84.1 years, 65.8% were women, and 44.3% lived alone. Pain was the most frequent outcome (53%). In the previous year, 73.5% of participants reported experiencing a fall, with 66.7% of those falls requiring assistance from Emergency Medical Services (EMS). Nearly, 40% did not take proactive steps to prevent future falls and walking aids (79.8%) were the most common preventive action. Conclusion: Indicators of a high-risk group of falls have been identified underscoring the need for appropriate fall interventions in the target population. Challenges of large sampling for randomized fall prevention trials were provided. Trial Registration: Clinicaltrials.gov identifier: NCT04132544. Registration date: 18/10/2019. https://www.clinicaltrials.gov/ct2/show/NCT04132544?term=rising-dom&draw=2&rank=1.

Prehospital pulse pressure and mortality of septic shock patients cared for by a mobile intensive care unit.

BACKGROUND: Septic shock medical treatment relies on a bundle of care including antibiotic therapy and hemodynamic optimisation. Hemodynamic optimisation consists of fluid expansion and norepinephrine administration aiming to optimise cardiac output to reach a mean arterial pressure of 65mmHg. In the prehospital setting, direct cardiac output assessment is difficult because of the lack of invasive and non-invasive devices. This study aims to assess the relationship between 30-day mortality and (i) initial pulse pressure (iPP) as (ii) pulse pressure variation (dPP) during the prehospital stage among patients cared for SS by a prehospital mobile intensive care unit (MICU). METHODS: From May 09th, 2016 to December 02nd, 2021, septic shock patients requiring MICU intervention were retrospectively analysed. iPP was calculated as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the first contact between the patient and the MICU team prior to any treatment and, dPP as the difference between the final PP (the difference between SBP and DBP at the end of the prehospital stage) and iPP divided by prehospital duration. To consider cofounders, the propensity score method was used to assess the relationship between (i) iPP < 40mmHg, (ii) positive dPP and 30-day mortality. RESULTS: Among the 530 patients analysed, pulmonary, digestive, and urinary infections were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality rate reached 31%. Cox regression analysis showed an association between 30-day mortality and (i) iPP < 40mmHg; aHR of 1.61 [1.03-2.51], and (ii) a positive dPP; aHR of 0.56 [0.36-0.88]. CONCLUSION: The current study reports an association between 30-day mortality rate and iPP < 40mmHg and a positive dPP among septic shock patients cared for by a prehospital MICU. A negative dPP could be helpful to identify septic shock with higher risk of poor outcome despite prehospital hemodynamic optimization.

Predictive factors for early requirement of respiratory support through phone call to Emergency Medical Call Centre for dyspnoea: a retrospective cohort study.

BACKGROUND: Acute dyspnoea is a common symptom in Emergency Medicine, and severity assessment is difficult during the first time the patient calls the Emergency Medical Call Centre. OBJECTIVE: To identify predictive factors regarding the need for early respiratory support in patients who call the Emergency Medical Call Centre for dyspnoea. DESIGN, SETTINGS AND PARTICIPANTS: This retrospective cohort study carried out in the Emergency Medical Call Centre of the University Hospital of Toulouse from 1 July to 31 December 2019. Patients over the age of 15 who call the Emergency Medical Call Centre regarding dyspnoea and who were registered at the University Hospital or died before admission were included in our study. OUTCOME MEASURE AND ANALYSIS: The primary end-point was early requirement of respiratory support [including high-flow oxygen, non-invasive ventilation (NIV) or mechanical ventilation after intubation] that was initiated by the physicians staffed ambulance before admission to the hospital or within 3 h after being admitted. Associations with patients' characteristics identified during Emergency Medical Call Centre calls were assessed with a backward stepwise logistic regression after multiple imputations for missing values. MAIN RESULTS: During the 6-month inclusion period, 1425 patients called the Emergency Medical Call Centre for respiratory issues. After excluding 38 calls, 1387 were analyzed, including 208 (15%) patients requiring respiratory support. The most frequent respiratory support used was NIV (75%). Six independent predictive factors of requirement of respiratory support were identified: chronic ß2-mimetics medication [odds ratio (OR) = 2.35, 95% confidence interval (CI) 1.61-3.44], polypnea (OR = 5.78, 95% CI 2.74-12.22), altered ability to speak (OR = 2.35, 95% CI 1.55-3.55), cyanosis (OR = 2.79, 95% CI 1.81-4.32), sweats (OR = 1.93, 95% CI 1.25-3) and altered consciousness (OR = 1.8, 95% CI 1.1-3.08). CONCLUSION: During first calls for dyspnoea, six predictive factors are independently associated with the risk of early requirement of respiratory support.

Setting up the Largest Mass Vaccination Center in Europe: The One-Physician One-Nurse Protocol.

To manage mass vaccination without impacting medical resources dedicated to care, we proposed a new model of Mass Vaccination Centers (MVC) functioning with minimum attending staffing requirements. The MVC was under the supervision of one medical coordinator, one nurse coordinator, and one operational coordinator. Students provided much of the other clinical support. Healthcare students were involved in medical and pharmaceutical tasks, while non-health students performed administrative and logistical tasks. We conducted a descriptive cross-sectional study to describe data concerning the vaccinated population within the MVC and the number and type of vaccines used. A patient satisfaction questionnaire was collected to determine patient perception of the vaccination experience. From 28 March to 20 October 2021, 501,714 vaccines were administered at the MVC. A mean rate of 2951 ± 1804 doses were injected per day with a staff of 180 ± 95 persons working every day. At peak, 10,095 injections were given in one day. The average time spent in the MVC was 43.2 ± 15 min (time measured between entry and exit of the structure). The average time to be vaccinated was 26 ± 13 min. In total, 4712 patients (1%) responded to the satisfaction survey. The overall satisfaction with the organization of the vaccination was 10 (9-10) out of 10. By using one attending physician and one nurse to supervise a staff of trained students, the MVC of Toulouse optimized staffing to be among the most efficient vaccination centers in Europe.

Relationship between prehospital modified Charlson Comorbidity Index and septic shock 30-day mortality.

CONTEXT: In the prehospital setting, early identification of septic shock (SS) at risk of poor outcome is mainly based on clinical vital signs alteration evaluation. The Charlson Comorbidity Index (CCI) is an in-hospital tool used for burden of co-morbidity assessment. We report the relationship between the modified prehospital CCI, and 30-day mortality of SS patients initially cared for in the prehospital setting by a mobile ICU (MICU). METHODS: SS patients defined according to the 2016 sepsis-3 conference cared for by MICU between February 2017 and December 2021 were retrospectively analysed. The modified prehospital CCI calculation was based on the available comorbid conditions collected in the prehospital setting. A threshold of ≥5, was chosen according to previous results. RESULTS: Five-hundred and twenty-nine patients were included among which 154 suffering from septic shock were analysed. Presumed origin of septic shock was mainly pulmonary (36%), digestive (33%) and urinary (16%). 30 day-mortality reached 33%. Logistic regression after propensity score matching found a significant association between the 30-day mortality in the modified prehospital CCI ≥ 5: aOR = 1.12 [1.07-1.31], p = 0.041. CONCLUSION: Among septic shock patients initially cared for by a MICU in the prehospital setting, a significant association between 30-day mortality. A modified prehospital CCI of at least 6 appears to be useful for early identification of septic shock patients with poorer outcome.

Prehospital Bundle of Care Based on Antibiotic Therapy and Hemodynamic Optimization Is Associated With a 30-Day Mortality Decrease in Patients With Septic Shock.

OBJECTIVES: This study aims to investigate the association between the 30-day mortality in patients with septic shock (SS) and a prehospital bundle of care completion, antibiotic therapy administration, and hemodynamic optimization defined as a fluid expansion of at least 10 mL.kg -1 .hr -1 . DESIGN: To assess the association between prehospital BUndle of Care (BUC) completion and 30-day mortality, the inverse probability treatment weighting (IPTW) propensity method was performed. SETTING: International guidelines recommend early treatment implementation in order to reduce SS mortality. More than one single treatment, a bundle of care, including antibiotic therapy and hemodynamic optimization, is more efficient. PATIENTS: From May 2016 to March 2021, patients with SS requiring prehospital mobile ICU (mICU) intervention were retrospectively analyzed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 529 patients with SS requiring action by the mICU enrolled in this study, 354 (67%) were analyzed. Presumed pulmonary, digestive, and urinary infections were the cause of the SS in 49%, 25%, and 13% of the cases, respectively. The overall 30-day mortality was 32%. Seventy-one patients (20%) received prehospital antibiotic therapy and fluid expansion. Log binomial regression weighted with IPTW resulted in a significant association between 30-day mortality and prehospital BUC completion (respiratory rate [RR] of 0.56 [0.33-0.89]; p = 0.02 and adjusted RR 0.52 [0.27-0.93]; p = 0.03). CONCLUSIONS: A prehospital bundle of care, based on antibiotic therapy and hemodynamic optimization, is associated with a 30-day mortality decrease among patients suffering from SS cared for by an mICU.

Association between prehospital shock index variation and 28-day mortality among patients with septic shock.

PURPOSE: Septic shock (SS) hyperdynamic phase is characterized by tachycardia and low-blood pressure reflecting the relative hypovolemia. Shock index (SI), the ratio between heart rate and systolic blood pressure, is a simple objective tool, usable for SS prognosis assessment. This study aims to evaluate the relationship between prehospital SI variation and 28-day mortality of SS patients initially cared for in prehospital setting by a mobile intensive care unit (mICU). METHODS: From April 6th, 2016 to December 31st, 2020, 406 patients with SS requiring prehospital mICU were retrospectively analyzed. Initial SI, i.e. first measurement after mICU arrival to the scene, and final SI, i.e. last measurement of the prehospital stage, were used to calculate delta SI (initial SI-final SI) and to define positive and negative delta SI. A survival analysis after propensity score matching compared the 28-day mortality of SS patients with positive/negative delta SI. RESULTS: The main suspected origins of infection were pulmonary (42%), digestive (25%) and urinary (17%). The 28-day overall mortality reached 29%. Cox regression analysis revealed a significant association between 28-day mortality and delta SI. A negative delta SI was associated with an increase in mortality (adjusted hazard ratio (HRa) of 1.88 [1.07-3.31] (p = 0.03)), whereas a positive delta SI was associated with a mortality decrease (HRa = 0.53 [0.30-0.94] (p < 10-3)). CONCLUSION: Prehospital hemodynamic delta SI among SS patients cared for by a mICU is associated with 28-day mortality. A negative prehospital delta SI could help physicians to identify SS with higher risk of 28-day mortality.

Prehospital norepinephrine administration reduces 30-day mortality among septic shock patients.

BACKGROUND: Despite differences in time of sepsis recognition, recent studies support that early initiation of norepinephrine in patients with septic shock (SS) improves outcome without an increase in adverse effects. This study aims to investigate the relationship between 30-day mortality in patients with SS and prehospital norepinephrine infusion in order to reach a mean blood pressure (MAP) > 65 mmHg at the end of the prehospital stage. METHODS: From April 06th, 2016 to December 31th, 2020, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To consider cofounders, the propensity score method was used to assess the relationship between prehospital norepinephrine administration in order to reach a MAP > 65 mmHg at the end of the prehospital stage and 30-day mortality. RESULTS: Four hundred and seventy-eight patients were retrospectively analysed, among which 309 patients (65%) were male. The mean age was 69 ± 15 years. Pulmonary, digestive, and urinary infections were suspected among 44%, 24% and 17% patients, respectively. One third of patients (n = 143) received prehospital norepinephrine administration with a median dose of 1.0 [0.5-2.0] mg h-1, among which 84 (69%) were alive and 38 (31%) were deceased on day 30 after hospital-admission. 30-day overall mortality was 30%. Cox regression analysis after the propensity score showed a significant association between prehospital norepinephrine administration and 30-day mortality, with an adjusted hazard ratio of 0.42 [0.25-0.70], p < 10-3. Multivariate logistic regression of IPTW retrieved a significant decrease of 30-day mortality among the prehospital norepinephrine group: ORa = 0.75 [0.70-0.79], p < 10-3. CONCLUSION: In this study, we report that prehospital norepinephrine infusion in order to reach a MAP > 65 mmHg at the end of the prehospital stage is associated with a decrease in 30-day mortality in patients with SS cared for by a MICU in the prehospital setting. Further prospective studies are needed to confirm that very early norepinephrine infusion decreases septic shock mortality.

Impact of a personalised care plan for the elderly calling emergency medical services after a fall at home: The RISING-DOM multi-centre randomised controlled trial protocol.

BACKGROUND: A growing number of emergency calls are made each year for elderly people who fall. Many of them are not taken to hospital or are rapidly discharged from the Emergency Department (ED). Evidence shows that, with no further support, this vulnerable population is particularly at risk of injuries, dependency and death. This study aims to determine the effectiveness of a comprehensive geriatric assessment and a tailored intervention in the elderly calling on an Emergency Medical Service (EMS) for a fall at home, but not conveyed to the ED or rapidly discharged from it (less than 24 h from hospitalisation), to the time to institutionalisation or death. METHODS: Rising-Dom is a two-arm randomised (ratio 1:1), interventional, multi-centre and open study. Community-dwelling elderly people (≥ 70 years) who call an EMS for a fall at home are recruited. The intervention group receives home visits by a nurse with a comprehensive fall risk assessment and a personalised intervention care plan with a planned follow-up (six nurse home visits and five nurse phone calls). Subjects enrolled in the usual care-control group continue to receive their routine care for the prevention or treatment of diseases. Primary (time to institutionalisation or death) and secondary (unscheduled hospitalisations, additional EMS calls relating to falls, functional decline and quality of life) outcome data will be collected for both groups through five phone calls made by Clinical Research Associates (CRA) blind to the participants' group during the follow-up period (24-months). Twelve hospital centres in the South-West of France are participating in the study as study sites. The inclusion period started in October 2019 and will end in March 2022. By the end of this period, 1,190 subjects are expected to be enrolled. DISCUSSION: Studies on elderly home falls have rarely concerned people who were not taken to hospital. The Rising-Dom intervention scheme should enhance understanding of features related to this vulnerable population and investigate the impact of a nurse care at home on delaying death and institutionalisation. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT04132544. Registration date: 18/10/2019. SPONSOR: University Hospital, Toulouse. https://www.clinicaltrials.gov/ct2/show/NCT04132544?term=rising-dom&draw=2&rank=1.

Adequacy of probabilistic prehospital antibiotic therapy for septic shock.

BACKGROUND: Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown. METHODS: From May 2016 to March 2021, all consecutive patients with SS cared for by a prehospital mICU intervention were retrospectively analyzed. RESULTS: Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) were deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p = 4.10-3). After propensity score matching, a significant association between adequate prehospital ABT administration and day-30 mortality was observed (aOR = 0.09 [0.01-0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR = 0.70 [0.53-0.93]. CONCLUSIONS: Among SS cared for by a mICU, probabilistic prehospital ABT is adequate most of the time and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.

Hydroxyzine for lowering patient's anxiety during prehospital morphine analgesia: A prospective randomized double blind study.

STUDY OBJECTIVE: Hydroxyzine is an antihistamine drug used for symptomatic relief of anxiety and tension. We hypothesized that managing the anxiety of patients with severe pain by adding hydroxyzine to a conventional intravenous morphine titration would relieve their pain more effectively. METHODS: This was a randomized, double-blind, controlled group study of prehospital patients with acute pain scored greater than or equal to 6 on a 0-10 verbal numeric rating scale (NRS). Patients'anxiety was measured with the self-reported Face Anxiety Scale (FAS) ranking from 0 to 4. The percentage of patients with pain relief (NRS score ≤ 3) 15 min after the first injection was the primary outcome. RESULTS: One hundred forty patients were enrolled. Fifty-one percent (95% CI 39% to 63%) of hydroxyzine patients versus 52% (95% CI 40% to 64%) of placebo patients reported a pain numeric rating scale score of 3 or lower at 15 min. Ninety-one percent (95% CI 83% to 98%) of patients receiving hydroxyzine reported no more severe anxiety versus 78% (95% CI 68% to 88%) of patients with placebo (p > 0.05). Adverse events were minor, with no difference between groups (6% in hydroxyzine patients and 14% in placebo patients). CONCLUSION: Addition of hydroxyzine to morphine in the prehospital setting did not reduce pain or anxiety in patients with acute severe pain and therefore is not indicated based on our results.

Evaluation of a prototype decontamination mobile unit (UMDEO) for COVID-19 vaccination: A cross-sectional survey in France.

AIM OF THE STUDY: In the context of the worldwide vaccination campaign against COVID-19, France has been deploying multiple sites for mass vaccination. This study aimed to assess the perceived usefulness of a prototype decontamination mobile unit (UMDEO) for COVID-19 vaccination among both the patient and healthcare providers perspectives. METHODS: This was a descriptive cross-sectional study conducted in Toulouse over two days. UMDEO is a fully comprehensive, versatile solution that was deployed as a 5-row vaccination unit. A written questionnaire was distributed from March 6th-7th, 2021 among all patients presenting for vaccination at the mobile center, as well as the team participating in the vaccination campaign. RESULTS: Among the vaccinated patients (n = 1659), 1409 participants (84.9%) filled out the survey, as well as 68 out of 85 (80%) within the UMDEO team. The maximum patient rate was 98 people per hour. The majority of participants and caregivers (1307 [93.2%] and 67 [98.5%] respectively) agreed that the mobile unit increased access to vaccination. A total of 91.3% patients (n = 1281) and 95.6% caregivers (n = 65) believed that it would speed up the overall vaccination campaign. CONCLUSION: The majority of the vaccinated population and of the team participating in the survey were satisfied with the usefulness of UMDEO as a vaccination center. Toulouse is currently the only city to have used such a structure for vaccination, but it could be used as a basis for planning other mobile units to increase vaccination access.

The prehospital SIGARC score to assess septic shock in-hospital, 30-day and 90-day mortality.

BACKGROUND: In the pre-hospital setting the early identification of septic shock (SS) patients presenting with a high risk of poor outcome remains a daily challenge. The development of a simple score to quickly identify these patients is essential to optimize triage towards the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the new SIGARC score and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). METHODS: SS patients cared for by a MICU between 2017, April 15th, and 2019, December 1st were included in this retrospective study. The SIGARC score consists of the addition of 5 following items (1 point for each one): shock index≥1, Glasgow coma scale<13, age > 65, respiratory rate > 22 and comorbidity defined by the presence of at least 2 underlying conditions among: hypertension, coronaropathy, chronic cardiac failure, chronic renal failure, chronic obstructive pulmonary disease, diabetes mellitus, history of cancer and human immunodeficiency virus infection. A threshold of SIGARC score ≥ 2 was arbitrarily chosen to define severity for its usefulness in clinical practice. RESULTS: Data from 406 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 71 ± 15 years and 268 of the patients (66%) were male. The presumed origin of SS was pulmonary (42%), digestive (25%) or urinary (17%) infection. Overall in-hospital mortality was 31% with, 30 and 90-day mortality was respectively 28% and 33%. A prehospital SIGARC score ≥ 2 is associated with an increase in 30 and 90-day mortality with HR = 1.57 [1.02-2.42] and 1.82 [1.21-2.72], respectively. CONCLUSION: A SIGARC score ≥ 2 is associated with an increase in in-hospital, 30 and 90-day mortality of SS patients cared for by a MICU in the prehospital setting. These observational results need to be confirmed by prospective studies.

Prehospital hemodynamic optimisation is associated with a 30-day mortality decrease in patients with septic shock.

INTRODUCTION: Septic shock (SS) is characterized by low blood pressure resulting in organ failure and poor prognosis. Among SS treatments, in hospital studies reported a beneficial effect of early hemodynamic resuscitation on mortality rate. This study aims to investigate the relationship between prehospital hemodynamic optimisation and 30-day mortality in patients with SS. METHODS: From April 6th, 2016 to December 31th, 2019, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (mICU) were included. Prehospital hemodynamic optimisation was defined as a arterial blood pressure of >65 mmHg, or >75 mmHg if previous hypertension history, at the end of the prehospital stage. RESULTS: Three hundred thirty-seven patients were retrospectively analysed. The mean age was 69 ± 15 years, and 226 patients (67%) were male. One hundred and thirty-six patients (40%) had previous hypertension history. Pulmonary, digestive and urinary infections were the suspected cause of the SS in respectively 46%, 23% and 15% of the cases. 30-day overall mortality was 30%. Prehospital hemodynamic optimisation was complete for 204 patients (61%). Cox regression analysis reports a significant association between prehospital hemodynamic optimisation and 30-day mortality (HRa = 0.52 95%CI [0.31-0.86], p = 0.01). CONCLUSION: In this study, we report that prehospital hemodynamic optimisation is associated with a decrease in 30-day mortality in patients with SS cared for by a mICU in the prehospital setting. An individualized mean arterial pressure target, based on previous hypertension history, may be considered from the prehospital stage of SS resuscitation.

Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality.

BACKGROUND: Septic shock (SS) is associated with high morbidity and mortality rate. Early antibiotic therapy administration in septic patients was shown to reduce mortality but its impact on mortality in a prehospital setting is still under debate. To clarify this point, we performed a retrospective analysis on patients with septic shock who received antibiotics in a prehospital setting. Methods: From April 15th, 2017 to March 1st, 2020, patients with septic shock requiring Mobile Intensive Care Unit (MICU) intervention were retrospectively analyzed to assess the impact of prehospital antibiotic therapy administration on a 30-day mortality. Results: Three-hundred-eight patients with septic shock requiring MICU intervention in the prehospital setting were analyzed. The mean age of the study population was 70 ± 15 years. Presumed origin of SS was mainly pulmonary (44%), digestive (21%) or urinary (19%) infection. Overall 30-day mortality was 29%. Ninety-eight (32%) patients received antibiotic therapy. Using Cox regression analysis, we showed that prehospital antibiotic therapy significantly reduces 30-day mortality for patients with septic shock (hazard ratio = 0.56, 95%CI [0.35-0.89], p = 0.016). Conclusion: In this retrospective study, prehospital antibiotic therapy reduces 30-day mortality of septic shock patients cared for by MICU. Further studies will be needed to confirm the beneficial effect of prehospital antibiotic therapy in association or not with prehospital hemodynamic optimization to improve the survival of septic shock patients.

Prehospital lactate clearance is associated with reduced mortality in patients with septic shock.

BACKGROUND: Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, blood lactate measurement is broadly used in combination with the clinical evaluation of patients as the clinical picture alone is not sufficient for assessing disease severity and outcomes. METHODS: From 15th April 2017 to 15th April 2019, patients with SS requiring prehospital mobile Intensive Care Unit intervention (mICU) were prospectively included in this observational study. Prehospital blood lactate clearance was estimated by the difference between prehospital (time of first contact between the patients and the mICU prior to any treatment) and in-hospital (at hospital admission) blood lactate levels divided by prehospital blood lactate. RESULTS: Among the 185 patients included in this study, lactate measurement was missing for six (3%) in the prehospital setting and for four (2%) at hospital admission, thus 175 (95%) were analysed for prehospital blood lactate clearance (mean age 70 ± 14 years). Pulmonary, digestive and urinary infections were probably the cause of the SS in respectively 56%, 22% and 10% of the cases. The 30-day overall mortality was 32%. Mean prehospital blood lactate clearance was significantly different between patients who died and those who survived (respectively 0.41 ± 2.50 mmol.l-1 vs 1.65 ± 2.88 mmol.l-1, p = 0.007). Cox regression analysis showed that 30-day mortality was associated with prehospital blood lactate clearance > 10% (HRa [CI95] = 0.49 [0.26-0.92], p = 0.028) and prehospital blood lactate clearance < 10% (HRa [CI95] = 2.04 [1.08-3.84], p = 0.028). CONCLUSION: A prehospital blood lactate clearance < 10% is associated with 30-day mortality increase in patients with SS handled by the prehospital mICU. Further studies will be needed to evaluate if prehospital blood lactate clearance alone or combined with clinical scores could affected the triage decision-making process for those patients.