TRANSCOV cohort protocol: an epidemiological study assessing the impact of critically ill COVID-19 patients long distance transfers between intensive care units.

INTRODUCTION: During spring 2020, four regions of France faced a surge of severe COVID-19 patients which threatened to overflow local intensive care units (ICU) capacities. As an emergency response, between 13 March 2020 and 10 April 2020, an estimated 661 patients were transferred from overcrowded ICUs to eight other French regions and four neighbouring countries. The intensity, geographical spread and the diversity of vectors used are unprecedented. The study aims at assessing the impact of these inter-ICU transfers on the short-term and medium-term physical and psychological outcomes in this population of severe COVID-19 patients. METHODS AND ANALYSIS: The TRANSCOV cohort is a multicentre observational retrospective study. All transferred patients between ICUs outside the origin region will be invited to take part. For each transfer, up to four control patients will be selected among those admitted in the same ICU during the same period (±4 days of transfer date). Clinical data will be extracted from medical records and will include haemodynamic and respiratory parameters, as well as clinical severity scores before, during and after transfer. Data linkage with medicoadministrative data will enrich the clinical database and allow follow-up up to 1 year after initial admission. ETHICS AND DISSEMINATION: The study has been approved by the French Ethics and Scientific Committee on the 16 July 2020 (file no. 2046524). The results will be disseminated via publication of scientific articles and communications in national and international conferences. TRIAL REGISTRATION NUMBER: 20 CO 015 CZ.

[Hypnosis in emergency medicine : let's change our habits!] / Hypnose en médecine d'urgence : bousculons nos habitudes !

The effectiveness of hypnosis in the management of pain and anxiety has been widely demonstrated today. While this technique is commonly used in anesthesia and psychiatry, its use in emergencies is still poorly developed. The fields of application in hospital and extra-hospital emergency are however multiple and, contrary to popular belief, emergencies are the ideal place for the practice of hypnosis. Hypnosis is a reliable, safe, effective and inexpensive technique that any caregiver can learn. It strengthens the caregiver-patient relationship and helps us to treat differently, more humanly and more serenely.

L'efficacité de l'hypnose dans la prise en charge de la douleur et de l'anxiété est aujourd'hui largement démontrée. Si cette technique est d'usage courant en anesthésie et psychiatrie, son utilisation en situation d'urgence est encore peu développée. Les champs d'application en médecine d'urgence (MU) hospitalière et préhospitalière sont pourtant multiples et, contrairement aux idées reçues, les urgences sont le lieu idéal pour la pratique de l'hypnose. C'est une technique fiable, sûre, efficace et peu coûteuse que tout soignant peut apprendre. Elle renforce la relation soignant-soigné et nous aide à intervenir autrement, plus humainement et plus sereinement.

One-Year Survival After ST-Segment-Elevation Myocardial Infarction in Relation With Prehospital Administration of Dual Antiplatelet Therapy.

Background The optimal timing of administration of dual antiplatelet therapy (DAPT) in acute ST-segment-elevation myocardial infarction patients is debated. Clinical trials have failed to demonstrate the superiority of pretreatment with P2Y12 inhibitors in ST-segment-elevation myocardial infarction, but they were not designed to assess hard clinical end points. We used data from the FAST-MI (French Registry on Acute ST-Segment-Elevation or Non-ST-Segment-Elevation Myocardial Infarction) cohorts to determine 1-year survival and in-hospital outcomes in patients receiving DAPT, comparing prehospital versus in-hospital administration. Methods and Results The FAST-MI program collects extensive data on patients admitted in France for acute myocardial infarction over a 1-month period every 5 years since 2005. For the present analysis, 3548 patients with ST-segment-elevation myocardial infarction ≤12 hours from symptom onset, transported by physician-staffed emergency medical system ambulances, not treated with intravenous fibrinolysis, and receiving DAPT were included, of whom 44% received DAPT in the ambulance. The primary end point was 1-year survival as assessed by multivariate Cox analysis and propensity score analysis. In-hospital bleeding and ischemic complications were also analyzed. Adjusted in-hospital mortality was numerically but not significantly lower in patients with prehospital DAPT. There were no differences in in-hospital bleeding complications. Fully-adjusted hazard ratio for 1-year death in patients with prehospital versus in-hospital DAPT was 0.69 (95% CI, 0.51-0.92; P=0.011), and propensity score-adjusted hazard ratio was 0.55 (95% CI, 0.41-0.73; P=0.001) in the whole population. In the propensity score-matched cohorts (360 patients each), 1-year survival was 93.9% in patients with prehospital versus 90.3% in those with in-hospital DAPT (hazard ratio, 0.62; 95% CI, 0.36-1.05; P=0.077). Results were consistent in subgroups, including by year of survey, age, presence of out-of-hospital cardiac arrest, morphine use, and type of P2Y12 inhibitor used. Conclusions In these cohorts of ST-segment-elevation myocardial infarction patients considered for primary percutaneous coronary intervention, prehospital administration of DAPT was associated with higher 1-year survival and no increase in in-hospital bleeding complications. The magnitude of the decrease in 1-year mortality, however, may suggest the persistence of some degree of residual confounding. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifiers: NCT00673036, NCT01237418, and NCT02566200.

Practical management of concomitant acute heart failure and worsening renal function in the emergency department.

Worsening renal function (i.e. any increase in creatinine or decrease in the estimated glomerular filtration rate) is common in patients admitted for acute heart failure in the emergency department. Although worsening renal function (WRF) has been associated with the occurrence of dismal outcomes, this only appears to be the case when associated with clinical deterioration. However, if the clinical status of the patient is improving, a certain increase in serum creatinine may be acceptable. This WRF, which is not associated with clinical deterioration or adverse outcomes (e.g. during treatment up-titration), has been referred to as 'pseudo-WRF' and should not detract clinicians from targeting 'guideline-recommended' therapies. This is an important message for emergency physicians to pursue diuretics as long as signs of pulmonary congestion persist to improve the clinical status of the patient. In the present review, we aim to provide clinicians in acute settings with an integrative and comprehensive approach to cardiorenal interactions in acute heart failure.

Integrative Assessment of Congestion in Heart Failure Throughout the Patient Journey.

Congestion is one of the main predictors of poor patient outcome in patients with heart failure. However, congestion is difficult to assess, especially when symptoms are mild. Although numerous clinical scores, imaging tools, and biological tests are available to assist physicians in ascertaining and quantifying congestion, not all are appropriate for use in all stages of patient management. In recent years, multidisciplinary management in the community has become increasingly important to prevent heart failure hospitalizations. Electronic alert systems and communication platforms are emerging that could be used to facilitate patient home monitoring that identifies congestion from heart failure decompensation at an earlier stage. This paper describes the role of congestion detection methods at key stages of patient care: pre-admission, admission to the emergency department, in-hospital management, and lastly, discharge and continued monitoring in the community. The multidisciplinary working group, which consisted of cardiologists, emergency physicians, and a nephrologist with both clinical and research backgrounds, reviewed the current literature regarding the various scores, tools, and tests to detect and quantify congestion. This paper describes the role of each tool at key stages of patient care and discusses the advantages of telemedicine as a means of providing true integrated patient care.

French Registry on Acute ST-elevation and non-ST-elevation Myocardial Infarction 2015 (FAST-MI 2015). Design and baseline data.

BACKGROUND: The FAST-MI programme, consisting of 1-month surveys of patients admitted to hospital for acute myocardial infarction (AMI) in France, has run since 2005. AIM: To gather data on the characteristics, management and outcomes of patients hospitalized for AMI at the end of 2015 in France and to provide comparisons with the previous surveys. METHODS: Consecutive adults with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment-elevation myocardial infarction (NSTEMI) with symptom onset≤48hours were included over a 1-month period, with a possible extension of recruitment for 1 additional month. Patients with AMI following cardiovascular procedures were excluded. In all, 204 centres participated in the survey (114 community hospitals, 40 academic, 48 private clinics, 2 army hospitals), representing 78% of French centres managing AMI patients. Inclusion started from 5 October 2015. Data were collected on-site from source files by external research technicians, using an electronic case record form with automatic quality checks. Centralized biology was organized in voluntary centres to collect RNA and DNA samples, serum and stools. Long-term follow-up was organized centrally with interrogation of municipal registry offices, physicians and by direct contact with the patients or their families. RESULTS: A total of 5291 patients were included over the entire recruitment period, with 3813 included during the first month (STEMI: 49%, NSTEMI: 51%). Mean age was 66±14 years, 29% were≥75 years of age, 28% were women; 80% presented with typical chest pain. In STEMI patients, 6% received intravenous fibrinolysis and 71% underwent primary PCI. The hospital death rate was 2.7% (STEMI: 2.8%, NSTEMI: 2.5%). CONCLUSIONS: Recruitment was in line with expectations and the first data show that management has continued to evolve since the 2010 survey, with continued improvement in hospital outcomes.

Stress and salivary cortisol in emergency medical dispatchers: A randomized shifts control trial.

Stress at work is a public health concern. Phone operators in emergency medical dispatch centers are particularly at risk. We aimed to demonstrate that the most stressful time for emergency medical dispatchers is the shift when they receive emergency incoming calls, with cortisol as a biomarker of stress. For each emergency medical dispatcher, we measured outcomes over a control day and during three types of shift: Incoming emergency call, Dispatch and Re-assessment. The pattern of shifts was randomized. Saliva was sampled every 15 minutes for 2 hours, i.e. 6 consecutive times, starting 15 minutes after the first life-and-death incoming emergency call between 2 and 5 pm during three types of shift. We measured saliva cortisol every 2 hours over a control day, from 7am to 9pm. Perceived stress was assessed by a visual analog scale. We recruited 22 phone operators aged 36.4+/-10.8 years old (14 women and 8 men). Cortisol values were higher during the Incoming emergency call shift than during the Dispatch (p = .04) and Re-assessment (p = .04) shifts. The increase in cortisol levels was greater in men than in women (p = .009). There were no differences between control values and those of the three shifts. The kinetics of cortisol increased with greater perceived stress overall (p < .001) and for each type of shift (Incoming emergency call, p = .02; Dispatch p = .03; Re-assessment: p < .001). The kinetics of cortisol in response to incoming emergency calls was greater when the call was an absolute emergency (p = .03), and also tended to further increase when a subsequent absolute incoming emergency call was received (p = 0.07). In conclusion, the incoming emergency call shift carries particular risk for dispatchers, who have greater perceived stress and a greater increase in cortisol levels.

Organizations for emergency care / Organisation pour la prise en charge des urgences

Organisations for emergency care. Often proposed, as much criticized than congratulated, emergency French medicine answers, each year, with the request of more than 30 million our fellow-citizens. Medicine of course of care, it's built on a rigorous organization articulating between a pre-hospital management and health care institutions. Based on the qualification of the request, the action to preserve life and/or the function of a vital organ and the orientation in the good pathway of care, this organization must adapt to answer the evolution of the needs for health and our health-care system. The territory of emergency health is the base of this new organization, coordinated by a medical call center "Samu-Santé" gathering all the actors of the answer to an urgent care request.

Organisations pour la prise en charge des urgences. Souvent mise en avant, autant décriée qu'encensée, la médecine d'urgence française répond, chaque année, à la sollicitation de plus de 30 millions de nos concitoyens. Médecine de parcours de soins, elle repose sur une organisation rigoureuse s'articulant entre une prise en charge pré-hospitalière et les établissements de santé. Fondée sur la qualification de la demande, l'action pour préserver la vie et/ou la fonction et l'orientation dans la bonne filière de soins, cette organisation doit s'adapter pour répondre à l'évolution des besoins de santé et de notre système de soins. Le territoire de santé d'urgence est la base de cette organisation nouvelle, coordonnée par une plateforme de régulation médicale « Samu-Santé ¼ regroupant tous les acteurs de la réponse à une demande de soins urgents.