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.

The analysis of the geographical distribution of emergency departments' frequent users: a tool to prioritize public health policies?

BACKGROUND: The individual factors associated to Frequent Users (FUs) in Emergency Departments are well known. However, the characteristics of their geographical distribution and how territorial specificities are associated and intertwined with ED use are limited. Investigating healthcare use and territorial factors would help targeting local health policies. We aim at describing the geographical distribution of ED's FUs within the Paris region. METHODS: We performed a retrospective analysis of all ED visits in the Paris region in 2015. Data were collected from the universal health insurance's claims database. Frequent Users (FUs) were defined as having visited ≥3 times any ED of the region over the period. We assessed the FUs rate in each geographical unit (GU) and assessed correlations between FUs rate and socio-demographics and economic characteristics of GUs. We also performed a multidimensional analysis and a principal component analysis to identify a typology of territories to describe and target the FUs phenomenon. RESULTS: FUs accounted for 278,687 (11.7%) of the 2,382,802 patients who visited the ED, living in 232 GUs. In the region, median FUs rate in each GU was 11.0% [interquartile range: 9.5-12.5]. High FUs rate was correlated to the territorial markers of social deprivation. Three different categories of GU were identified with different profiles of healthcare providers densities. CONCLUSION: FUs rate varies between territories and is correlated to territorial markers of social deprivation. Targeted public policies should focus on disadvantaged territories.

Prevention of hypothermia in trauma victims - the HYPOTRAUM 2 study.

INTRODUCTION: Hypothermia is common in trauma patients. It contributes to increasing mortality rate. Hypothermia is multifactorial, favoured by exposure to cold, severity of the patient's state and interventions such as infusion of fluids at room temperature. AIM: To demonstrate that specific management of hypothermia (or of the risk of hypothermia) increases the number of trauma patients arriving at the hospital with a temperature >35°C. DESIGN: This is a prospective, multicentre, open-label, pragmatic, cluster randomized clinical trial of an expected 1,200 trauma patients included by 12 out-of-hospital mobile intensive care units (MICU). Trauma patients are included in a prehospital setting if they present at least one of the following criteria known to be associated with an increased incidence of hypothermia: ambient temperature <18°C, Glasgow coma scale <15, systolic arterial blood pressure <100 mm Hg or body temperature <35°C. Patients are randomized, by cluster, to receive a conventional management or 'interventional' nursing management associating: continuous epitympanic temperature monitoring, early installation in the heated ambulance (temperature target >30°C controlled by infrared thermometer), protection by a survival blanket, and use of heated solutes (temperature objective >35°C controlled by infrared thermometer). The primary end point is the prevalence of hypothermia on arrival at the hospital. The hypothesis tested is a reduction from 20% to 13% in the prevalence of hypothermia. Secondary end points are to evaluate the interaction between the effectiveness of the measures taken and: (1) the severity of the patients assessed by the Revised Trauma Score; (2) the meteorological conditions when they are managed; (3) the time of care; and (4) therapeutic interventions. DISCUSSION: This trial will assess the effectiveness of an invasive, out-of-hospital, temperature management on the onset of hypothermia in moderate to severe trauma patients. IMPACT: Specific management of hypothermia is expected to decrease hypothermia in trauma patients.

Low-Dose Methoxyflurane versus Standard of Care Analgesics for Emergency Trauma Pain: A Systematic Review and Meta-Analysis of Pooled Data.

PURPOSE: Undertreatment of trauma-related pain is common in the pre-hospital and hospital settings owing to barriers to the use of traditional standard of care analgesics. Low-dose methoxyflurane is an inhaled non-opioid analgesic with a rapid onset of pain relief that is approved for emergency relief of moderate-to-severe trauma-related pain in adults. This analysis was performed to compare the efficacy and safety of low-dose methoxyflurane with standard of care analgesics in adults with trauma-related pain. METHODS: A meta-analysis was performed on pooled data from randomized controlled trials identified via a systematic review. The primary endpoint was the pain intensity difference between baseline and various time intervals (5, 10, 15, 20, and 30 minutes) after initiation of treatment. RESULTS: The pain intensity difference was statistically superior with low-dose methoxyflurane compared with standard of care analgesics (overall estimated treatment effect=11.88, 95% CI=9.75-14.00; P<0.0001). The superiority of low-dose methoxyflurane was demonstrated at 5 minutes after treatment initiation and was maintained across all timepoints. Significantly more patients treated with methoxyflurane achieved response criteria of pain intensity ≤30 mm on a visual analog scale, and relative reductions in pain intensity of ≥30% and ≥50%, compared with patients who received standard of care analgesics. The median time to pain relief was shorter with methoxyflurane than with standard of care analgesics. The findings were consistent in a subgroup of elderly patients (aged ≥65 years). CONCLUSION: Methoxyflurane can be considered as an alternative to standard of care analgesics in pre-hospital and hospital settings for treatment of adult patients with acute trauma-related pain.

Role of Inhaled Methoxyflurane in the Management of Acute Trauma Pain.

Adequate treatment of trauma pain is an integral part of the management of trauma patients, not just for ethical reasons but also because undertreated pain can lead to increased morbidities and worse long-term outcomes. Trauma pain management presents challenges in the pre-hospital setting, particularly in adverse or hostile environments as well as in busy emergency departments (EDs). Inhaled methoxyflurane, administered at analgesic doses via a disposable inhaler, has recently become available in Europe for the emergency treatment of moderate to severe pain in conscious adult trauma patients. A growing body of evidence demonstrates that inhaled methoxyflurane is well tolerated and effective in providing a rapid onset of analgesia. In this paper, we discuss the rationale for methoxyflurane use in trauma pain management, data from clinical trials recently conducted in Europe, its efficacy and safety profile compared to current standard treatments, its place in therapy and organizational impact. We conclude that inhaled methoxyflurane represents an effective treatment option in the different settings where trauma patients require rapid and flexible pain resolution, with potential organizational advantages.

Nitrous oxide/oxygen plus acetaminophen versus morphine in ST elevation myocardial infarction: open-label, cluster-randomized, non-inferiority study.

BACKGROUND: Studies have shown disparate results on the consequences of morphine use in ST-segment elevation myocardial infarction (STEMI). No study has evaluated alternative treatments that could be at least non-inferior to morphine without its potentially damaging consequences for myocardial function and platelet reactivity. The aim of this study was to evaluate whether nitrous oxide/oxygen plus intravenous acetaminophen (NOO-A) is non-inferior to morphine to control chest pain in STEMI patients. METHODS: This multicenter, open-label, cluster-randomized, controlled, non-inferiority study compared NOO-A with morphine in 684 prehospital patients with ongoing suspected STEMI of < 12 h duration and a pain rating score ≥ 4. The primary endpoint was the proportion of patients achieving pain relief (numeric rating score ≤ 3) after 30 min. Secondary safety endpoints included serious adverse events and death at 30 days. RESULTS: The median baseline pain score was 7.0 in both groups. The primary endpoint occurred in 51.7% of the NOO-A group and 73.6% of the morphine group (absolute risk difference - 21.7%; 95% confidence interval - 29.6 to - 13.8). At 30 days, the rate of serious adverse events was 16.0 and 18.8% in the NOO-A and morphine groups respectively (p = NS). The rate of death was 1.8% (NOO-A group) and 3.8% (morphine group) (p = NS). CONCLUSION: Analgesia provided by NOO-A was inferior to morphine at 30 min in patients with acute STEMI in the prehospital setting. Rates of serious adverse events did not differ between groups. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02198378.

Inhaled methoxyflurane for the management of trauma related pain in patients admitted to hospital emergency departments: a randomised, double-blind placebo-controlled trial (PenASAP study).

BACKGROUND: Oligo-analgesia is common in the emergency department (ED). This study aimed at reporting, when initiated by triage nurse, the superior efficacy of inhaled methoxyflurane plus standard of care (m-SoC) analgesia versus placebo plus SoC (p-SoC) for moderate-to-severe trauma-related pain in the hospital ED. METHODS: A randomised, double-blind, placebo-controlled trial was conducted at eight EDs. Adults with pain score ≥4 (11-point numerical rate scale, NRS) at admission were randomised to receive one or two inhalers containing m-SoC or p-SoC. Primary outcome measure was time until pain relief ≤30 mm, assessed on the 100-mm Visual Analogic Scale (VAS). RESULTS: A total of 351 patients were analysed (178 m-SoC; 173 p-SoC). Median pain prior to first inhalation was 66 mm, 75% had severe pain (NRS 6-10). Median time to pain relief was 35 min [95% confidence interval (CI), 28-62] for m-SoC versus not reached in p-SoC (92 - not reached) [hazard ratio), 1.93 (1.43-2.60), P < 0.001]. Pain relief was most pronounced in the severe pain subgroup: hazard ratio, 2.5 (1.7-3.7). As SoC, 24 (7%) patients received weak opioids (6 versus 8%), 4 (1%) strong opioid and 44 (13%) escalated to weak or strong opioids (8 versus 17%, respectively, P = 0.02). Most adverse events were of mild (111/147) intensity. CONCLUSIONS: In this study, we report that methoxyflurane, initiated at triage nurse as part of a multimodal analgesic approach, is effective in achieving pain relief for trauma patients. This effect was particularly pronounced in the severe pain subgroup.

Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial.

Importance: Rocuronium and succinylcholine are often used for rapid sequence intubation, although the comparative efficacy of these paralytic agents for achieving successful intubation in an emergency setting has not been evaluated in clinical trials. Succinylcholine use has been associated with several adverse events not reported with rocuronium. Objective: To assess the noninferiority of rocuronium vs succinylcholine for tracheal intubation in out-of-hospital emergency situations. Design, Setting and Participants: Multicenter, single-blind, noninferiority randomized clinical trial comparing rocuronium (1.2 mg/kg) with succinylcholine (1 mg/kg) for rapid sequence intubation in 1248 adult patients needing out-of-hospital tracheal intubation. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. The date of final follow-up was August 31, 2016. Interventions: Patients were randomly assigned to undergo tracheal intubation facilitated by rocuronium (n = 624) or succinylcholine (n = 624). Main Outcomes and Measures: The primary outcome was the intubation success rate on first attempt. A noninferiority margin of 7% was chosen. A per-protocol analysis was prespecified as the primary analysis. Results: Among 1248 patients who were randomized (mean age, 56 years; 501 [40.1%] women), 1230 (98.6%) completed the trial and 1226 (98.2%) were included in the per-protocol analysis. The number of patients with successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, with a between-group difference of -4.8% (1-sided 97.5% CI, -9% to ∞), which did not meet criteria for noninferiority. The most common intubation-related adverse events were hypoxemia (55 of 610 patients [9.0%]) and hypotension (39 of 610 patients [6.4%]) in the rocuronium group and hypoxemia (61 of 616 [9.9%]) and hypotension (62 of 616 patients [10.1%]) in the succinylcholine group. Conclusions and Relevance: Among patients undergoing endotracheal intubation in an out-of-hospital emergency setting, rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate. Trial Registration: ClinicalTrials.gov Identifier: NCT02000674.

Withholding and withdrawing life-support in adults in emergency care: joint position paper from the French Intensive Care Society and French Society of Emergency Medicine.

For many patients, notably among elderly nursing home residents, no plans about end-of-life decisions and palliative care are made. Consequently, when these patients experience life-threatening events, decisions to withhold or withdraw life-support raise major challenges for emergency healthcare professionals. Emergency department premises are not designed for providing the psychological and technical components of end-of-life care. The continuous inflow of large numbers of patients leaves little time for detailed assessments, and emergency department staff often lack training in end-of-life issues. For prehospital medical teams (in France, the physician-staffed mobile emergency and intensive care units known as SMURs), implementing treatment withholding and withdrawal decisions that may have been made before the acute event is not the main focus. The challenge lies in circumventing the apparent contradiction between the need to make immediate decisions and the requirement to set up a complex treatment project that may lead to treatment withholding and/or withdrawal. Laws and recommendations are of little assistance for making treatment withholding and withdrawal decisions in the emergency setting. The French Intensive Care Society (Société de Réanimation de Langue Française, SRLF) and French Society of Emergency Medicine (Société Française de Médecine d'Urgence, SFMU) tasked a panel of emergency physicians and intensivists with developing a document to serve both as a position paper on life-support withholding and withdrawal in the emergency setting and as a guide for professionals providing emergency care. The task force based its work on the available legislation and recommendations and on a review of published studies.

Assessment of procedural pain in French emergency departments: a multi-site, non-interventional, transverse study in patients with minor trauma injury.

Objective: To determine the mean number of procedural painful episodes per patient, and to retrieve information regarding diagnosis, therapeutic procedures and analgesic management, in patients visiting Emergency Departments (EDs) for minor trauma. Methods: This observational, non-interventional, multicenter study in adult patients was performed in 35 French EDs. All patients entering the EDs for minor trauma on a specified day between noon and 10 pm were registered; consenting patients were included in the study. Pain intensity was assessed using a verbal Numerical Rating Scale from 0 (no pain) to 10 (worst possible pain). An episode was described as painful if the difference in pain intensity between pain just before the procedure and maximal pain during the procedure was ≥2. Two independent nurses recorded data on 1 day in each center. Results: Overall, 909 patients were registered, 422 were included in the study, and complete data for 409 patients (1899 procedures) were available for analysis. The mean number of painful episodes per patient was 1.0 ± 1.3. Fifty-one percent of patients reported at least one painful procedure episode. Twenty-one percent of procedures were considered painful. Clinical examination was the procedure most often reported as painful. No preventive or curative analgesic treatment was reported in 95.1% of procedures. Conclusions: There is a need for improvement in routine pain assessment and, therefore, procedural pain management for ED patients. Specific protocols should be developed for procedural pain management, and teams should be trained especially for procedures usually not considered painful.

Diabetes education of patients and their entourage: out-of-hospital national study (EDUCATED 2).

AIMS: To determine the contributing factors in the successful diabetes education of patients and their entourage. METHODS: Prospective observational study conducted in a pre-hospital setting by 17 emergency services across France (September 2009-January 2011) included all insulin-treated patients (≥18 years) provided that at least one family member was present on scene. Data were collected from patients and their entourage: (1) personal details including language proficiency and educational attainment, (2) treatments, (3) diabetes-related data (log sheets, glucose meter, glucagon, glycated hemoglobin, prior hypoglycemic episodes); (4) care by diabetologist, general practitioner and/or visiting nurse. The main end points were ability to measure capillary blood sugar (patient) and awareness of hypoglycemia symptoms and ability to administer glucagon (entourage). RESULTS: Overall, 561 patients and 736 family members were included; 343 patients (61%) were experiencing a hypoglycemic episode (<2.5 mmol/L). A total of 141 (75%) patients and 343 (50%) family members could measure capillary blood sugar. They could name a median of 2 [0-3‰] hypoglycemia symptoms although 217 (39%) patients and 262 (39%) family members could name no symptom. Few patients (33%) had glucagon available. In multivariate analyses, the main factor associated with better patient education was care by a diabetologist. Lack of an educational qualification and visits by a nurse were associated with poor patient education, and French mother tongue and care by a diabetologist with better education of the entourage. CONCLUSIONS: In France, diabetic patients and their entourage are inadequately educated. Their education benefits most from care by a diabetologist.

Effectiveness and cost-effectiveness of telephone consultations for fever or gastroenteritis using a formalised procedure in general practice: study protocol of a cluster randomised controlled trial.

BACKGROUND: Telephone consultations in general practice are on the increase. However, data on their efficiency in terms of out-of-hours general practitioner (GP) workload, visits to hospital emergency departments (ED), cost, patient safety and satisfaction are relatively scant. The aim of this trial is to assess the effectiveness of telephone consultations provided by French emergency call centres in patients presenting with isolated fever or symptoms of gastroenteritis, mainly encountered diseases. METHODS/DESIGN: This is a prospective, open-label, multicentre, pragmatic, cluster randomised clinical trial of an estimated 2880 patients making an out-of-hours call to one of six French emergency call centres for assistance with either fever or symptoms of gastroenteritis without seriousness criteria. Each call is handled by a call centre physician. Out-of-hours is 8 p.m. to 7.59 a.m. on weekdays, 1 p.m. to 7.59 a.m. on Saturdays and round-the-clock on Sundays and school holidays. Patients will be enrolled over 1 year. In the intervention arm, a telephone consultation based on a protocol, the formal Telephone Medical Advice (fTMA), is offered to each patient calling. This protocol aims to overcome a physical consultation during out-of-hours periods. It offers reassurance and explanations, advice on therapeutic management which may include, in addition to hygiene and diet measures, a telephone prescription of antipyretic, analgesic, rehydration medication or others, and recommendations on surveillance of the patient and any action to be taken. The patient is invited to call again if the condition worsens or new symptoms develop and to make an appointment with their family GP during office hours. In the control arm, the call centre physician handles calls as usual. This physician can carry out a telephone consultation with or without a telephone prescription, dispatch an on-duty GP, the fire brigade or an ambulance to the patient, or refer the patient to an on-duty physician or to the ED. Each patient will receive a follow-up call on day 15. The primary endpoint is the frequency of out-of-hours, face-to-face GP consultations or visits to the ED during the 15 days following the index call. The secondary endpoints measured on day 15 are the number of stays in intensive care, the number of hospital admissions, the number of interventions by the fire brigade, emergency medical and ambulance services, the number and length of prescribed sick-leave episodes, all-cause mortality, morbidity, clinical outcome, patient compliance, patient satisfaction, the number of renewed calls to the call centre, the number of patients receiving multiple face-to-face GP consultations and costs incurred. DISCUSSION: This trial will assess the effectiveness and the cost-effectiveness of a formalised response to calls for assistance with fever or symptoms of gastroenteritis without seriousness criteria. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02286245 , registered on 9 September 2014.

Family presence during cardiopulmonary resuscitation.

BACKGROUND: The effect of family presence during cardiopulmonary resuscitation (CPR) on the family members themselves and the medical team remains controversial. METHODS: We enrolled 570 relatives of patients who were in cardiac arrest and were given CPR by 15 prehospital emergency medical service units. The units were randomly assigned either to systematically offer the family member the opportunity to observe CPR (intervention group) or to follow standard practice regarding family presence (control group). The primary end point was the proportion of relatives with post-traumatic stress disorder (PTSD)-related symptoms on day 90. Secondary end points included the presence of anxiety and depression symptoms and the effect of family presence on medical efforts at resuscitation, the well-being of the health care team, and the occurrence of medicolegal claims. RESULTS: In the intervention group, 211 of 266 relatives (79%) witnessed CPR, as compared with 131 of 304 relatives (43%) in the control group. In the intention-to-treat analysis, the frequency of PTSD-related symptoms was significantly higher in the control group than in the intervention group (adjusted odds ratio, 1.7; 95% confidence interval [CI], 1.2 to 2.5; P=0.004) and among family members who did not witness CPR than among those who did (adjusted odds ratio, 1.6; 95% CI, 1.1 to 2.5; P=0.02). Relatives who did not witness CPR had symptoms of anxiety and depression more frequently than those who did witness CPR. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, or the level of emotional stress in the medical team and did not result in medicolegal claims. CONCLUSIONS: Family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team, or result in medicolegal conflicts. (Funded by Programme Hospitalier de Recherche Clinique 2008 of the French Ministry of Health; ClinicalTrials.gov number, NCT01009606.).

Response time evaluation for emergency medical service as a part of its performance.

The study aimed to evaluate the response time (RT) of a French physician-staffed emergency medical service unit in both first-line and second-line service zones a part of its performance and how best to integrate it into its geographical specificity and showed acceptable RTs (mostly <10 min). Interestingly, because of the particular location next to other districts, RTs are in the same range for some municipalities that are adjacent to the first-line and area. In a new system in which catching areas would not only be based on administrative criteria anymore but also on performance evaluation, RTs for emergency medical service might be optimised.

Family witnessed resuscitation: nationwide survey of 337 prehospital emergency teams in France.

OBJECTIVE: To assess the practices and opinions of prehospital emergency medical services (EMS) with regard to family witnessed resuscitation (FWR) and to analyse the differences between physicians' and nurses' responses. DESIGN: An anonymous questionnaire (30 yes/no questions on demographics and FWR) was sent to all prehospital emergency staff (physicians, nurses and support staff) working for the 377 Mobile Intensive Care Units in France. RESULTS: Of the 2689 responses received 2664 were analysed. Mean respondent age was 38 ± 8 years, the male to female ratio was 1:2. 87% of respondents had already performed FWR and 38% had offered relatives the option to be present during resuscitation. Most respondents (90%) felt that FWR might cause psychological trauma to the family; 70% thought that FWR might impact on the duration of resuscitation and 68% on EMS team concentration. In the 28% of cases when relatives had asked to be present, 59% of respondents had acquiesced but only 27% were willing to invite relatives to be routinely present. CONCLUSIONS: Prehospital EMS teams in France seems to support FWR but are not yet ready to offer it systematically to relatives. Following our survey, written guidelines are currently in development in our department. These guidelines could be the first step of a national strategy for developing FWR in France. We await results from other studies of family members' opinions to compare prehospital practitioners' and family members' views to further develop our practice.

Factors associated with difficult intubation in prehospital emergency medicine.

OBJECTIVES: When managing airways in a prehospital setting, emergency physicians have to deal with difficult intubation (DI), which increases morbidity and mortality. The primary goal of this study was to determine predictors of DI in the out-of-hospital field faced by the French physician-staffed Emergency Medical Service. METHODS: The study was a prospective, observational study, including all consecutive patients intubated during a 30-month period. Patients having experienced standard intubation (two attempts or less) or DI (more than two attempts) were compared. RESULTS: Six hundred and ninety-four patients were included: 70 (11%) were classified as DI and 583 as standard intubations. Logistic regression showed that airways obstruction [odds ratio (OR), 4.1; 95% confidence interval (CI), 1.71-14.4], intubation on the floor (OR, 2.6; 95% CI, 1.04-6.6), and a hyoid-mental distance less than three fingers (OR, 2.3; 95% CI, 1.2-4.7) were independent predictors of DI. Immediate complications occurred in 89 patients (16%): 66 (11%) in the standard intubation group and 23 (31%) in the DI group (P<0.01). CONCLUSION: For prehospital orotracheal intubation, independent risk factors of DI are a mental-thyroid distance less than three fingers, a patient on the floor, and a superior airways obstruction. Anticipation of DI could result in fewer attempts, and fewer complications, as the rate of complication increases with the difficulty of intubation.

Collaboration between prehospital emergency medical teams and palliative care networks allows a better respect of a patient's will.

This study aimed to evaluate whether patient's wishes were respected by prehospital emergency medical teams after implementing collaboration and a standardized process between a community-based palliative network and the Emergency Medical Service system. Forty patients were included. In 75% of cases, the doctor of the prehospital emergency team decided in collaboration with the network's doctor according to the established procedure. This has enabled a respect of the care plan in 83% of cases. Without collaboration with the palliative care network, through the ignorance of its existence or through the wish of the prehospital emergency medical teams for taking decisions alone, the care plan was only respected in 40% of cases, P=0.025. Collaboration between prehospital emergency medical teams and community-based palliative care networks seems to enable a better respect of the care plan in the event of emergency situations affecting the patient in a palliative situation.

Feasibility of cardiac output estimation by ultrasonic cardiac output monitoring in the prehospital setting.

The possible benefits of ultrasonic cardiac output monitoring (USCOM) in emergency medicine practice could be significant if evaluated in a goal-directed protocol. The aim of this study was to perform a feasibility study in a physician-staffed prehospital emergency medicine system. This study enrolled a convenient sample of 50 patients with circulatory distress. Main criteria were visualization of acceptable curves and obtaining interpretable values. Acceptable curves and interpretable values (main criterion) were obtained for 35 patients (70%). In case of failure, the patient was very often dyspneic (80 vs. 23%, when the technique was successful, P<0.001). Mean duration of USCOM examination was 105 ± 60 s. The acceptable success rate for a new technique we observed and the high easy-to-use score suggests that the use of USCOM is feasible in prehospital emergency medicine.

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.

Quality of pain management in the emergency department: results of a multicentre prospective study.

OBJECTIVES: The purpose of this study was to evaluate pain management in a large sample of emergency departments (EDs) and identify potential corrective measures. METHOLOGY: A multicentre prospective study was performed in 50 EDs participating in a national quality improvement programme. The rate of inclusion was determined a priori in each ED. Patients were questioned about their pain and pain intensity was assessed by a visual analogue scale. A bivariate and a multivariate analysis were conducted to identify the criteria associated with inadequate pain management. RESULTS: A total of 11 670 patients were included and 7265 patients reported pain on admission. On arrival, pain intensity was assessed in 90% of patients (44% experienced severe pain). However, reassessments were performed less often (48% on discharge). Fifty-one percent of patients received pain treatment. Intravenous morphine was used in only 9% of patients with severe pain. Initial treatment was provided within 60 min of admission to 74% of patients. Among patients who were assessed on discharge, 27% still had pain (8% with severe pain). Delay for pain management was significantly related to the ED volume, lack of triage nurses, patients' disorders and initial pain intensity. CONCLUSION: This multicentre study conducted on a nationwide scale shows that pain relief can be improved in the ED. Pain intensity is not sufficiently reassessed, analgesics are underutilised, morphine sulfate is rarely used and delay in treatment is common. Reasons for inadequate analgesia were identified in order to identify relevant corrective measures to improve quality of pain management in the ED.