[Out-of-hospital equipment of emergency medical services for hemorrhagic shock management: can do better!]. / Équipement des Smur pour la prise en charge préhospitalière du choc hémorragique : peut mieux faire !

INTRODUCTION: Hemorrhagic shock is an emergency, which may benefit from a medicalized prehospital care. Our goal was to survey the means available in the 370 French prehospital medicalized emergency services (SMUR) for hemorrhagic situations. METHODS: Multicenter descriptive observational study by email then phone with all the 370 French SMUR leaders. The questionnaire was created by investigators of the project through a Delphi method, and was about service protocols concerning hemorrhagic patient care, hemorrhagic parameters measure equipment available, intravenous solutes and drugs as well as various medical devices useful or perceived to be useful to support prehospital hemorrhagic shock. The results are expressed in numbers and percentages. RESULTS: The overall response rate was 48% (n=178). Protocols were established in between 43% (n=76) and 47% (n=83) according to etiology, measuring devices were available in 5% (n=9) of the Smur for hemostasis up to 89% (n=158) for hemoglobin measurement. Available intravenous solutes were mainly isotonic salty serum (95%, n=169), hydroxylethylstarch (83%, n=148) and Ringer lactate (73%, n=130). Tranexamic acid was available in 84 (47%) Smur. The teams had access to erythrocytes concentrates, fresh frozen plasma and platelets in 84% (n=150), 44% (n=79) and 23% (n=41) respectively. Eighty-one (46%) Smur had tourniquets and 127 (71%) anti-shock trousers. Finally, 57 (32%) had a pelvic restraint belt. CONCLUSION: There is a great disparity in the means available in the French Smur for the support of prehospitalization bleeding. The majority the Smur physicians can transfuse in a prehospital setting. On the other hand, a minority of teams can actively warm patients, employ tranexamic acid or use pelvic restraint belts.

Adverse drug reactions in an emergency medical dispatching centre.

PURPOSE: The purpose of this study is to assess the incidence of adverse drug reactions (ADR) leading to call an emergency medical dispatching centre. METHODS: A prospective, observational, monocentric clinical study performed over a 2-year period (2011-2012) in a French prehospital emergency dispatching centre, the Service d'Aide Médicale Urgente (SAMU) covering 1,156,000 inhabitants. All adult patients (age≥18) who called for any cause were included. We created an electronic trigger 'iatrogenic event' implemented by the dispatching physician for each suspected case of ADR, then we completed the analyses of all the cases with a chief complain represented in more than 1% of the triggered cases. The primary outcome variable was the occurrence of any possible ADR. We then used the French method of causal relationship assessment. RESULTS: The SAMU dispatched 339,915 calls during the study. In total, 1,467 ADRs were identified, representing 0.95% (CI 95% 0.90-1.00%) of cases. ADRs were as serious (SADR) in 51.06% (CI 95% 48.45-53.67%) of cases. The major ADR observed was haemorrhage, (42.81% (CI 95% 40.62-45.00%), n=628) followed by allergy, hypoglycaemia, vomiting, dizziness and drowsiness. The class of drugs most frequently involved was antithrombotic (43.69% (CI 95% 41.45-45.93%), n=641), followed by insulin (17.98% (CI 95%:17.06-18.90%), n=264). CONCLUSIONS: Emergency calls concerning ADRs were estimated as 9/1,000, and one out of two is serious.

[State of the art. Publications of French emergency's teams since 5 years]. / Publications des équipes françaises de médecine d'urgence. Où en est-on depuis cinq ans ?

INTRODUCTION: The development of emergency medicine in France and its valuation can take place only through acknowledged scientific publications. The aim of our study was to analyze the publications of French teams in emergency medicine since 2006. MATERIAL AND METHODS: Observational, descriptive study, from January 1st, 2006 to December 31st, 2010 including, thanks to Medline, studies related to emergency medicine with, as keywords, "medicine d'urgences; urgences; emergency; emergency medicine; French; France" the names of heads of the emergency departments, of the urgent medical aid services (samu) and of anaesthetics services in mainland France. Data collection focused on the type of study, subject, place of conducting the study and grade of international quality. RESULTS: Three hundred and twenty-five publications were listed: 39% (n=126) of the studies were carried out in prehospital. We identified 28% of observational studies (n=92), 20% of randomized prospective (n=66), 19% of cohorts (n=62), 18% of case reports (n=59), 10% of clarifications (n=32) and 4% of general reviews (n=11). The most frequent theme was the cardiology (38% of cases). The most favourite journal was the Annales françaises d'anesthésie et de réanimation (Afar) (18%, n=57). CONCLUSION: The release of French studies in emergency medicine is increasing, with an improvement in the quality of the published studies. All these results demonstrate the progress made since five years in emergency medicine in France but also the work that remains to be done in our rising medical specialization.

[Physician staffed ambulances are better for patients' analgesia on arrival at the emergency department]. / Le Smur meilleur vecteur pour une analgésie des patients traumatisés à l'arrivée aux urgences.

OBJECTIVES: To find out prehospital factors linked with low pain on arrival into a traumatic emergency unit. METHODS: A 4-month monocentric prospective study, including patients recruited at their arrival into a traumatic emergency unit. Pain (with a numerical rating scale [NRS]), anxiety, prehospital care including the type of transportation (physician staffed ambulances {service mobile d'urgence et de réanimation [Smur]}, emergency medical technicians, or firemen ambulances), immobilization and analgesics used were evaluated. These data were collected on arrival at the hospital by the ED orientation nurse. Uni- and multivariate analysis were performed to identify low pain's predictive factors (e.g. with a NRS ≤3). RESULTS: Three hundred and four patients were recruited, mean age=51±25, sex ratio=1.8, mean pain/10=5.8±2.9, 64% with a moderate or severe pain on arrival (NRS>3). For one third of patients, immobilizations hadn't been performed during the prehospital phase. Medical management by Smur is a low pain predictive factor (OR=5.8; CI 95%=1.4-24.16), anxiety is a pejorative factor (OR=0.53 CI 95%=0.38-0.75). CONCLUSION: Our study highlights the physician staffed ambulances' effectiveness in prehospital trauma victims' management and raises the question of anxiolysis as an adjuvant for traumatic pain management.

[Fibrinolysis and acute stroke in maritime search and rescue medical evacuation]. / Thrombolyse et accident vasculaire cérébral, à propos d'un cas de secours en mer.

Medical management of a female passenger with acute stroke aboard a cruise ship at the sea allowed a fast evacuation towards a stroke unit by an helicopter staffed with an emergency medical doctor. Fibrinolysis begun in a short delay after magnetic resonance imaging.

[Prehospital cricothyrotomy: a case report]. / Cricothyrotomie préhospitalière: à propos d'un cas.

Case report of a patient with tonsillitis treated with anti-inflammatory. The patient presented a dyspnoea and finally a cardiac arrest. The oral intubation was impossible and cricothyrotomy had to be performed with a catheter over needle technique. We found a total airway obstruction due to an epiglottis abscess. The patient died few days later of sepsis. We recommend having wire-guided cricothyrotomy technique or catheter-over-needle technique in all prehospital emergency unit and having emergency physician trained to the cricothyrotomy technique.

[Management of acute coronary syndromes without ST elevation: the TOSCANE registry]. / Prise en charge des syndromes coronaires aigus sans sus-décalage du segment ST. Registre TOSCANE.

The problem of pre-hospital management of acute coronary syndromes without ST elevation has not been extensively studied. The practitioner is faced with three simultaneous problems: suspecting the diagnosis, how to confirm the diagnosis to introduce appropriate, rapid and effective treatment, and which prognostic criteria to use to install aggressive therapy in high risk groups (anti GP lIb/IIIa, clopidogrel, angioplasty). TOSCANE is the first multicentre French registry which analyses the impact of the emergency ambulance serve in the management of these patients. There are two objectives: to gather epidemiological data about pre-hospital and hospital management by the emergency physician and the cardiologist, and to identify at an early stage criteria of "high risk" (HR) which, according to the recommendations of the European Society of Cardiology, justify using the most aggressive therapies. From April to September 2003, 797 patients with suspected acute coronary syndromes were enrolled by 36 French centre. Of these patients, 780 were managed successfully by the emergency ambulance service and hospital cardiological department with or without a "Cath Lab", and included for analysis. The diagnosis of acute coronary syndrome without ST elevation was rarely certain in the pre-hospital period. The lack of formal paraclinical features confirming the diagnosis was often a handicap for the emergency physician. Although the European recommendations are well observed in the cardiology departments, their application and adaptability should be improved in the pre-hospital period. TOSCANE showed that all invasive strategies preceded by platelet anti-aggregant therapy in the prehospital period administered to high risk patients, significantly reduced the mortality and morbidity at one month.

[Evaluation of therapeutic strategies for myocardial infarction: the ESTIM Midi-Pyrénées survey]. / Evalualion des stratégies thérapeutiques dans l'infarctus du myocarde: le registre ESTIM Midi-Pyrénées.

UNLABELLED: The aim of the ESTIM Midi-Pyrénées survey was to monitor the management of acute coronary syndrome with ST segment elevation by cardiologists and emergency departments in the Midi-Pyrénées region. Over a period of 2 years between June 2001 and June 2003, 1287 patients presenting with acute coronary syndrome within the first 24 hours were recruited prospectively. The initial management of these patients was undertaken either by a mobile medical team in the pre-hospital phase, or in a hospital emergency department, non-interventional cardiology department or an interventional cardiology department in 51.8%, 28.8%, 9.6% et 9.9% of cases respectively. Depending on these four modes of initial management, the median time for initial management was 1h30, 2h45, 4h30 et 4h respectively. Emergency coronary reperfusion was proposed in 89.6% of cases. Of the patients in whom reperfusion was attempted within the first 12 hours, 33.7% underwent pre-hospital thrombolysis (median delay of 1h48), 35.8% underwent thrombolysis in hospital (median delay 3h), and 30.4% underwent primary angioplasty (median delay 4h40). Thrombolysis was followed by angioplasty in 80% of cases. A combined approach with thrombolysis and angioplasty was applied in 41% of patients. At one month the rate of major cardiac events, death, and/or subsequent myocardial infarction was 12%. Multivariate analysis revealed that the only significant adverse prognostic features were: not offering reperfusion [Odds ratio (OR) 4, confidence interval (CI) 2.3-3.7] and age [OR 3.8, CI 2.3-6.2]. The method of reperfusion did not influence the subsequent outcome in this regional survey. CONCLUSION: pre-hospital management allows early revascularisation. In our region there was no significant prognostic difference between pre-hospital thrombolysis and primary angioplasty. It shows that the logistic and therapeutic potentials of prehospital care are not being sufficiently exploited.

[Evaluation of regional anesthesia procedure in an emergency department]. / Evaluation de l'utilisation de l'anesthésie locorégionale dans un service d'urgence.

OBJECTIVES: Evaluation of regional anaesthesia procedures for limb traumatic surgery performed in an emergency department. METHOD: Anaesthetic procedures concerning traumatic emergencies have been studied from 1995 to 2000. RESULTS: A 32% increase in anaesthesia practice was observed from 1995 (221) to 2000 (292) with a 52% increase in regional anaesthesia. Since 1996, regional anaesthesia represents more than 80% of the anaesthetic procedures and 90% for the upper limb surgery (66% of the surgical procedures). Axillary block (50%), interscalene brachial plexus block (15%) and combined sciatic and femoral nerve block (17%) were the main regional anaesthesia procedures. Spinal anaesthesia (9 cases) and intravenous locoregional anaesthesia (12 cases) were rarely used. CONCLUSION: In our study, regional anaesthesia is the most used technique when compared to general anaesthesia for emergency procedure. The anaesthetic staff has to be motivated and trained.

Peritraumatic dissociation, acute stress, and early posttraumatic stress disorder in victims of general crime.

OBJECTIVE: To compare the relation between peritraumatic dissociation and acute stress and the early development of posttraumatic stress disorder (PTSD) in victims of general crime. METHOD: A total of 48 subjects were assessed within 24 hours of the trauma, using the Peritraumatic Dissociative Experiences Questionnaire Self-Report Version (PDEQ-SRV). They were followed longitudinally to assess acute stress (2 weeks after the assault,) using the Standford Acute Stress Reaction Questionnaire (SASRQ), and posttraumatic stress (at 5 weeks), using the Clinician-Administered PTSD Scale (CAPS) and the Impact of Event Scale (IES). RESULTS: Among PTSD subjects mean PDEQ scores were significantly higher (mean 3, SD 0.9) than in those without PTSD (mean 2.3, SD 0.7) (t = 2.78, df 46, P = 0.007). Among PTSD subjects, mean SASRQ scores were significantly higher (mean 97.9, SD 29.2) than in those without PTSD (mean 54.8, SD 28.2) (t = 4.9, df 46, P = 0.00007). CONCLUSIONS: High levels of peritraumatic dissociation and acute stress following violent assault are risk factors for early PTSD. Identifying acute reexperiencing can help the clinician identify subjects at highest risk.

Descriptive analysis of emergency hospital admissions of patients with Alzheimer disease.

The aim of this project was to study the underlying reasons for emergency hospital admission of patients with dementia of the Alzheimer type (DAT) and their characteristics. This prospective 4-month study identified 118 patients with DAT, most of whom were referred to the two emergency departments of the Toulouse University Hospital. The two main reasons for admission were behavioral problems (26.3%) and falls (18.6%). Patients were generally at an advanced stage of the disease process and had substantial evidence of poor nutritional status and loss of activities of daily living ability. About one third of patients had already been admitted to the hospital for the same reasons in the preceding months. Psychotropic drugs predominated (71%) among the current medications taken by the patients and were mainly anxiolytics and neuroleptics. Finally, the discharge report indicated that medications were a contributing factor in the disorders of 25% of patients. We believe that improved information for caregivers and early management and treatment are essential to respond adequately to the problems raised by this population.

[Radiologic study of renal colic]. / Exploration radiologique de la colique néphrétique.

Ureterolithiasis is a common disease responsible for a large number of admissions in emergency departments and a wide utilization of imaging studies. The purpose of this review was to analyze the respective role of the different available imaging techniques. Intravenous urography is the gold-standard for diagnosis of acute obstruction, but positive detection of a stone may prove difficult at times. US is less accurate than urography for both diagnoses of obstruction and lithiasis, but it represents a non invasive alternative to IVU (no ionizing radiation and no IV contrast). The information obtained from measurements of intra-renal resistive index is poorly contributive. Non contrast helical CT has become the gold-standard for the diagnosis of ureterolithiasis, the two main factors limiting its widespread use are its accessibility and the radiation exposure. Nevertheless, its excellent diagnostic performance tends to dramatically reduce the need for IVU.

[Victims of general crimes. Prospective and longitudinal assessment of psychological injuries]. / Victimes d'agression physique: évaluation prospective et longitudinale des blessures psychologiques.

OBJECTIVE: The aim of this study was to assess the relations between acute psychological injury, particularly peritraumatic dissociation, and early development of posttraumatic stress disorder in victims of violence. METHODS: Thirty-five subjects were prospectively assessed in an emergency department, within 24 hours of the trauma, for acute dissociative experiences with the Peritraumatic Dissociative Experiences Questionnaire (PDEQ). All of them were followed longitudinally to assess post traumatic stress disorder (PTSD) 5 weeks after with the Clinician-administered PTSD scale (CAPS) and the Impact of event scale (IES). RESULTS: Of the 35 victims 10 (28%) were diagnosed with a posttraumatic stress disorder at 5 weeks. Among PTSD subjects mean PDEQ scores were significantly higher (3+/-1.1) than in those without PTSD (2.3+/-0.7) (t=2.24, df=33, p=0.029). The PTSD subjects reported more "out of body experience" (p=0.015) and more "sense of body distorsion" (p=0.03) than non PTSD subjects. CONCLUSION: High levels of peritraumatic dissociation following violent assault are risk factors for early posttraumatic stress disorder. Psychological assessment of acute traumatic dissociative experiences must be included in emergency departments.

Treatment of acute renal colic in a French emergency department: a comparison of simulated cases and real cases in acute pain assessment and management.

OBJECTIVE: Use of analgesic drugs in acute renal colic varies widely in different countries. In order to assess the prescribing patterns in acute renal colic in French emergency departments (EDs), the present study compared intentions of prescription, real prescription and evidence-based data in a sample of emergency practitioners. METHODS: A sample of 51 emergency practitioners (27 medical doctors and 24 residents) randomly selected in nine EDs in the southwest of France participated in this observational study. In a first step (January 2000), participants were asked about a simulated case of acute renal colic. In a second step, real prescriptions for the same indication were retrospectively identified and collected among hospital medical databases during a period of 6 months (July-December 1999). RESULTS: In simulated cases, non-steroidal anti-inflammatory drugs (NSAIDs) were prescribed in 100% of cases, in addition to propacetamol (70%), antispasmodic drugs (53%) and opiate analgesics (100%). Daily dose of these drugs was underestimated in approximately 30% of cases. In real prescription, there was no significant difference in the use of NSAIDs, propacetamol and anti-spasmodic drugs. However, daily doses were more frequently underestimated, and opiate analgesics were less prescribed. Several points could explain these discrepancies: lack of knowledge about pharmacological properties, inadequate daily review of drug intake, underutilisation of opiates and insufficient clinical evaluation of pain in several centres. CONCLUSION: These results show a clear difference between intention to treat and real prescriptions for patients suffering from acute renal colic.

[Management of acute respiratory distress syndrome in Midi-Pyrnees]. / Prise en charge du syndrome de détresse respiratoire aiguë en Midi-Pyrénées.

OBJECTIVE: To assess management of acute respiratory distress syndrome (ARDS) in Midi-Pyrénées, France. METHODS: A prospective study using a questionnaire divided into 10 parts, definition, etiology, radiography, computed tomography, management, was conducted in 26 intensive care units in the Midi-Pyrénées. Management of ARDS in Midi-Pyrénées was comparted with management elsewhere as described in the literature. RESULTS: Overall participation rate was 73%. Disparities were found concerning the definition. Four etiologies accounted for 75% of all ARDS cases. Chest x-rays were used for positive diagnosis and thoracic scans for complications. Ventilatory and hemodynamic optimizations were the first line therapy used. Twenty-nine percent and 41% of the intensive care unites used nitric oxide and prone position respectively. CONCLUSIONS: There are differences between ARDS management in Midi-Pyrénées and that described in the current literature. Epidemiologic studies such as this one are necessary before publishing guidelines for the management of ARDS.

[Trauma, traumatic stress and depression following an airline catastrophy]. / Traumatismes, stress traumatique, et dépression à la suite de catastrophes aériennes.

OBJECTIVES: Acute stress responses following a trauma indicate a sensitivity to posttraumatic stress disorder (PTSD), and is often comorbid with depression. Earlier exposure to a traumatic event can be an additional risk factor in PTSD development. METHOD: Eight injured patients hospitalized after a major air disaster were monitored and assessed for a month. The symptoms of acute stress response (ASR), PTSD, and depression were assessed using DSM-IV criteria immediately following the accident, then each week thereafter. The Impact of Event Scale (IES) was completed on the 30th day (D30). RESULTS: Four patients presented with an ASR, and 3 of them had a PTSD at D30. Of those 3 patients with PTSD, 2 presented with an associated depression. These 2 patients had been exposed to a traumatic event before the disaster; and a significant relation was found between the history of the earlier trauma and the PTSD associated with depression. CONCLUSION: The traumatized victims with a history of earlier traumas seem more susceptible to developing a PTSD associated with depression.

[Asthmatic crisis and spontaneous rupture of the esophagus]. / Crise d'asthme et rupture spontanée de l'oesophage.

We report a case of spontaneous rupture of oesophagus revealed by a severe asthma attack, in a 78-year-old woman, with continuous dyspneic asthma treated with corticosteroids. We discuss the diagnostic difficulties in spontaneous oesophageal rupture, and emphasize the necessity for always looking for a triggering factor in case of severe attacks of asthma not responding to treatment.

[Potential value of hyperbaric oxygenation in the treatment of post-radiation myelopathies]. / Intérêt potentiel de l'oxygénothérapie hyperbare dans le traitement des myélopathies post-radiques.

We describe 9 patients with radiation myelopathy treated by hyperbaric oxygenation (HBO). In this retrospective study, six out of nine (66%) could have been stabilized or improved by HBO. Physiopathological mechanisms of radiation myelopathy remain controversial and incompletely known. We discuss the putative mechanisms of the beneficial action of HBO on radiation myelopathy. Controlled studies are required to clarify the interest of HBO in this disease.