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1.
JAMA ; 322(23): 2303-2312, 2019 12 17.
Artigo em Inglês | MEDLINE | ID: mdl-31846014

RESUMO

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.


Assuntos
Serviços Médicos de Emergência , Rocurônio/administração & dosagem , Succinilcolina/administração & dosagem , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Método Simples-Cego
2.
Intern Emerg Med ; 14(6): 981-988, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31104303

RESUMO

Emergency management of deliberate self-poisoning (DSP) by drug overdose is common in emergency medicine. There is a paucity of data about the prehospital care of these patients. The principal aim was to describe the intensity of care received by patients with DSP who were managed by prehospital emergency medical service (EMS) physicians. A 48-h cross-sectional study was conducted in 319 EMS and emergency units in France. Patient and poisoning characteristics and treatments administered were recorded. Complications of poisoning, hospitalization, intensive care unit admission and death were recorded until day 30. The primary endpoint was the probability of receiving prehospital intensive care, including fluid resuscitation, vasopressor therapy, invasive ventilation, or antidotal treatments, depending whether prehospital treatment was carried out by an EMS physician or not. Data from 703 patients (median age was 43 [30-52] years, 288 (40%) men) were analyzed. One hundred and fifteen (16%) patients were attended by an EMS physician. Patients attended by EMS physicians were more likely to receive intensive treatment in the prehospital setting [odds ratio (OR) 7.4, 95% confidence interval 4.3-12.9]. These patients had more severe poisoning as suggested mainly by a lower Glasgow Coma Score (13 [8-15] vs. 15 [15-15]; p < 0.001) and a higher rate of admission to an intensive care unit [29 (25%) vs. 15 (2%), p < 0.001]. Patients with DSP attended by prehospital EMS physicians frequently received intensive care. The level of care seemed appropriate for the severity of the poisoning.

4.
Anaesth Crit Care Pain Med ; 38(2): 131-135, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-29684654

RESUMO

Out-of-hospital cardiac arrest (OHCA) is considered an important public health issue but its incidence has not been examined in France. The aim of this study is to define the incidence of OHCA in France and to compare this to other neighbouring countries. Data were extracted from the French OHCA registry. Only exhaustive centres during the period from January 1, 2013, to September 30, 2014 were included. All patients were included, regardless of their age and cause of OHCA. The participating centres covered about 10% of the French population. The study involved 6918 OHCA. The median age was 68 years, with 63% of males. Paediatric population (<15years) represented 1.8%. The global incidence of OHCA was 61.5 per 100,000 inhabitants per year in the total population corresponding to approximately 46,000 OHCA per year. In the adult population, we found an incidence of 75.3 cases per 100,000 inhabitants per year. In adults, the incidences were 100.3 and 52.7 in males and females, respectively. Most (75%) OHCA occurred at home and were due to medical causes (88%). Half of medical OHCA had cardiovascular causes. Survival rates at 30 days was 4.9% [4.4; 5.4] and increased to 10.4% [9.1; 11.7] when resuscitation was immediately performed by bystander at patient's collapse. The incidence and survival at 30 days of OHCA in France appeared similar to that reported in other European countries. Compared to other causes of deaths in France, OHCA is one of the most frequent causes, regardless of the initial pathology.

5.
Prehosp Emerg Care ; : 1-8, 2018 Aug 17.
Artigo em Inglês | MEDLINE | ID: mdl-30118612

RESUMO

OBJECTIVE: Survival rate of cardiac arrest due to hanging (H-CA) victims is low. Hence, this leads to the question of the utility of resuscitation in these patients. The objective was to investigate whether there are predictive criteria for survival with a good neurological outcome or predictive criteria for non-survival or survival with a poor neurological outcome enabling us to define the termination of resuscitation rules in these patients. METHODS: Between July 1, 2011 and January 1, 2016, we included 1,689 out-of-hospital cardiac arrests due to hanging. We compared the characteristics of survivors with a good neurological outcome at day 30 with the others. RESULTS: The study population was mainly composed of males with a median age of 48 [37-60]. The overall survival was 2.1%, among which 48.6% had a good neurological outcome. Survivors benefited more often from immediate basic life support than the rest of the subjects, which was corroborated by the shorter no-flow durations. We did not record any difference in terms of advanced cardiac life support initiation frequency and technique between survivors with a good neurological outcome and the rest. Nevertheless, ACLS duration was longer in survivors with a good neurological outcome than in others. CONCLUSIONS: Basic life support (BLS) was the decisive criterion for 15/17 survivors. However, a detailed analysis showed 2 survivors presenting no BLS before the arrival of mobile medical teams and non-shockable rhythms who survived at day 30 with a good neurological outcome. These results lead us to consider that mobile medical team intervention and ACLS attempt are not futile, and the benefit justifies the cost. Thus, we cannot define any rule for the termination of resuscitation.

6.
Resuscitation ; 131: 48-54, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30059713

RESUMO

INTRODUCTION: The survival from traumatic vs. medical out-of-hospital cardiac arrest (OHCA) are not yet well described. The objective of this study was to compare survival to hospital discharge and 30-day survival of non-matched and matched traumatic and medical OHCA cohorts. MATERIAL & METHODS: National case-control, multicentre study based on the French national cardiac arrest registry. Following descriptive analysis, we compared survival rates of traumatic and medical cardiac arrest patients after propensity score matching. RESULTS: Compared with medical OHCA (n = 40,878) trauma victims (n = 3209) were younger, more likely to be male and away from home at the time and less likely to be resuscitated. At hospital admission and at 30 days their survival odds were lower (OR: respectively 0.456 [0.353;0.558] and 0.240 [0.186;0.329]). After adjustment the survival odds for traumatic OHCA were 2.4 times lower at admission (OR: 0.416 [0.359;0.482]) and 6 times lower at day 30 (OR: 0.168 [0.117;0.241]). CONCLUSIONS: The survival rates for traumatic OHCA were lower than for medical OHCA, with wider difference in matched vs. non-matched cohorts. Although the probability of survival is lower for trauma victims, the efforts are not futile and pre-hospital resuscitation efforts seem worthwhile.


Assuntos
Reanimação Cardiopulmonar/mortalidade , Parada Cardíaca Extra-Hospitalar/etiologia , Parada Cardíaca Extra-Hospitalar/mortalidade , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Estudos de Coortes , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , França/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Sistema de Registros , Distribuição por Sexo , Taxa de Sobrevida
7.
J Eval Clin Pract ; 24(2): 431-438, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29356255

RESUMO

RATIONALE, AIMS AND OBJECTIVES: Care quality is a primary concern in health field. In France, the care practice report card (CPRC) is compulsory for practitioners. It is the first step towards the culture of excellence. In this context, practitioners have to assess and improve their practices. Competent authorities define registries as reliable sources for CPRC. The first aim of this work is to describe how we designed and built a universally transposable CPRC model based on an Utstein-style cardiac arrest registry. The second aim is to measure the adherence of practitioners to this approach and to show how such a tool can be used in real situation. METHODS: Our report card is adapted from in-hospital CA care quality and safety indicators. We built a 2-section grid. The first part described the quality and completeness of the analysed data. The second part distinguished medical and traumatic CA and assesses care practices. We analysed the practitioners' adherence thanks to a satisfaction survey. Finally, we presented a CPRC case study. RESULTS: This tool was tested in 92 centres gathering 8433 patients. The satisfaction survey showed that this CPRC was well accepted by emergency professionals. We presented an implementation example of this tool in a centre in real-life situation. CONCLUSIONS: We designed and implemented a fully automated CPRC tool routinely usable for Utstein-style CA registries. This CPRC is easily transferable in all other Utstein CA registries. The debriefing report source codes are freely distributed upon request. This tool enables the care assessment and improvement.


Assuntos
Reanimação Cardiopulmonar/normas , Serviços Médicos de Emergência/normas , Parada Cardíaca Extra-Hospitalar/terapia , Qualidade da Assistência à Saúde/normas , Sistema de Registros , Reanimação Cardiopulmonar/métodos , Competência Clínica , França , Humanos , Guias de Prática Clínica como Assunto
8.
Eur J Cardiovasc Nurs ; 17(6): 505-512, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29206063

RESUMO

BACKGROUND: Although some studies have questioned whether cardiopulmonary resuscitation (CPR) in older people could be futile, age is not considered an essential out-of-hospital cardiac arrest (OHCA) prognostic factor. However, in the daily clinical practice of mobile medical teams (MMTs), age seems to be an important factor affecting OHCA care. AIMS: The purpose of this study was to compare OHCA care and outcomes between young patients (<65 years old) and older patients. METHODS: We performed a case-control study based on data extracted from the French National Cardiac Arrest (CA) registry. All adult patients with CA recorded between July 2011 and May 2014 were included. Each older patient was matched on three criteria: sex, initial cardiac rhythm and no-flow duration. RESULTS: We studied 4347 pairs. We found significantly less basic life support initiation, shorter advanced cardiac life support duration, less MMT automated chest compression, less MMT ventilation and less MMT epinephrine injection in the older patients. Significant differences were also observed for return of spontaneous circulation (odds ratio (OR)=0.84, 95% confidence interval (CI) 0.77-0.92, p<0.001), transport to hospital (OR=0.58, 95% CI 0.51-0.61, p<0.001), vital status at hospital admission (OR=0.55, 95% CI 0.50-0.60, p<0.001) and vital status 30 days after CA (OR=0.42, 95% CI 0.35-0.50, p<0.001). CONCLUSION: All OHCA guidelines, ethical statements and clinical procedures do not propose age as a discrimination criterion in OHCA care. However, in our case-control study, we notice a shorter duration and less intensive care among older patients. This finding may partly explain the lower survival rate compared with younger people.


Assuntos
Fatores Etários , Ageismo/psicologia , Reanimação Cardiopulmonar/psicologia , Reanimação Cardiopulmonar/normas , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Análise de Sobrevida , Taxa de Sobrevida
9.
J Emerg Med ; 54(3): 295-301, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29273461

RESUMO

BACKGROUND: Even if age is not considered the key prognostic factor for survival in cardiac arrest (CA), some studies question whether cardiopulmonary resuscitation (CPR) in the elderly could be futile. OBJECTIVE: The aim of this study was to describe differences in out-of-hospital CA survival rates according to age stratification based on the French National CA registry (RéAC). The second objective was to analyze the differences in resuscitation interventions according to age. METHODS: We performed a retrospective cohort study based on data extracted from the RéAC. All 18,249 elderly patients (>65 years old) with non-traumatic CA recorded between July 2011 and March 2015 were included. Patients' ages were stratified into 5-year increments. RESULTS: Cardiopulmonary resuscitation (CPR) was started significantly more often in younger patients (p = 0.019). Ventilation and automated external defibrillation by bystanders were started without any difference between age subgroups (p = 0.147 and p = 0.123, respectively). No difference in terms of rate of external chest compressions or ventilation initiation was found between the subgroups (p = 0.357 and p = 0.131, respectively). Advanced cardiac life support was started significantly more often in younger patients (p = 0.023). Total CPR duration, return of spontaneous circulation, and survival at hospital admission and at 30 days or hospital discharge decreased significantly with age (p < 10-3). The survival decrease was linear, with a loss of 3% survival chances each 5-year interval. CONCLUSIONS: This study found that survival in older persons decreased linearly by 3% every 5 years. However, this diminished rate of survival could be the consequence of a shorter duration and less advanced life support.


Assuntos
Fatores Etários , Parada Cardíaca Extra-Hospitalar/mortalidade , Ressuscitação/normas , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , França , Humanos , Modelos Lineares , Masculino , Sistema de Registros/estatística & dados numéricos , Ressuscitação/métodos , Estudos Retrospectivos , Análise de Sobrevida , Fatores de Tempo , Estados Unidos
10.
J Eval Clin Pract ; 23(6): 1180-1186, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28471061

RESUMO

RATIONALE, AIMS AND OBJECTIVES: Neurological emergencies consumed a high amount of resources in emergency department (ED). We aimed to study the effect of the implementation of a magnetic resonance imaging (MRI) dedicated to emergencies on the management of patients admitted in ED for neurological emergencies. METHODS: We enrolled consecutive patients who underwent computed tomography and/or MRI for neurological disorders categorized as the suspicion of stroke and other reasons, over 2 periods that differed according to the priority access to computed tomography in the first period versus priority access to MRI in the second one. Criteria used to evaluate the effectiveness of the management were door-to-imaging time, ED length of stay, diagnostic performance, patient orientation, and length of hospitalization stay. RESULTS: When priority access to MRI, the door-to-imaging time was 31 minutes longer (P = .005) for patients suspected of stroke or transient ischaemic attack (TIA) and 70 minutes for the others (P < .001). The ED length of stay was 42 minutes shorter (P = .013) for stroke/TIA patients and 26 minutes longer (P = .029) for other patients. The proportion of patients with stroke mimics (no stroke amongst suspected stroke/TIA) increased (16.7% vs 25.6%, P = .017) as well as discharged patients (21.6% vs 29.6%, P = .002). The proportion of patients with stroke/TIA amongst other reasons of admission remained unchanged (P = .114). The median length of hospitalization stay decreased from 9 to 7 days for the stroke/TIA patients (P = .042). CONCLUSIONS: The implementation of a MRI optimized the quality of care and diagnostic accuracy for patients admitted in ED with a better identification of stroke mimics, avoiding unnecessarily hospitalizations. The management of stroke-TIA patients was not modified, but their length of hospital stay reduced.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Ataque Isquêmico Transitório/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Melhoria de Qualidade/organização & administração , Acidente Vascular Cerebral/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Encefalopatias/diagnóstico por imagem , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/diagnóstico , Centros de Atenção Terciária/organização & administração , Fatores de Tempo , Tomografia Computadorizada por Raios X
11.
J Am Coll Cardiol ; 68(1): 40-9, 2016 07 05.
Artigo em Inglês | MEDLINE | ID: mdl-27364049

RESUMO

BACKGROUND: Preliminary data suggested a clinical benefit in treating out-of-hospital cardiac arrest (OHCA) patients with a high dose of erythropoietin (Epo) analogs. OBJECTIVES: The authors aimed to evaluate the efficacy of epoetin alfa treatment on the outcome of OHCA patients in a phase 3 trial. METHODS: The authors performed a multicenter, single-blind, randomized controlled trial. Patients still comatose after a witnessed OHCA of presumed cardiac origin were eligible. In the intervention group, patients received 5 intravenous injections spaced 12 h apart during the first 48 h (40,000 units each, resulting in a maximal dose of 200,000 total units), started as soon as possible after resuscitation. In the control group, patients received standard care without Epo. The main endpoint was the proportion of patients in each group reaching level 1 on the Cerebral Performance Category (CPC) scale (survival with no or minor neurological sequelae) at day 60. Secondary endpoints included all-cause mortality rate, distribution of patients in CPC levels at different time points, and side effects. RESULTS: In total, 476 patients were included in the primary analysis. Baseline characteristics were similar in the 2 groups. At day 60, 32.4% of patients (76 of 234) in the intervention group reached a CPC 1 level, as compared with 32.1% of patients (78 of 242) in the control group (odds ratio: 1.01; 95% confidence interval: 0.68 to 1.48). The mortality rate and proportion of patients in each CPC level did not differ at any time points. Serious adverse events were more frequent in Epo-treated patients as compared with controls (22.6% vs. 14.9%; p = 0.03), particularly thrombotic complications (12.4% vs. 5.8%; p = 0.01). CONCLUSIONS: In patients resuscitated from an OHCA of presumed cardiac cause, early administration of erythropoietin plus standard therapy did not confer a benefit, and was associated with a higher complication rate. (High Dose of Erythropoietin Analogue After Cardiac Arrest [Epo-ACR-02]; NCT00999583).


Assuntos
Epoetina alfa/administração & dosagem , Hematínicos/administração & dosagem , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Idoso , Intervenção Médica Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Método Simples-Cego
12.
Artif Organs ; 40(9): 904-9, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26684540

RESUMO

Out-of-Hospital refractory Cardiac Arrest (OHrCA) has a mortality rate between 90 and 95%. Since 2009, French medical academic societies have recommended the use of extracorporeal life support (ECLS) for OHrCA. According to these guidelines, patients were eligible for ECLS support if vital signs were still present during cardiopulmonary resuscitation (CPR), or if cardiac arrest was secondary to intoxication or hypothermia (≤32°C). Otherwise, patients would receive ECLS if (i) no-flow duration was less than 5 min; (ii) time delays from CPR to ECLS start (low flow) were less than 100 min; and (iii) expiratory end tidal CO2 (ETCO2 ) was more than 10 mm Hg 20 min after initiating CPR. We have reported here our experience with ECLS in OHrCA according to the previous guidelines. We retrospectively analyzed mortality rates of patients supported with ECLS in case of OHrCA. From December 2009 to December 2013, 183 patients were assisted with ECLS, among which 32 cases were of OHrCA. Mean age for the OHrCA patients was 43.6 years. Over two-thirds were male (71.9%). Causes of OHrCA included intoxication, isolated hypothermia <32°C, acute coronary syndrome, pulmonary edema, and other cardiac pathology. Despite adherence to protocols, only two patients (6.2%) with hypothermia and acute myocardium ischemia, respectively, could be discharged from hospital after cardiac recovery. Causes of death were brain death and multiple organ failure. Despite ECLS support setting in accordance with French guidelines in case of refractory OHrCA, mortality rates remained high. French ECLS support recommendations for OHrCA due to presumed cardiac cause should be re-examined through new studies. Low flow duration should be improved by a shorter time of CPR before hospital transfer.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Suporte Vital Cardíaco Avançado/métodos , Reanimação Cardiopulmonar/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/cirurgia , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Análise de Sobrevida
13.
Epilepsy Res ; 113: 1-4, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25986185

RESUMO

BACKGROUND AND PURPOSE: Seizure is a frequent reason of admission in emergency department (ED) but little is known about the proportion and the characteristics of known epileptic patients (KEPs) who used emergency services. METHODS: Over a 12-month period, we prospectively recruited adults admitted for seizure to a tertiary hospital ED. For KEPs, clinical epilepsy features and characteristics of the admission were collected. RESULTS: Of the 60,578 ED admissions, 990 were related to seizure; 580 of these admissions concerned 448 different KEPs (257 males; median age: 44); 339 were residents in the health district. Epilepsy was structural/metabolic in 268 (59.8%) patients, genetic in 44 (9.8%) and unknown/undetermined in 136 (30.3%); 218 (48.7%) patients were under a single antiepileptic drug and 135 (30.1%) were followed by an epileptologist. Of the 580 KEP admissions, 440 (75.8%) concerned patients who had called the emergency medical assistance number, 252 (43.4%) with a discharge diagnosis of usual seizure and 43 (7.4%) of a status epilepticus. Half the KEPs were discharged without hospitalization. We estimated that 9.0% of KEPs residing in the district had used the ED during the period. CONCLUSION: Proportion of KEPs using ED is high. Most of the admissions concerned usual seizures suggesting that staff training and educational programmes for patients and for their relatives need to be improved. The organization of the prehospital and of the emergency medical services should also be adjusted to this specific need. Further research should be conducted to optimize the seizure care pathway for KEPs.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Epilepsia/terapia , Adulto , Serviços Médicos de Emergência/métodos , Epilepsia/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
14.
Prehosp Emerg Care ; 19(1): 10-16, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-24932670

RESUMO

Abstract Objective. Although ketamine has recently been demonstrated to provide a morphine-sparing effect, no previous study reports the effect of continuous infusion of ketamine for analgesia in out-of-hospital environments. The aim of this study was to compare the effect of a continuous infusion of ketamine (IK group) vs. a continuous infusion of saline (IS group) on morphine requirements in out-of-hospital trauma patients suffering from severe acute pain. Methods. In this prospective, multicenter, randomized, single-blind clinical study, patients suffering from isolated orthopedic injuries secondary to trauma with severe acute pain received a low-dose intravenous (IV) bolus of ketamine (0.2 mg·kg-1) combined with an IV bolus of morphine (0.1 mg·kg-1) and were randomized either in the IK group (IV continuous infusion of ketamine 0.2 mg·kg-1·h-1), or in the IS group (IV continuous infusion of saline at the same volume). The primary endpoint was morphine requirements in terms of total dose of morphine (excluding the baseline bolus) injected at the end of prehospital emergency care at hospital admission (final time, Tf). The secondary endpoint was evaluation of pain with visual analogic scale (VAS). Results. Sixty-six patients were enrolled. Total morphine dose was not significantly reduced with continuous infusion of ketamine (0.048 [0.000; 0.150] vs. 0.107 [0.052; 0.150] in IK and IS groups), with similar mean duration of care (median 35.0 min). Analgesia was as efficient without any significant difference in VAS at Tf between groups (3.1 ± 2.3 (IK group) vs. 3.7 ± 2.7 (IS group), p = 0.5). Conclusions. Continuous ketamine infusion did not reduce morphine requirements in severe acute pain trauma patients in the out-of-hospital emergency settings.

15.
Prehosp Emerg Care ; 18(4): 511-9, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24877567

RESUMO

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is an important public health issue with an estimated incidence of 50,000 cases per year in France. Community survival rates for OHCA are still low (approximately 5%). An effective, recognized way to study, assess, and improve OHCA care is to create a standard-format database. OBJECTIVE: The aim of this work is to present the French OHCA registry (RéAC). METHODS: RéAC is a secure, web-based data management system that was initiated in 2009 and deployed nationally in June 2012. The main goal of this registry is to improve the care and survival rate of OHCA patients. The survey form is in compliance with the requirements of French organizations and is organized in accordance with the Utstein universal style. RéAC provides real-time statistical analyses and enables all French mobile emergency and resuscitation services (MERS) to assess and improve their professional OHCA care practices. RESULTS: In June 2012, the RéAC was nationally opened for all French MERSs. In June 2013, 221 of a possible 320 MERS participated in the RéAC. A total of 15,944 OHCA have been collected (14,939 cases closed with follow-up monitoring). The current rate of inclusion is approximately 1,500 cases per month. Since August 2012, the inclusion rate has increased by 9.5% per month, while the participation rate has increased by 9% per month. The first results show that the population is mainly male (65.4%) and the mean age is 65 ± 19 years. On MERS arrival, 73.5% of the patients were in asystole. The rates of return of spontaneous circulation, survival to hospital admission, and 30-day survival are low (respectively 21.1%, 17.2%, 4.6%). Of those who survived 30 days, 84.0% had a good neurological recovery. CONCLUSIONS: The RéAC registry is a reliable observation tool to improve public health management of OHCA. It provides relevant information to adapt or to develop diagnosis, treatments, and prognostic resources. Moreover, it enables the development of targeted awareness programs for the unique purpose of increasing the survival rates of OHCA patients.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Parada Cardíaca Extra-Hospitalar/epidemiologia , Sistema de Registros/estatística & dados numéricos , Ressuscitação/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , França , Inquéritos Epidemiológicos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Taxa de Sobrevida
16.
Int J Emerg Med ; 6(1): 25, 2013 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-23866080

RESUMO

Pulmonary embolism (PE) is potentially fatal and often requires emergency management. Because PE associated with shock and/or hypotension carries a high risk of sudden death, emergency clinicians must rapidly make a diagnosis and initiate appropriate therapeutic strategies, usually involving anticoagulant treatment. Traditional anticoagulants, such as heparins and vitamin K antagonists, although effective and recommended by guidelines, are associated with limitations. Several targeted, orally administered anticoagulants that may overcome some of these constraints have been developed recently and undergone analysis in randomised, phase III clinical trials. Rivaroxaban, a direct factor Xa inhibitor, was non-inferior to standard therapy with enoxaparin plus a vitamin K antagonist for the prevention of recurrent, symptomatic venous thromboembolism (VTE) in patients with acute PE and led to a 50% reduction in major bleeding. Dabigatran, a direct thrombin inhibitor, was also non-inferior to standard therapy for the prevention of recurrent VTE or VTE-related death when given after a parenteral anticoagulant and had a similar incidence of major bleeding. The results of a phase III study of apixaban, another direct factor Xa inhibitor, for the acute treatment of VTE are expected in the near future. Rivaroxaban is now approved in Europe and the US for the treatment of acute PE and prevention of recurrent VTE. This article reviews the current guidance on the treatment of PE with special focus on the emergency setting, and considers data regarding rivaroxaban and the other non-vitamin K antagonist oral anticoagulants and their potential role, including patients who are and are not appropriate for treatment with these agents. Issues such as drug interactions, reversal of anticoagulant effect and coagulation monitoring are also discussed.

17.
J Neurol ; 260(2): 635-9, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23052603

RESUMO

Pre-hospital notification enhances thrombolysis rate and improves intra-hospital delays, but the impact of the notification to the neurologist by the emergency medical system (EMS) call centre remains unknown. Our objective was to compare pre-hospital and in-hospital delays in stroke patients treated by intravenous recombinant tissue plasminogen activator (rt-PA), with and without pre-hospital notification. We compared baseline characteristics and in-hospital delays in stroke patients treated by rt-PA with a high-level notification (call to EMS and EMS-neurologist discussion), a low-level notification (call to EMS without EMS-neurologist discussion ) and no pre-hospital notification. Of 302 consecutive patients [165 women, 54.6 %; median age 74 years, interquartile range (IQR) 59-83], patients with high-level, low-level and no notification differed for the severity at admission (median National Institutes of Health Stroke Scale scores, respectively, of: 12, IQR 7-17; 9, IQR 6-15, and 8, IQR 6-14, p = 0.029). Patients with high-level notification had shorter (1) admission-to-completion of imaging times (27 min, IQR 14-35) than patients with low-level notification (35 min, IQR 17-54) or no notification (36 min, IQR 30-58) (p < 0.01); (2) door-to-needle times (49 min, IQR 39-62 vs. 57 min, IQR 39-81 vs. 63 min, IQR 51-97; p = 0.003); and (3) onset-to-needle times (140 min, IQR 110-175 vs. 155 min, IQR 106-230 vs. 182 min, IQR 131-234; p < 0.001). They did not differ for onset-to-admission time and imaging-to-needle time. Pre-hospital notification by the EMS reduces intra-hospital delays in patients eligible for rt-PA, but the benefit is higher in the case of discussion between the EMS and the neurologist before admission.


Assuntos
Comunicação , Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Serviços Médicos de Emergência , Feminino , Hospitalização , Humanos , Masculino , Estudos Retrospectivos , Acidente Vascular Cerebral/psicologia , Resultado do Tratamento
18.
EuroIntervention ; 8 Suppl P: P36-43, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22917788

RESUMO

Acute initial management of patients with acute coronary syndrome (ACS) is based on a precise clinical and electrocardiographic diagnosis. Initial risk stratification in the pre-hospital phase is the key step. The last step, adequate patient routing, is decided based on emergency level and reperfusion strategies, considered right from the pre-hospital phase. The management of a patient with an ACS requires close collaboration between emergency physicians and cardiologists, according to simplified protocols for easier access to catheterisation. The next challenges for the pre-hospital management of ACS are based on: - precise knowledge of new antiplatelet and anticoagulant drugs by the emergency physicians, in order to adjust their prescriptions to the patient profile; - developing co-operation between hospitals, according to regional specificities (geographic considerations and distribution of PCI centres) in order to reduce access time to catheterisation rooms; - organising the healthcare network, where the SAMU has an essential role in coordinating the different medical actors; - regular analysis of the evolution of our professional practices, considering, e.g., the guidelines of the "HAS" (French official healthcare guidelines institute);- integrating pre-hospital medicine in health prevention programmes; - improving our understanding of the population's presentations of coronary artery disease, in order to encourage the patients and their families to call the EMS as soon as possible. The challenge of the emergency physician is to adapt the strategies to the patient's needs.


Assuntos
Síndrome Coronariana Aguda/terapia , Ambulâncias , Unidades de Cuidados Coronarianos , Prestação Integrada de Cuidados de Saúde , Serviços Médicos de Emergência , Infarto do Miocárdio/terapia , Reperfusão Miocárdica , Síndrome Coronariana Aguda/diagnóstico , Ambulâncias/normas , Anticoagulantes/uso terapêutico , Unidades de Cuidados Coronarianos/normas , Prestação Integrada de Cuidados de Saúde/normas , Eletrocardiografia , Serviços Médicos de Emergência/normas , Humanos , Infarto do Miocárdio/diagnóstico , Reperfusão Miocárdica/métodos , Reperfusão Miocárdica/normas , Seleção de Pacientes , Inibidores da Agregação de Plaquetas/uso terapêutico , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento
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