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.

First Description of a Helicopter-Borne ECPR Team for Remote Refractory Out-of-Hospital Cardiac Arrest

Introduction: Access time to extracorporeal cardiopulmonary resuscitation (ECPR) refractory out of hospital cardiac arrest (OHCA) is a crucial factor. In our region, some patients are not eligible to this treatment due to the impossibility to reach the hospital with reasonable delay (ideally 60 min). In order to increase accessibility for patients far from ECPR centers, we developed a helicopter-borne ECPR-team which is sent out to the patient for ECPR implementation on the scene of the OHCA.Methods: We conducted a retrospective monocentric study to evaluate this strategy. The team is triggered by the local emergency medical service and heliborne on the site of the OHCA. All consecutive patients implemented with ECPR by our heliborne ECPR team from January 2014 to December 2017 were included. We analyzed usual CA characteristics, different times (no-flow, low-flow, time between OHCA and dispatch…), and patient outcome.Results: During this 4-year study period, 33 patients were included. Mean age was 43.9 years. Mean distance from the ECPR-team base to OHCA location was 41 km. Mean low-flow time was 110 minutes. Five patients survived with good neurological outcome; 6 patients developed brain death and became organ donors.Conclusion: These results show the possibility to make ECPR accessible for patients far from ECPR centers. Survival rate is non negligible, especially in the absence of therapeutic alternative. An earlier trigger of the ECPR-team could reduce the low-flow time and probably increase survival. This strategy improves equity of access to ECPR and needs to be confirmed by further studies.

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.

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.

État des lieux de la prise en charge de la douleur

Le concept d’oligoanalgésie en structure d’urgences reste une réalité en France comme dans de nombreux pays qui publient sur le sujet. Les motifs de cette oligoanalgésie sont multiples, le plus souvent liés à des contraintes organisationnelles plus que médicales. Les solutions existent, et la douleur aiguë persistante ne doit plus être une fatalité en structure d’urgences. L’analyse des raisons de l’oligoanalgésie avec des audits ciblés et la mise en place de protocoles thérapeutiques locaux sont des prérequis à l’amélioration de la prise en charge. Les nouveaux enjeux de la médecine d’urgence, liés à l’augmentation constante de la sollicitation, mais également en lien avec l’évolution des techniques médicales et des compétences des équipes médicales et soignantes, donnent de nouvelles perspectives pour améliorer la qualité–sécurité de la prise en charge de la douleur en structure d’urgences.

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.).

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.

[Out-of-hospital management of elderly patients for trauma injury]

Elderly patients should benefit from maximum care in cases of serious trauma, starting with pre-hospital care. A proper evaluation of the gravity of the trauma is an essential element in the management. The elderly are at risk of "under-triage", which can result in inappropriate hospital admission and delayed trauma care. Particular attention must be paid to "common" trauma, because such trauma is often associated with a potentially serious outcome in elderly patients. The Vittel criteria offer an important tool to estimate the level of gravity and to help in patient triage. The kinetic of the accident is important in identifying serious trauma. Emergency medical services with physicians on board must be the norm in cases of severe trauma, irrespective of the age of the patient. The literature clearly indicates the benefit of an aggressive strategy in elderly trauma patients, thus justifying direct admission in a trauma center in cases of real or potentially serious trauma. There is no difference in pre-hospital care management between elderly and younger trauma patients. Analgesia must be a priority. When a self-assessment of pain intensity is impossible, specific scales for pain can be used, such as Algoplus(®). Morphine titration is the recommended strategy for analgesia in the pre-hospital setting and the same protocol must be used for both the elderly and younger patients. Locoregional anaesthesia should be used when possible in this setting, in particular the ilio-facial block. Age is not a criterion for a non-resuscitation order in trauma patients. The decisions of limitation of therapeutic, if they were not anticipated, will be discussed after admission, according to the principles of the current legislation.

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.

Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial

BACKGROUND

Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.

METHODS

In this randomised, controlled, single-blind trial, 655 patients who needed sedation for emergency intubation were prospectively enrolled from 12 emergency medical services or emergency departments and 65 intensive care units in France. Patients were randomly assigned by a computerised random-number generator list to receive 0.3 mg/kg of etomidate (n=328) or 2 mg/kg of ketamine (n=327) for intubation. Only the emergency physician enrolling patients was aware of group assignment. The primary endpoint was the maximum score of the sequential organ failure assessment during the first 3 days in the intensive care unit. We excluded from the analysis patients who died before reaching the hospital or those discharged from the intensive care unit before 3 days (modified intention to treat). This trial is registered with ClinicalTrials.gov, number NCT00440102.

FINDINGS

234 patients were analysed in the etomidate group and 235 in the ketamine group. The mean maximum SOFA score between the two groups did not differ significantly (10.3 [SD 3.7] for etomidate vs 9.6 [3.9] for ketamine; mean difference 0.7 [95% CI 0.0-1.4], p=0.056). Intubation conditions did not differ significantly between the two groups (median intubation difficulty score 1 [IQR 0-3] in both groups; p=0.70). The percentage of patients with adrenal insufficiency was significantly higher in the etomidate group than in the ketamine group (OR 6.7, 3.5-12.7). We recorded no serious adverse events with either study drug.

INTERPRETATION

Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis.

FUNDING

French Ministry of Health.

[Results of a national survey about the use of sedation scales in emergency prehospital medicine]

The primary goal of sedation in emergency prehospital care is to guarantee the security of the mechanically ventilated patients by optimising their adaptation to the respirator. If the French prehospital guidelines are well codified, their applicability in routine clinical practice seem to be rather empirical. The aim of this national survey was to evaluate the use of the clinical sedation scales by the prehospital physicians. This prospective and clinical practice survey was begun in January 2005. An anonymous questionnaire was sent to the physicians working in the 377 Mobile Intensive Care Unit of the 105 French Emergency Medical Service System. The total response rate from physicians was 28% (n=497). Only 29% of the physicians (n=145) declared to use a sedation scale for a mechanically ventilated patient. The Ramsay score was used in 97% of the cases (n=141).The principal reasons given by the physicians for not using the sedation scales were their ignorance in 57% of the cases (n=200) and the systematic choice of a deep sedation in 42% of the cases (n=147). For 18% of them (n=62), the use of sedation scores was considered too complicated. The final results show that the utilisation ratio of the sedation scores is very low in emergency prehospital medicine and suggest that an effort toward improving the use of sedation in prehospital emergency medicine is necessary.

Prise en charge par le Smur d'un patient en arrêt cardiaque en vue d'un prélèvement d'organe à cœur arrêté

After their prehospital management by EMS system and on-scene declaration of death, some patients are potential non-heart-beating donors. We report the case of refractory cardiac arrest, transferred to the hospital assisted by chest compression device. Time factor might be an important brake on prehospital recruitment. Future networks should attempt to shorten the time intervals.

A quality control programme for acute myocardial infarction management in out-of-hospital critical care medicine

This study, conducted over two time periods, aimed to evaluate the effectiveness of the diffusion of data, implementation of correctives measures and updated protocols in reducing time to reperfusion in acute myocardial infarction (AMI) management in the out-of-hospital setting. Mean (SD) time to hospital admission and to arterial puncture improved (58 (13) vs 67 (18) min, p = 0.03; and 82 (16) vs 95 (29) min, p = 0.02). The study, performed according to quality control programme methodology, showed that the chronology of AMI management could be improved by appropriate interventions and monitoring of intervention times.

Le syndrome de tako-tsubo: enjeu thérapeutique

The authors report the case of 2-old-caucasian women in the pre- and interhospital setting, who presented chest pain with ST segment elevation. Coronary angiography did not show any significant coronary lesion, ventriculography revealed typical aspect of tako-tsubo. It resolved in a short time, with normalisation of the left ventricule function. The tako-tsubo syndrome, or transient left ventricular apical ballooning syndrome, first described by Japanese physicians, is more and more frequently observed in caucasian patients. This cardiomyopathy associates an apical transient dysfunction without any significant coronary lesion. This syndrome is usually observed in elderly women, occurs frequently after acute emotional or physical stress. The clinical presentation looks like an acute coronary syndrome, with chest pain, electrocardiographic changes and moderate cardiac enzymes release. Coronary angiography shows no significant coronary disease and ventriculography a systolic dysfunction with akinesia of middle and apical segments, leading apical ballooning, and basale hyperkinesia. These abnormalities are transient, with quick favorable outcome. The aetiopathegenia is still uncertain. The differential diagnosis with an acute coronary syndrome with thrombosis is not yet possible. Clinical or biological criteria allowing early diagnosis would lead to optimize the therapeutic management.

[Faisability of foetal monitoring in prehospital care]

The use of mobile monitoring system for foetal cardiotachometry has never been evaluated in the prehospital care. The aim of the survey was to evaluate the faisability of this device. Twenty-five patients were enrolled, mostly within the context of interhospital transfer because of threatening premature delivery (n = 20). Foetal monitoring was effective for 64 % of the patients during initial physical examination and for 52 % during transport by ambulance. Prehospital treatment was improved in one case of eclampsia after on-scene fetal monitoring. Cardiotocography can be easily performed in the prehospital setting.

[Haemorrhagic shock after severe blunt shoulder trauma]

The management of severe injured patients requires life-threatening lesions research, especially potential haemorrhagic lesions. The haemorrhagic shock is a rare but serious complication of shoulder girdle traumas. We report in this study the clinical and paraclinical signs that lead us to take care from such evolution.

Enquête sur l’utilisation du mannitol en réanimation préhospitalière en Île-de-France

OBJECTIVE

To evaluate the use of mannitol in prehospital care in Paris area.

STUDY DESIGN

Survey using telephone interviews.

METHODS

Emergency physicians on duty in the 37 emergency departments in charge of prehospital care in Paris area were called by one investigator. They were asked to answer a questionnaire about their own use of mannitol in the prehospital setting.

RESULTS

Ninety-six questionnaires were recorded. Physicians were anaesthesiologists (9%) or emergency physicians (87%). In three departments, mannitol was not available in the ambulances. Thirty-five per cent (n = 34) reported no use of mannitol and 17% (n = 16) just once. Fourteen physicians (15%) did not want to use it. The reasons for not using mannitol were lack of knowledge about efficacy for five, need for previous brain imaging for seven or neurosurgeon's agreement before using mannitol for three. For those who had already used mannitol or were ready to use it, the main indication was increased intracranial pressure with clinical signs of brain herniation after severe brain injury for 92% of physicians. Thirty-one % reported not knowing the dose of mannitol, 33% having a memorandum immediately available and among those who answered the question, 63% gave a value compatible with guidelines.

CONCLUSION

A significant percentage of physicians tacking part in the French prehospital care system, do not follow published guidelines on the use of mannitol. Actions improving implementation of those guidelines should be supported.

Quality control programme for acute pain management in emergency medicine: a national survey

OBJECTIVE

This national survey was carried out to evaluate the quality programme for acute pain management in the emergency department (ED) and in pre-hospital emergency medical services (EMS).

METHODS

Two types of questionnaires were sent to the chief consultant and the chief nurse of all ED and EMS. Data collected were: the type of structure, quality programme organization, acute pain management, and the training needs to initiate a pain quality programme.

RESULTS

A total of 363 questionnaires were recorded (198 from chief consultants) with 98% of questionnaires being usable. A pain management committee existed in 71% of cases, a quality committee in 83%. A complete quality control procedure existed in 53% of units. An audit on pain management was carried out in only 23% of cases. Training in quality was performed for 64% of physicians and 68% of nurses. Training specifically for pain management was carried out for physicians in 56% of cases and for nurses in 68% of cases. Pain therapeutics protocols existed in 69% of cases. Pain intensity was evaluated 'systematically or often' in 64% at the beginning of patient management, and in 56% at the end of patient management. The staff was 'not very motivated' for a pain management quality programme in less than 3% of responses. A total of 61% of chief consultants and 58% of chief nurses requested advice.

CONCLUSION

Most ED and EMS units seem to master the quality control programme methodology. Units are highly motivated to initiate a quality control programme on pain. Nevertheless, its implementation could benefit from some external support.

Epidemiology of adverse effects of prehospital sedation analgesia

The aim of this study was to introduce a continuous monitoring of side effects related to sedation-analgesia in the field. A document was completed by physicians on board the ambulances for all prehospital interventions and checked daily by the medical staff. A total of 3605 interventions were evaluated over a 12-month period. Six hundred four patients undertook analgesia and/or sedation: group 1 (spontaneously breathing patients) n = 289 and group 2 (intubated-ventilated patients) n = 315. Sixty-four percent of patients received intravenous opioids in group 1. The anesthetic technique used for intubation was the rapid sequence induction in 70% of patients. Side effects were observed in 5.5% in group 1 (nausea: 2%, hypotension: 1%, hypoxemia: 1%) and 22% of patients in group 2 (hypotension-arrhythmia: 12%, cardiac arrest: 2%, difficult intubation: 5%, hypoxemia: 1%, pulmonary aspiration: 1%, laryngospasm/bronchospasm: 2%). No death was related to these medications. A close monitoring of side effects related to sedation-analgesia must be included in a quality program to improve patient safety in the field.

[Changes in reperfusion strategies in the acute phase of myocardial infarction from 1988 to 2001]

The objective of this study was to evaluate the evolution of therapeutic strategies in the course of myocardial infarction. Two successive periods were studied: 1988/96 (700 patients) and 1996/2001 (700 patients). The following parameters were compared: patient characteristics, management methods, and results on the hospital morbidity and mortality. The patient characteristics were little changed, in terms of age and sex, with a drop in the frequency of anterior infarcts during the second period (46 vs 51%, p = 0.0001). The average delay to admission remained stable over both periods, 186 vs 189 min. During the second period, primary angioplasty was favoured (66 versus 44%, p = 0.0001), associated with a wider use of stents (47 against 4%, p = 0.0001) and anti GP IIb/IIIa (24 against 0.5%, p = 0.0001). In the acute phase, TIMI3 reperfusion was obtained in 81% of cases (88/96 period) against 88% during the second period (p = 0.02). The hospital mortality was reduced by 1.2% (8.9 against 7.7%, NS). Without cardiogenic shock, the mortality was comparable between the two groups (5%), whereas it diminished in the small group of patients (5%) in cardiogenic shock, from 76 to 66% (NS). Haemorrhagic complications were reduced, but the rate of symptomatic reocclusion remained stable (2.5%). With multivariate analysis, the independent predictive mortality factors were identical in the two groups: age and cardiogenic shock on admission. Currently, TIMI3 reperfusion is possible in close to 90% of patients in the acute phase of infarction. Our efforts should focus on earlier management, especially for older patients, too often excluded without reason, and for those in cardiogenic shock, which constitutes a therapeutic quest for the future. The theory of angioplasty facilitated by anti GP IIb/IIIa and/or prehospital thrombolysis must be evaluated scientifically with the goal of early and efficient reperfusion for the greatest number of patients.

[Out-of hospital management of elderly patients]

OBJECTIVE

To evaluate prehospital management of elderly patients, agreement between prehospital and hospital diagnosis and to observe clinical course during hospitalization.

TYPE OF STUDY

Retrospective study.

PATIENTS AND METHOD

Out-of hospital patients of 65-year-old or more were included. Apart from demographic data, were collected: reasons for call, medicalization length, SAPS score, prehospital management, destination, prehospital and hospital diagnosis and patients evolution. Three groups were defined: G1 (65-74), G2 (75-84), G3 (> 84 year old). Statistical analysis was done by an Anova for quantitative data and by a Chi squared test for qualitative data.

RESULTS

Two hundred and seventy-one patients were included (mean age 80 +/- 8 years, 43% of men). Eighty-two per cent of interventions were followed by a medicalized transport. Twelve per cent of patients died in the field. Forty-four per cent were hospitalised in intensive care unit, but patients of more than 84 year-old were significantly less often admitted in intensive care unit. There was no difference between the three groups in term of degree medicalization during transport. Eight per cent of patients required tracheal intubation in the field. Prehospital diagnoses were in agreement with reason for call in 61% of patients and with in-hospital diagnosis in 85% of patients. Fifty three per cent of patients came back home after hospitalisation.

CONCLUSION

Analysis of elderly patient evolution after hospitalisation confirms the idea that the age should not influence the decision and the degree of prehospital medicalization.

[Exposure of French emergency medical personnel to violence]

OBJECTIVES

Evaluate the problem of violence in French EMS system and characterize assaults.

STUDY DESIGN

Multicentric, descriptive, open study.

PATIENTS AND METHODS

A questionnaire was given to a sample of prehospital care providers in Paris area. People were asked about assaults during their careers, typology of the assaults and consequences. Results are presented in percentage and means.

RESULTS

Two hundred seventy-six questionnaires were returned. One or more assaults were recounted by 23% (61/271) of the sample (median of 8 +/- 7 years experience on the job). The injuries were bruises in 40% (17/43), wounds in 9% (4/43) and fractures in 2% (1/43). Only 4% of assaults were followed by sick leave, 15% by a complaint. After the assaults, 4% (2/45) reported having got therapy against post-traumatic stress disorder. Eighty-eight per cent reported verbal threat and 41% physical threat. Thirteen per cent (25/200) were threatened with a knife and 12% (23/200) with a gun. Only 9% (24/270) had a formal training for management of violence.

CONCLUSION

Formal training in the management of violent encounters and prevention of post-traumatic stress should be developed.

Succinylcholine improves the time of performance of a tracheal intubation in prehospital critical care medicine

BACKGROUND AND OBJECTIVE

The study aimed to evaluate and improve airway management in the prehospital setting, i.e. physicians working on board ambulances. A quality control programme focusing on anaesthesia was instituted to improve the time taken to perform endotracheal intubation.

METHODS

All consecutive patients requiring tracheal intubation were prospectively analysed before (first period) and after the training programme focusing on anaesthetic protocols for tracheal intubation (second period). The number of attempts at laryngoscopy, the time taken to achieve tracheal intubation, the difficulties encountered and the related complications of the anaesthetic technique were recorded. At the end of the first period, the results were reported to the whole staff of the unit and the anaesthesia protocols were then modified by introducing succinylcholine into the induction sequence, as part of a training programme.

RESULTS

Two-hundred-and-eighty patients were evaluated (97 in the first period, 183 in the second). All patients were successfully intubated in both periods. The percentage of difficult intubations (as assessed by the physician) was lower in the second period (20 versus 35%, respectively; P < 0.01). The success rate at the first attempt was significantly higher (74% [68-80] 95% CI versus 55% [45-65] 95% CI, P < 0.01) and the duration of intubation was significantly shorter in the second period than in the first (1.4 +/- 3.2 vs. 4.1 +/- 6.7 min, respectively; P < 0.001). The incidence of complications (hypoxaemia, laryngospasm, bronchospasm) was lower in the second period (15 versus 31%, P < 0.01).

CONCLUSIONS

The time to perform tracheal intubation can be improved by the introduction of succinylcholine into the prehospital anaesthetic protocol. Rapid sequence induction should be taught as a way of improving tracheal intubation in the prehospital setting.

Out-of-hospital thrombolytic therapy during cardiopulmonary resuscitation in refractory cardiac arrest due to acute myocardial infarction

Out-of-hospital thrombolytic therapy was administrated to a 53-year-old woman with confirmed acute myocardial infarction and refractory cardiac arrest. Standard advanced cardiac life support measures were performed by an out-of-hospital critical care team but they were unsuccessful. Thrombolytic therapy was given as a rescue therapy after prolonged cardiopulmonary resuscitation. The patient recovered a sinus rhythm and circulation 20 minutes after a bolus infusion of tissue plasminogen activator and was fit to be transported to the hospital. Reversal of arterial occlusion was confirmed at the hospital. There was no sequelae related to thrombolytic therapy and the patient was finally discharged 21 days later. This is the first published report of out-of-hospital thrombolytic therapy during cardiopulmonary resuscitation for a patient with refractory cardiac arrest due to acute myocardial infarction.

Intubating trauma patients before reaching hospital -- revisited

Endotracheal intubation is widely used for airway management in a prehospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome in adult patients. The benefits, in term of outcomes of invasive airway management before reaching hospital, remain controversial. However, inadequate airway management in this patient population is the primary cause of preventable mortality. An increase in intubation failures and in the rate of complications in trauma patients should induce us to improve airway management skills at the scene of trauma. If the addition of emergency physicians to a prehospital setting is to have any influence on outcome, further studies are merited. However, it has been established that sedation with rapid sequence intubation is superior in terms of success, complications and rates of intubation difficulty. Orotracheal intubation with planned neuromuscular blockade and in-line cervical alignment remains the safest and most effective method for airway control in patients who are severely injured.

[Management of severe head-injured patients in the first 24 hours. Resuscitation and initial diagnostic strategy]

Limitation of secondary insults after severe head injury is a permanent concern during the early phase of head trauma management. The objectives are to maintain mean arterial pressure between 80 and 100 mmHg, to avoid hypoxaemia, and to maintain arterial PCO2 near to 35 mmHg. Volume loading can be necessary to improve arterial pressure, and is carried out with isotonic critalloid (NaCl 9/1000) or colloids, with the exclusion of all hypotonic solutions (Ringer lactate or glucose). The use of catecholamines is reserved for patients with unstable haemodynamics despite an adequate volume loading. The rapid sequence induction is recommended for endotracheal intubation and is followed by continuous analgesia-sedation to keep patient-ventilator dysynchrony, but without compromising haemodynamic objectives. Mannitol is used in case of life-threatening intracranial hypertension. Conversely, specific treatment of intracranial hypertension, especially hypocapnia, is not recommended. Initial diagnostic procedures include cerebral tomodensitometry (TDM). However, TDM may be delayed in case of haemorrhage, which requires a rapid treatment. Intrahospital transport for additional explorations risks secondary insults, and thus requires close monitoring to detect and treat in due time all adverse events. This monitoring includes invasive arterial blood pressure assessment, use of continuous capnography and repeated arterial blood gas measurements. The usefulness of transcranial Doppler for initial management of head-trauma patients needs further evaluation.

A quality control program for acute pain management in out-of-hospital critical care medicine

STUDY OBJECTIVE

This study was conducted to evaluate a quality control program for improving pain treatment in the out-of-hospital setting.

METHODS

Pain was evaluated for all patients at the beginning (T(0)) and the end (T(end)) of out-of-hospital management. During the first part of the study (part 1, n=108), the administration and choice of analgesics was left to the physician's discretion. Pain protocols were then modified to encourage the use of opioids. The effectiveness of this new pain management was analyzed (part 2, n=105) using pain scales and quality of relief.

RESULTS

Seventy percent of patients who expressed meaningful pain did not request analgesia, and 36% did not receive any analgesia in part 1 in contrast to 7% in part 2 of the study. The verbal rating scale and visual analog scale scores were substantially improved at T(end) versus T(0) in both periods, but the improvement was greater in part 2 (mean visual analog scale score at T(end) was 29.3+/-23 mm [+/-SD]) than in part 1 (38.6+/-25 mm). The percentage of patients who expressed satisfactory relief increased in part 2 (67% versus 49% in part 1). The mean dose of intravenous morphine was 7.2+/-6 mg. Adverse effects were rare and minor.

CONCLUSION

This program focusing on pain treatment plus implementation of pain protocols (with intravenous morphine) improved pain management in the field.

[Evaluation of acute pain in prehospital medicine]

OBJECTIVE

To evaluate acute pain in prehospital setting.

STUDY DESIGN

Prospective survey.

PATIENTS

All eligible patients during a 3-month-period, excepted children less than 10-year-old.

METHOD

Pain intensity was evaluated by verbal rating scale with 5 points (VRS), visual analog scale (VAS), demand for antalgics by the patient and the relief obtained. These data were collected at the beginning (T0) and the end (Tend) of medical management. Analgesic treatments were let at the physician's choice.

RESULTS

A series of 255 patients were included (mean age 58 +/- 1.5 SEM, sex-ratio 57M/43F). Among them, 42% experienced pain at VRS. VAS could be used in 60% of patients. VRS evaluated by the patient was correlated to the VAS (P < 0.001). Among those with significant pain (defined by a VAS > or = 30 mm), only 31% asked for analgesia and 64% received analgesics. Pain scales (VRS and VAS) were significantly improved (P < 0.001) at the end of the medical management, except for patients who did not receive any treatment. However, mean VAS was still above 30 mm, even in patients receiving analgesics. Only 49% of patients expressed a good relief at the end of the medical management.

CONCLUSION

Acute pain is frequently observed in prehospital emergency medicine. Pain scales such as VRS and VAS are used easily and convenient for the assessment of pain intensity in this context. However, even if pain is correctly evaluated, it is still inadequately treated. The reasons of these inadequacies must be assessed and corrected with pain treatment protocols including opioids.