Association Between Frailty and Head Impact Location After Ground-Level Fall in Older Adults

BACKGROUND

Mild traumatic brain injuries (TBIs) are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury.

OBJECTIVE

This study aimed to assess whether frailty was associated with head impact location among older patients who sustained a ground-level fall-related, mild TBI. The secondary objective was to measure the association between frailty and intracranial hemorrhages.

METHODS

We conducted a planned sub-analysis of a prospective observational study in two urban university-affiliated emergency departments (EDs). Patients 65 years and older who sustained a ground-level fall-related, mild TBI were included if they consulted in the ED between January 2019 and June 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). Patients were stratified into the following three groups: robust (CFS score 1-3), vulnerable-frail (CFS score 4-6), and severely frail (CFS score 7-9).

RESULTS

A total of 335 patients were included; mean ± SD age was 86.9 ± 8.1 years. In multivariable analysis, frontal impact was significantly increased in severely frail patients compared with robust patients (odds ratio [OR] 4.8 [95% CI 1.4-16.8]; p = 0.01). Intracranial hemorrhages were found in 6.2%, 7.5%, and 13.3% of robust, vulnerable-frail, and severely frail patients, respectively. The OR of intracranial hemorrhages was 1.24 (95% CI 0.44-3.45; p = 0.68) in vulnerable-frail patients and 2.34 (95% CI 0.41-13.6; p = 0.34) in those considered severely frail.

CONCLUSIONS

This study found an association between the level of frailty and the head impact location in older patients who sustained a ground-level fall. Our results suggest that head impact location after a fall can help physicians identify frail patients. Although not statistically significant, the prevalence of intracranial hemorrhage seems to increase with the level of frailty.

Impact of delayed mobile medical team dispatch for respiratory distress calls: a propensity score matched study from a French emergency communication center

BACKGROUND

Shortness of breath is a common complaint among individuals contacting emergency communication center (EMCCs). In some prehospital system, emergency medical services include an advanced life support (ALS)-capable team. Whether such team should be dispatched during the phone call or delayed until the BLS-capable paramedic team reports from the scene is unclear. We aimed to evaluate the impact of delayed MMT dispatch until receiving the paramedic review compared to immediate dispatch at the time of the call on patient outcomes.

METHODS

A cross-sectional study conducted in Lyon, France, using data obtained from the departmental EMCC during the period from January to December 2019. We included consecutive calls related to adult patients experiencing acute respiratory distress. Patients from the two groups (immediate mobile medical team (MMT) dispatch or delayed MMT dispatch) were matched on a propensity score, and a conditional weighted logistic regression assessed the adjusted odds ratios (ORs) for each outcome (mortality on days 0, 7 and 30).

RESULTS

A total of 870 calls (median age 72 [57-84], male 466 53.6%) were sought for analysis [614 (70.6%) "immediate MMT dispatch" and 256 (29.4%) "delayed MMT" groups]. The median time before MMT dispatch was 25.1 min longer in the delayed MMT group (30.7 [26.4-36.1] vs. 5.6 [3.9-8.8] min, p < 0.001). Patients subjected to a delayed MMT intervention were older (median age 78 [66-87] vs. 69 [53-83], p < 0.001) and more frequently highly dependent (16.3% vs. 8.6%, p < 0.001). A higher proportion of patients in the delayed MMT group required bag valve mask ventilation (47.3% vs. 39.1%, p = 0.03), noninvasive ventilation (24.6% vs. 20.0%, p = 0.13), endotracheal intubation (7.0% vs. 4.1%, p = 0.07) and catecholamine infusion (3.9% vs. 1.3%, p = 0.01). After propensity score matching, mortality at day 0 was higher in the delayed MMT group (9.8% vs. 4.2%, p = 0.002). Immediate MMT dispatch at the call was associated with a lower risk of mortality on day 0 (0.60 [0.38;0.82], p < 0.001) day 7 (0.50 [0.27;0.72], p < 0.001) and day 30 (0.56 [0.35;0.78], p < 0.001) CONCLUSIONS: This study suggests that the deployment of an MMT at call in patients in acute respiratory distress may result in decreased short to medium-term mortality compared to a delayed MMT following initial first aid assessment.

The real incidence of sudden death: Fair estimations or futile speculations?

BACKGROUND

The true incidence of sudden death remains undetermined, with controversial results from various publications over time and countries.

AIM

To investigate if different estimations would reach the values usually reported for France.

METHODS

Three different kinds of estimations were used. First, the number of resuscitated sudden deaths and necropsies for sudden death in the Haute-Garonne French administrative department (i.e. county) over the last 10years was expanded to the national level. Second, sudden death coding of death certificates was collected at the national level. Third, the total number of out-of-hospital cardiac arrests leading to any emergency call (with/without intervention) in Haute-Garonne over the last 10years was expanded to the national level.

RESULTS

There was a mean of 26 resuscitated sudden deaths and 145 necropsies for sudden death each year in Haute-Garonne, i.e. 12 to 14 sudden deaths for 100,000 inhabitants, and 7700 to 9400 sudden deaths yearly when related to the whole French population, according to the year of inclusion. Based on death certificates, a mean of 6584 sudden deaths was registered each year in France. Finally, there were about 600 yearly calls/interventions for out-of-hospital cardiac arrests in Haute-Garonne, i.e. 40 to 50 sudden deaths for 100,000 inhabitants, and 16,000 to 27,000 sudden deaths yearly for the whole French territory, according to the year of inclusion.

CONCLUSIONS

The incidence of sudden death ranges from 6500 to 27,000 in France according to the calculation methods. This huge difference raises the question of the true current incidence of sudden death, which may have been overestimated previously or may be underestimated in France. More straight prospective surveys are needed to solve this question, because of relevant implications for priorities that should be given to sudden death.

Risk factors and effect of dyspnea inappropriate treatment in adults' emergency department: a retrospective cohort study

Dyspnea is a frequent symptom in adults' emergency departments (EDs). Misdiagnosis at initial clinical examination is common, leading to early inappropriate treatment and increased in-hospital mortality. Risk factors of inappropriate treatment assessable at early examination remain undescribed herein. The objective of this study was to identify clinical risk factors of dyspnea and inappropriate treatment in patients admitted to ED. This is an observational retrospective cohort study. Patients over the age of 15 who were admitted to adult EDs of the University Hospital of Toulouse (France) with dyspnea were included from 1 July to 31 December 2019. The primary end-point was dyspnea and inappropriate treatment was initiated at ED. Inappropriate treatment was defined by looking at the final diagnosis of dyspnea at hospital discharge and early treatment provided. Afterward, this early treatment at ED was compared to the recommended treatment defined by the International Guidelines for Acute Heart Failure, bacterial pneumonia, chronic obstructive pulmonary disease, asthma or pulmonary embolism. A total of 2123 patients were analyzed. Of these, 809 (38%) had inappropriate treatment in ED. Independent risk factors of inappropriate treatment were: age over 75 years (OR, 1.46; 95% CI, 1.18-1.81), history of heart disease (OR, 1.32; 95% CI, 1.07-1.62) and lung disease (OR, 1.47; 95% CI, 1.21-1.78), SpO2 <90% (OR, 1.64; 95% CI, 1.37-2.02), bilateral rale (OR, 1.25; 95% CI, 1.01-1.66), focal cracklings (OR, 1.32; 95% CI, 1.05-1.66) and wheezing (OR, 1.62; 95% CI, 1.31-2.03). In multivariate analysis, under-treatment significantly increased in-hospital mortality (OR, 2.13; 95% CI, 1.29-3.52) compared to appropriate treatment. Over-treatment nonsignificantly increased in-hospital mortality (OR, 1.43; 95% CI, 0.99-2.06). Inappropriate treatment is frequent in patients admitted to ED for dyspnea. Patients older than 75 years, with comorbidities (heart or lung disease), hypoxemia (SpO2 <90%) or abnormal pulmonary auscultation (especially wheezing) are at risk of inappropriate treatment.

Impact of emergency department length of stay on in-hospital mortality: a retrospective cohort study

BACKGROUND AND IMPORTANCE

Emergency Department (ED) workload may lead to ED crowding and increased ED length of stay (LOS). ED crowding has been shown to be associated with adverse events and increasing mortality. We hypothesised that ED-LOS is associated with mortality.

OBJECTIVE

To study the relationship between ED-LOS and in-hospital mortality.

DESIGN

Observational retrospective cohort study.

SETTINGS AND PARTICIPANTS

From 1 January 2015 to 30 September 2018, all visits by patients aged 15 or older to one of the two ED at Toulouse University Hospital were screened. Patients admitted to the hospital after ED visits were included. Visits followed by ED discharge, in-ED death or transfer to ICU or another hospital were not included.

OUTCOME MEASURE AND ANALYSIS

The primary outcome was 30-day in-hospital mortality. ED-LOS was defined as time from ED registration to inpatient admission. ED-LOS was categorised according to quartiles [<303 min (Q1), between 303 and 433 minutes (Q2), between 434 and 612 minutes (Q3) and >612 min (Q4)]. A multivariable logistic regression tested the association between ED-LOS and in-hospital mortality.

MAIN RESULTS

A total of 49 913 patients were admitted to our hospital after ED visits and included in the study. ED-LOS was not independently associated with in-hospital mortality. Compared to ED-LOS < 303 min (Q1, reference), odd-ratios (OR) [95% CI] of in-hospital mortality for Q2, Q3, and Q4 were respectively 0.872 [0.747-1.017], 0.906 [0.777-1.056], and 1.137 [0.985-1.312]. Factors associated to in-hospital mortality were: aged over 75 years (OR [95% CI] = 4.3 [3.8-4.9]), Charlson Comorbidity Index score > 1 (OR [95% CI] = 1.3 [1.1-1.5], and 2.2 [1.9-2.5] for scores 2 and ≥ 3 respectively), high acuity at triage (OR [95% CI] = 3.9 [3.5-4.4]), ED visit at Hospital 1 (OR [95% CI] = 1.6 [1.4-1.7]), and illness diagnosis compared to trauma (OR [95% CI] = 2.1 [1.7-2.6]). Night-time arrival was associated with decreased in-hospital mortality (OR [95% CI] = 0.852 [0.767-0.947]).

CONCLUSION

In this retrospective cohort study, there was no independent association between ED-LOS before admission to general non-ICU wards and in-patient mortality.

Predictive factors for early requirement of respiratory support through phone call to Emergency Medical Call Centre for dyspnoea: a retrospective cohort study

BACKGROUND

Acute dyspnoea is a common symptom in Emergency Medicine, and severity assessment is difficult during the first time the patient calls the Emergency Medical Call Centre.

OBJECTIVE

To identify predictive factors regarding the need for early respiratory support in patients who call the Emergency Medical Call Centre for dyspnoea.

DESIGN, SETTINGS AND PARTICIPANTS

This retrospective cohort study carried out in the Emergency Medical Call Centre of the University Hospital of Toulouse from 1 July to 31 December 2019. Patients over the age of 15 who call the Emergency Medical Call Centre regarding dyspnoea and who were registered at the University Hospital or died before admission were included in our study.

OUTCOME MEASURE AND ANALYSIS

The primary end-point was early requirement of respiratory support [including high-flow oxygen, non-invasive ventilation (NIV) or mechanical ventilation after intubation] that was initiated by the physicians staffed ambulance before admission to the hospital or within 3 h after being admitted. Associations with patients' characteristics identified during Emergency Medical Call Centre calls were assessed with a backward stepwise logistic regression after multiple imputations for missing values.

MAIN RESULTS

During the 6-month inclusion period, 1425 patients called the Emergency Medical Call Centre for respiratory issues. After excluding 38 calls, 1387 were analyzed, including 208 (15%) patients requiring respiratory support. The most frequent respiratory support used was NIV (75%). Six independent predictive factors of requirement of respiratory support were identified: chronic β2-mimetics medication [odds ratio (OR) = 2.35, 95% confidence interval (CI) 1.61-3.44], polypnea (OR = 5.78, 95% CI 2.74-12.22), altered ability to speak (OR = 2.35, 95% CI 1.55-3.55), cyanosis (OR = 2.79, 95% CI 1.81-4.32), sweats (OR = 1.93, 95% CI 1.25-3) and altered consciousness (OR = 1.8, 95% CI 1.1-3.08).

CONCLUSION

During first calls for dyspnoea, six predictive factors are independently associated with the risk of early requirement of respiratory support.

MEESSI-AHF score to estimate short-term prognosis of acute heart failure patients in the Emergency Department: a prospective and multicenter study

BACKGROUND

The assessment of acute heart failure (AHF) prognosis is primordial in emergency setting. Although AHF management is exhaustively codified using mortality predictors, there is currently no recommended scoring system for assessing prognosis. The European Society of Cardiology (ESC) recommends a comprehensive assessment of global AHF prognosis, considering in-hospital mortality, early rehospitalization rates and the length of hospital stay.

OBJECTIVE

We aimed to prospectively evaluate the performance of the Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF (MEESSI-AHF) score in estimating short prognosis according to the ESC guidelines.

DESIGN, SETTINGS AND PATIENTS

A multicenter study was conducted between November 2020, and June 2021. Adult patients who presented to eleven French hospitals for AHF were prospectively included.

OUTCOME MEASURES AND ANALYSIS

According to MEESSI-AHF score, patients were stratified in four categories corresponding to mortality risk: low-, intermediate-, high- and very high-risk groups. The primary outcome was the number of days alive and out of the hospital during the 30-day period following admission to the Emergency Department (ED).

RESULTS

In total, 390 patients were included. The number of days alive and out of the hospital decreased significatively with increasing MEESSI-AHF risk groups, ranging from 21.2 days (20.3-22.3 days) for the low-risk, 20 days (19.3-20.5 days) for intermediate risk,18.6 days (17.6-19.6 days) for the high-risk and 17.9 days (16.9-18.9 days) very high-risk category.

CONCLUSION

Among patients admitted to ED for an episode of AHF, the MEESSI-AHF score estimates with good performance the number of days alive and out of the hospital.

Overnight Stay in the Emergency Department and Mortality in Older Patients

Importance

Patients in the emergency department (ED) who are waiting for hospital admission on a wheeled cot may be subject to harm. However, mortality and morbidity among older patients who spend the night in the ED while waiting for a bed in a medical ward are unknown.

Objective

To assess whether older adults who spend a night in the ED waiting for admission to a hospital ward are at increased risk of in-hospital mortality.

Design, Settings, and Participants

This was a prospective cohort study of older patients (≥75 years) who visited the ED and were admitted to the hospital on December 12 to 14, 2022, at 97 EDs across France. Two groups were defined and compared: those who stayed in the ED from midnight until 8:00 am (ED group) and those who were admitted to a ward before midnight (ward group).

Main Outcomes and Measures

The primary end point was in-hospital mortality, truncated at 30 days. Secondary outcomes included in-hospital adverse events (ie, falls, infection, bleeding, myocardial infarction, stroke, thrombosis, bedsores, and dysnatremia) and hospital length of stay. A generalized linear-regression mixed model was used to compare end points between groups.

Results

The total sample comprised 1598 patients (median [IQR] age, 86 [80-90] years; 880 [55%] female and 718 [45%] male), with 707 (44%) in the ED group and 891 (56%) in the ward group. Patients who spent the night in the ED had a higher in-hospital mortality rate of 15.7% vs 11.1% (adjusted risk ratio [aRR], 1.39; 95% CI, 1.07-1.81). They also had a higher risk of adverse events compared with the ward group (aRR, 1.24; 95% CI, 1.04-1.49) and increased median length of stay (9 vs 8 days; rate ratio, 1.20; 95% CI, 1.11-1.31). In a prespecified subgroup analysis of patients who required assistance with the activities of daily living, spending the night in the ED was associated with a higher in-hospital mortality rate (aRR, 1.81; 95% CI, 1.25-2.61).

Conclusions and Relevance

The findings of this prospective cohort study indicate that for older patients, waiting overnight in the ED for admission to a ward was associated with increased in-hospital mortality and morbidity, particularly in patients with limited autonomy. Older adults should be prioritized for admission to a ward.

Is a Positive Prehospital FAST Associated with Severe Bleeding? A Multicenter Retrospective Study

INTRODUCTION

Severe hemorrhage is the leading cause of early preventable death in severe trauma patients. Delayed diagnosis is a poor prognostic factor, and severe hemorrhage prediction is essential. The aim of our study was to investigate if there was an association between the detection of peritoneal or pleural fluid on prehospital sonography for trauma and posttraumatic severe hemorrhage.

METHODS

We retrospectively studied data from records of thoracic or abdominal trauma patients managed in mobile intensive care units from January 2017 to December 2021 in four centers in France. Severe hemorrhage was defined as a condition necessitating transfusion of at least four packed red blood cells or surgical intervention/radioembolization for hemostasis within the first 24 h. Using a multivariate analysis, we investigated the predictive performance of focused assessment with sonography for trauma (FAST) alone or in combination with the five Red Flags criteria validated by Hamada et al.

RESULTS

Among the 527 patients analyzed, 371 (71%) were men, the mean age was 41 ± 19 years, and the Injury Severity Score was 11 (Interquartile range = [5; 22]). Seventy-three (14%) patients had severe hemorrhage - of whom 28 (38%) had a positive FAST, compared to 61 (13%) without severe hemorrhage (p < 0.01). For severe hemorrhage prediction, FAST had a sensitivity of 38% (95%CI = [27%; 50%]) and a specificity of 87% (95%CI = [83%; 90%]) (AUC = 0.62, 95%CI = [0.57; 0.68]). The comparison of the other outcomes between positive and negative FAST was: hemostatic procedure, 22 (25%) vs 28 (6%), p < 0.01; intensive care unit admission 71 (80%) vs 190 (43%), p < 0.01; mean length of hospital stay 11 [4; 27] vs 4 [0; 14] days, p = 0.02; 30-day mortality 13 (15%) vs 22 (5%), p < 0.01.

CONCLUSION

A positive FAST performed in the prehospital setting is associated with severe hemorrhage and all prognostic criteria we studied.

Performance of high-sensitivity cardiac troponin T in predicting major cardiovascular events in patients admitted to the emergency department for syncope with normal ECG: An observational prospective study

INTRODUCTION

History of syncope, clinical examination and electrocardiographic (ECG) findings are fundamental to assess the risk of major cardiovascular events (MACE) in patients attending the emergency department (ED) for syncope. However, in the absence of abnormal clinical examination findings or an abnormal ECG in the ED, transient rhythm or conduction disorders may not be safely excluded, hence predicting MACE remains challenging. High-sensitivity cardiac troponin T (hs-cTnT) may be a useful tool in this context.

AIM

The primary objective was to evaluate the performance of hs-cTnT in the diagnosis of MACE at 30 days in patients attending the ED for syncope with a normal initial ECG.

METHODS

This was a prospective observational cohort study that took place in the ED of a French university hospital between June 2018 and June 2019. Patients≥18 years admitted to the ED for syncope with a normal ECG were eligible. After receiving verbal consent from patients, the ED physician collected clinical and ECG data and all patients had a blood sample taken that included hs-cTnT measurement. The primary outcome was MACE within 30 days after the ED visit. MACE were evaluated by consulting the patient's medical records and telephoning patients or their general practitioners. Sensitivity, specificity, positive and negative predictive values were calculated with their 95% confidence intervals (CI) for different hs-cTnT thresholds.

RESULTS

Data from 246 patients were analysed, including 21 (9%) with MACE. Hs-cTnT had an area under the curve of 0.917 (CI: 0.872-0.962). Hs-cTnT with a threshold of 19ng/L had a sensitivity of 86% (CI: 64-97) and a specificity of 86% (CI: 81-90) for predicting MACE.

CONCLUSION

Hs-cTnT may be a relevant tool for assessing MACE risk in patients with syncope and normal ECG results.

Validation of the cutaneous impact location to predict intracranial lesion among elderly admitted to the Emergency Department after a ground-level fall

INTRODUCTION

In the Emergency Departments, almost one out of two head CT scans are carried out for traumatic brain injuries among elderly victims of ground level-falls. Recently, a new predictive factor for intracranial lesions in this population has been suggested: presence and location of cutaneous impact. The aim of this study was to establish determinants of intracranial lesion among older patients admitted to EDs due to ground-level falls with traumatic brain injury using the head cutaneous impact location.

METHODS

A retrospective, observational and monocentric study of patients admitted to Emergency Department for ground-level falls with traumatic brain injury was carried out between 01 January 2017 and 31 July 2017. The primary outcome was identification of an acute intracranial lesion. A bootstrap procedure was employed to evaluate performance and internal validity of the final model.

RESULTS

Among the 1036 patients included, the mean age was 85.6 (SD 7.6) years and 94/1036 (9.1%, 95% CI 7.4-10.9) patients presented with an acute intracranial lesion. Multivariable analysis adjusted by bootstrap shrinkage showed that compared with temporal-parietal or occipital impact, Odds Ratio of intracranial lesions were 0.61 (95% CI 0.39-0.95, p = 0.03) in patients with frontal impact, 0.27 (95% CI 0.12-0.59, p = 0.001) in patients with facial impact and 0.21 (95% CI 0.06-0.77, p = 0.018) in patients without cutaneous impact. Subcutaneous hematoma (OR 1.97, p = 0.007), loss of consciousness (OR 4.66, p<0.001), fall-related amnesia (OR 2.58, p = 2.6), vomiting (OR 2.62, p = 0.002) and altered Glasgow Score (OR 6.79, p<0.001) were as well associated with high risk of intracranial lesion. Taking antiplatelets or anticoagulants were not associated with an increased risk of intracranial lesions. The model discrimination was adequate (C-statistic 0.79; 95% CI 0.73 - 0.85).

CONCLUSION

Our results establish specific determinants of intracranial lesions among elderly after ground level-falls. The cutaneous impact location may identify patients with high risk of intracranial lesion. Further researches are needed to propose a specific score based on these determinants so as to better target Head CT scan use.

Teleconsultation at Sea and Acute Wound Management Onboard

Introduction: The French Tele-Medical Assistance Service (TMAS) provides medical teleconsultation for any ship at sea. At the end of the consultation, the doctor decides whether the problem can be taken care of onboard or not. In this study, we determined the factors associated with the decision for disembarkation or evacuation in case of wounds. Methods: We conducted a retrospective epidemiological study between 2011 and 2019 from consultations with the French TMAS. The inclusion criterion was the presence of an acute wound. Results: One thousand six patients (n = 1,006) were analyzed and 586 (58%) patients were disembarked or evacuated. Factors associated with disembarkation or evacuation are wound characteristics (severity and location), the onboard staff's medical training, the availability of photography, and the ship's location. Wound severity is a risk factor for disembarkation or evacuation. The availability of photography, staff with advanced training, and being at >1 day of navigation from a harbor are protective factors against being disembarked or evacuated. Conclusion: The added value of photography and an update of medium medical training could increase the number of wounds taken care of onboard.

Risk factors for the presence of important fractures in ED patients with shoulder dislocation: a retrospective cohort study

BACKGROUND

Prereduction shoulder X-rays are frequently done to rule out an important fracture that might preclude reduction of a shoulder dislocation in the ED. Our objective was to determine the risk factors for an important fracture in patients admitted to the ED with shoulder dislocation.

METHODS

This retrospective cohort study was conducted at the Toulouse University Hospital from 1 January 2017 to 31 December 2018. All patients admitted to the ED with clinical presentation of shoulder dislocation were included. The primary end point was the presence of an important fracture (excluding Bankart and Hill-Sachs fractures). Logistic regression was used to determine independent risk factors for the presence of an important fracture.

RESULTS

Six hundred and two patients were included in the study and 81 (13%) had an important fracture. Three risk factors were associated with important fracture: age over 40 years (adjusted OR (aOR)=2.7; 95% CI 1.5 to 4.8), first incident (aOR=4.3; 95% CI 1.7 to 10.8) and the circumstances in which the trauma occurred (fall from a height or direct impact, fall of over 1 m, road accident or epilepsy) (aOR=5.5; 95% CI 2.6 to 30). One hundred sixty-six patients (28%) had no risk factors in our cohort. In the absence of these risk factors, the risk of an important fracture was found to be 0.6% (95% CI 0 to 3.3).

CONCLUSION

We describe 3 independent clinical risk factors associated with an important fracture in ED patients with shoulder dislocation: age >40 years, first incident and a traumatic circumstance. Prereduction radiography may be safely avoided when these factors are absent.

Régulation médicale de la dyspnée de l’enfant : intérêt d’une régulation pédiatrique

Introduction :L’évaluation téléphonique du patient pédiatrique peut être difficile à la régulation médicale du Samu-Centre 15 (aide médicale urgente [AMU] ou permanence de soins [PDS]). La dyspnée est un motif d’appel fréquent dans cette population et présente des particularités importantes comparée à la population adulte. Nous avons voulu évaluer la pertinence de l’évaluation téléphonique de la dyspnée en pédiatrie selon la qualification du médecin régulateur (urgentiste, généraliste ou pédiatre).

Matériel et méthode :Il s’agit d’une étude observationnelle rétrospective monocentrique menée au Samu de Haute-Garonne entre le 1er décembre 2018 au 31 janvier 2019. Les critères d’inclusion étaient un appel pour tout patient avec un âge inférieur à dix ans pour dyspnée. Le critère de jugement principal était le surtriage.

Résultats : Nous avons analysé 717 appels pour dyspnée pédiatrique sur la période. La non-adéquation entre la décision médicale et le devenir du patient était retrouvée chez 174 patients (24 %) : 173 patients (99 %) étaient surtriés et un patient était sous-trié (< 1 %). En analyse multivariée, les facteurs protecteurs de surtriage étaient l’âge de six mois à trois ans (OR = 0,56 ; IC 95 % = [0,36–0,86]) comparé à un âge jeune (≤ 6 mois ; référence) et l’évaluation par un régulateur de PDS (OR = 0,38 ; IC 95 % = [0,23–0,62]) ou pédiatre (OR = 0,54 ; IC 95 % = [0,34–0,86]) comparé à un régulateur de l’AMU (référence). L’appel nocturne était un facteur de risque de surtriage (OR = 1,98 ; IC 95 % = [1,39–2,84]).

Conclusion : La régulation par un pédiatre ou un médecin de la PDS permet de réduire le surtriage dans un centre où les régulateurs AMU n’ont pas d’activité pédiatrique clinique.

Factors associated with Emergency Medical Dispatcher request and residents' inappropriate transfers from Nursing Homes to Emergency Department

PURPOSE

In the last decades, the amount of emergency department (ED) transfers of nursing home (NH) residents has disproportionally increased in western countries. The main role of emergency medical dispatcher (EMD) among this population is to refer residents to EDs in the most appropriate way. The aim of this study was to assess risk factors of inappropriate transfers from NH to ED after EMD request.

METHODS

This research was a secondary analysis of a prospective observational multicenter study carried out in 17 EDs entitled FINE aimed to assess potentially inappropriate transfer prevalence among this population. Inappropriate transfers were determined in the FINE study threw a standardized approach by a unique expert team.

RESULTS

Overall, 572/1037 (55.2%) of residents were transferred to the ED after an EMD's decision. Among them, 92/572 (16.1%) transfers was defined as inappropriate. The average age was 87.3 years old (SD = 0.3). The main reason for ED transfer were falls (217/572, 37.9%). In multivariate analysis, the presence of a Special Care Unit in NH was significantly associated with a high rate of inappropriate transfer (OR 1.78; 95 CI [1.07-2.93]; p = 0.02) whereas a medical examination by a general practitioner before the transfer (OR 0.55; 95 CI [0.33-0.83]; p = 0.02) and a prompt access to psychiatric advice (OR 0.54; 95 CI [0.33-0.84]; p = 0.007) were associated with a low rate of potentially inappropriate transfer.

CONCLUSION

Promoting onsite medical assessment and partnership thanks to available geriatrician's advice may help the emergency medical dispatcher to improve the appropriateness of residents' transfer from Nursing Home to the emergency department.

Effect of combined individual-collective debriefing of participants in interprofessional simulation courses on crisis resource management: a randomized controlled multicenter trial

OBJECTIVES

Interprofessional simulation (IPS) training is an effective way to learn crisis resource management. The type of debriefing used in IPS training may affect participants' performance and their level of psychological safety. We aimed to assess and compare performance after standard collective debriefing versus a combination of individual and collective debriefing ("combined" approach).

MATERIAL AND METHODS

Randomized, controlled multicenter trial. IPS sessions were randomized to have either standard or combined debriefing. Each team's performance in the IPS session was assessed with the Team Emergency Assessment Measure. The participants assessed the debriefing quality with the Debriefing Assessment for Simulation in Healthcare.

RESULTS

Forty IPS sessions were randomized, and 30 were analyzed, 15 using standard collective debriefing and 15 the combined individual-collective method. Teams' performance improved with both types of debriefing, based on pre-post testing (P<.01), and there were no significant differences in overall performance scores between the 2 types of debriefing (P=.64). However, the combined approach was associated with higher scores for leadership skills (P<.05) and psychological safety, and the participants' learning experience was better (P<.05).

CONCLUSION

During IPS courses on crisis resource management, debriefing improves participants' performance, but similar overall results can be obtained with both debriefing methods. Combined debriefing might be more effective for improving participants' leadership skills and psychological safety and also provide a better learning experience.

Management of pharmaceutical and recreational drug poisoning

BACKGROUND

Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis.

METHODS

A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology.

RESULTS

The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature.

CONCLUSIONS

The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.

Cutaneous impact location: a new tool to predict intracranial lesion among the elderly with mild traumatic brain injury?

Background

Mild traumatic brain injury is the leading cause of arrivals to emergency department due to trauma in the 65-year-old population and over. Recent studies conducted in ED suggested a low intracranial lesion prevalence. The objectives of this study were to assess the prevalence and risk factors of intracranial lesion in older patients admitted to emergency department for mild traumatic brain injury by reporting in the emergency department the precise anamnesis of injury and clinical findings.

Methods

Patients of 65 years old and over admitted in emergency department were prospectively included in this monocentric study. The primary outcome was the prevalence of intracranial lesion threw neuroimaging.

Results

Between January and June 2019, 365 patients were included and 66.8% were women. Mean age was 86.5 years old (SD = 8.5). Ground-level fall was the most common cause of mild traumatic brain injury and occurred in 335 patients (91.8%). Overall, 26 out of 365 (7.2%) patients had an intracranial lesion. Compared with cutaneous frontal impact (medium risk group), the relative risk of intracranial lesion was 2.54 (95% CI 1.20 to 5.42) for patients with temporoparietal or occipital impact (high risk group) and 0.12 (95% CI 0.01 to 0.93) for patients with facial impact or no cutaneous impact (low risk group). There was not statistical increase in risk of intracranial injury with patients receiving antiplatelets (RR = 1.43; 95% CI 0.68 to 2.99) or anticoagulants (RR = 0.98; 95% CI 0.45 to 2.14).

Conclusion

Among patients of 65 years old and over, the prevalence of intracranial lesion after a mild traumatic brain injury was similar to the younger adult population. The cutaneous impact location on clinical examination at the emergency department may identify older patients with low, medium and high risk for intracranial lesion.

Qui sont les patients adressés en structure d'urgence par leur médecin traitant ?

Introduction : Acteur central du soin primaire, le médecin généraliste peut être amené à adresser des patients aux structures d’urgences (SU). Les objectifs de notre travail étaient d’évaluer l’incidence des patients adressés en SU par leur médecin traitant, d’évaluer leur gravité par rapport aux autres patients admis en SU et de connaître leur motif de consultation.

Méthode : Il s’agit d’une étude de cohorte se déroulant sur les SU adultes du CHU de Toulouse au cours d’une semaine de 2019. Tous les malades admis dans les SU ont été inclus. Les variables démographiques, le caractère « adressé par le médecin traitant » ou non, le score de tri initial sur la classification infirmière des malades aux urgences (CIMU) et l’hospitalisation post-SU ont été relevés.

Résultats : Sur les 2 289 passages dans les SU sur la période, 212 (9 %) étaient liés à des patients adressés par leur médecin traitant. Ces malades étaient plus âgés (58 ans vs 45 ans, p < 0,001), plus graves (taux de CIMU 3 plus élevés : 65 vs 38 %, p < 0,001) et plus souvent hospitalisés (39 vs 19 %, p < 0,001) que les patients admis en SU non adressés par leur médecin traitant. Le motif le plus fréquent d’admission était la douleur abdominale (21 %).

Discussion : Une attention particulière doit être portée sur les malades admis en SU adressés par leur médecin traitant. Ils semblent en effet plus graves et nécessitant plus de ressources hospitalières.

Événements indésirables au cours de transfert interhospitalier de patients présentant un syndrome coronaire aigu non ST+

Introduction : Cette étude a pour objectif de connaître l’incidence et la nature des événements indésirables (EI) se produisant lors des transports interhospitaliers (TIH) des patients souffrant d’un syndrome coronarien aigu sans sus-décalage du segment ST (SCA non ST+). L’objectif secondaire est d’étudier les performances pronostiques des différentes évaluations de risque existantes de ces malades (score de GRACE, score de TIMI, grille de Fiancette et niveau de risque de la Société européenne de cardiologie [ESC]) dans la prédiction de ces EI.

Méthode : Il s’agit d’une étude de cohorte multicentrique rétrospective. Du 1er novembre 2016 au 31 octobre 2017, les patients SCA non ST+ et bénéficiant d’un transport secondaire ont été inclus à partir des fiches de régulation de trois Samu du sud-ouest de la France. Les types d’EI ont été recueillis. Les différents scores ont été calculés pour chaque patient ainsi que leur performance pronostique (sensibilité, spécificité, valeurs prédictives positives [VPP] et négatives [VPN]).

Résultats : Sur un an, 315 patients ont été inclus, et neuf patients (3 % ; IC 95 % : 1,3–5,3) ont présenté un EI. Soixante-dix-huit pour cent des événements recueillis n’ont pas engagé le pronostic vital des patients, et 40 % n’ont pas nécessité d’intervention thérapeutique nécessitant la présence physique d’un médecin. Aucun score n’est retrouvé statistiquement significatif dans la prédiction des EI. Toutefois, la stratification du risque de la ESC semble être la plus simple d’utilisation tout en assurant une valeur prédictive négative de 98 % (IC 95 % : 94–99).

Conclusion : Il y a peu d’EI lors du transport des SCA non ST+. L’utilisation en régulation de l’évaluation du risque ischémique de la ESC pourrait réduire la surmédicalisation de ces malades au bénéfice des TIH.

Winter virus season impact on acute dyspnoea in the emergency department

OBJECTIVE

To compare the epidemiology of dyspnoea presented to emergency departments (EDs) during and of winter virus season (WVS).

METHODS

This is a monocentric retrospective cohort study. All patients attending to the ED of the Rangueil University Hospital (Toulouse, France) for dyspnoea in September 2016 (off WVS period) and January 2017 (during WVS period) were included. The primary endpoint was the final diagnosis. The patients' medical profiles, care duration, seriousness and futures were studied as secondary endpoints.

RESULTS

A total of 395 patients were studied: 125 patients during off-peak influenza season and 270 patients during the peak influenza season. The incidence of patients attending because of dyspnoea increased significantly during WVS (4.2% of ED presentations during the off WVS period versus 8.4% during the WVS period, P < 0.001). Patients attending the ED because of dyspnoea during WVS period were significantly older with more extensive medical backgrounds and more serious diseases. Most of those patients were hospitalized (54%), and largely in the geriatrics department.

CONCLUSION

The incidence of patients attending because of dyspnoea doubled during the WVS period, with patients who were older and had more complex histories. This time-consuming population largely requires hospitalization and may be one of the causes of the emergency department's overcrowding during epidemics.

Patients présentant un syndrome coronarien aigu avec sus-décalage du segment ST admis en structure d’urgence après régulation par un Centre 15

Introduction : La cardiopathie ischémique est une des principales causes de mortalité en Europe. Cette mortalité importante est l’apanage particulier des syndromes coronariens avec élévation du segment ST (SCA ST+). Si la prise en charge préhospitalière de ces patients (de l’appel à la table de coronarographie) est sous la responsabilité des Samu, certains patients échappent à la filière malgré un appel au Centre 15. Notre objectif était de décrire ces patients porteurs d’un SCA ST+, admis en structure d’urgence (SU) après régulation par un Centre 15.

Méthode : Il s’agit d’une étude observationnelle de cohorte rétrospective incluant tous les patients admis en SU du CHU de Toulouse du 1er avril 2015 au 31 janvier 2017 avec un diagnostic final de SCA ST+.

Résultats : Sur les 139 patients qui ont été admis en SU pour SCA ST+, 96 (69 %) avaient contacté le Centre 15. Les dossiers de 89 patients ont été analysés. On retrouve une importante proportion de patientes de plus de 75 ans, qui représentent un quart de la population. Seulement 30 patients (34 %) présentaient une douleur typique.

Discussion : Notre étude retrouve un taux de douleurs atypiques et une proportion de femmes âgées plus importante que la littérature portant sur la description des patients porteurs de SCA ST+. Ces atypies de présentation peuvent expliquer la difficulté à réguler et orienter ces patients.

Identifying key factors leading to the optimal care pathway for patients with ST-segment elevation myocardial infarction: Results from the RESCAMIP registry

BACKGROUND

In France, when someone presents with chest pain, it is recommended to call a health emergency number. The patient talks with an emergency doctor at a medical dispatch centre, who decides whether (or not) to send a Mobile Intensive Care Unit (MICU). Patients with an ST-segment elevation myocardial infarction (STEMI) should have an MICU as their first medical contact, to speed up confirmation of diagnosis and enable them to benefit from reperfusion therapy as quickly as possible.

AIM

To evaluate the proportion of patients with STEMI benefiting from an optimal care pathway, and to identify the key factors leading to this pathway.

METHODS

RESCAMIP was a multicentre registry conducted between May 2015 and May 2017 in Midi-Pyrénées. All patients treated for STEMI within 12hours of symptoms onset, without initially going into cardiac arrest, were included.

RESULTS

Data from 1371 patients with STEMI were analysed; 60% had an MICU as their first medical contact. In-hospital mortality was 4%. Factors associated with calling the medical dispatch centre when presenting chest pain were: age>65 years (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.02-1.83), personal history of cardiovascular disease (OR 1.9, 95% CI 1.22-2.96) and having cardiovascular risk factors (OR 1.84, 95% CI 1.35-2.5). Factors associated with sending an MICU as first medical contact were: male sex (OR 2.11, 955 CI 1.49-2.99) and personal history of cardiovascular disease (OR 1.69, 95% CI 1.07-2.65).

CONCLUSIONS

The proportion of patients with STEMI going through non-optimal pathways was 40% in our area. We note that there are sex-based inequalities in accessing MICUs.