[Toward a medical approach to the evaluation of activity in a physician-staffed mobile intensive care unit]. / Vers une médicalisation de l'évaluation de l'activité en Smur.

OBJECTIVE: To test the ability of various medical criteria for classifying the patients in a physician-staffed mobile intensive care unit (MICU) by referring to intervention times. STUDY DESIGN: Prospective, open study. PATIENTS AND METHODS: For all the on-scene interventions of the MICUs over a 10-month period, the following data were prospectively collected: pre-hospital diagnosis, initial severity score, medical care score, immediate outcome and three intervention times: on-scene time (OS), time spent with the patient by the MICU team (MT), total duration of intervention (TD). RESULTS: A total of 3,672 MICU interventions were included. Median times were 45 min (32-59) for OS, 66 min (41-91) for MT and 85 min (61-116) for TD. The amount of interventions in a city was correlated with the population (R = 0.95; P < 0.001). The medical care score was greater than one in more than half of the patients. It defined five groups of patients which were different for the three intervention times (P < or = 0.001). A third of the patients were directly transported by the MICU to an ICU. For the median test, immediate outcome groups were different for the three intervention times (P < 0.001). After exclusion of patients with initial cardiac arrest, initial severity score defined five groups of patients which were different for the three intervention times (P < 0.002). Initial severity score and medical care score were correlated (R = 0.37; P < 0.001). CONCLUSION: A classification of the patients based on immediate outcome would be a more accurate indicator of the variability in medical care and consumption of resources in a physician-staffed MICU. In addition, a medical intervention score should be developed to better characterise this medical activity.

[Tracheal intubation in prehospital resuscitation: importance of rapid-sequence induction anesthesia]. / Intubation [correction of Induction] trachéale en réanimation préhospitalière: intérêt de l'induction anesthésique à séquence rapide.

OBJECTIVE: To investigate complications of emergency endotracheal intubation (EEI), possibly facilitated by rapid-sequence induction, in the prehospital critical care setting: 1) the difficulty of intubation; 2) the cardiorespiratory consequences of intubation; 3) the relationship between the occurrence of complications and prognosis. STUDY DESIGN: Prospective non randomized, open study. PATIENTS: All patients treated over a 5-month period by a physician-manned ambulance service and requiring EEI. METHODS: Patients were allocated either in with cardiac arrest (CA) group or a group with maintained spontaneous circulation (SC). Difficulty of intubation was assessed by the number of attempts. RESULTS: Two hundred and twenty-four consecutive EEI were carried out by physicians (46%) and residents (38%) not trained in anaesthesia, anaesthetists (8%), or nurse anaesthetists (7%). Trachea was intubated after a maximum of three attempts in all patients. Success rate at the first attempt was 91%. It was 92% in CA patients (n = 76) and 90% in SC patients (P = 0.59). Anaesthetic induction, with (n = 112) or without (n = 12) succinylcholine, was used to facilitate 84% of intubations in SC patients. Complications occurred in 30 patients (20%). There was no relationship between the latter and hospital mortality, duration of ventilatory support, duration of stay in the intensive care unit. CONCLUSION: In this study, EEI in SC patients was frequently facilitated by rapid sequence induction and was associated with a high success rate at the first attempt, as in CA patients. Morbidity was low. All physicians involved in emergency airway management should be skilled in this technique.