Pediatric victims involved in urban fires in Paris and its suburbs: Epidemiology, prehospital care, and lessons learned.

AIM: The literature includes few reports on the prehospital care of pediatric casualties of urban house fires. Here we aimed to describe the epidemiology of pediatric fire victims, focusing on their injuries, prehospital care, and survival. METHODS: This retrospective study included children under 15 years of age who were victims of urban house fires and who received care from prehospital medical teams. The variables analyzed included epidemiology, specific care provided by prehospital emergency services, the number of cardiac arrests, and survival rates. RESULTS: Over the 15-month study period, 365 house fires required the presence of at least one prehospital medical team. Casualties of these fires included 121 pediatric victims (median age, 4 years [interquartile range: 2-9 years]). All children were initially treated by a prehospital medical team that was not specialized in pediatrics. Six children (4.9%) received secondary treatment from a pediatric support team. Of the 121 children, 114 (94.2%) suffered from smoke inhalation and seven (5.8%) from burns. Two patients who were in cardiac arrest at their initial medical care did not survive. CONCLUSION: Pediatric fire casualties were initially managed by prehospital medical teams that were not specialized in pediatrics. As in adults, the main injuries were secondary to smoke inhalation, but this has increased toxicity in children. Prehospital teams not specialized in pediatrics can optimize their practice via the sharing of experiences, team training, and cognitive aid checklist for pediatric fire victims.

[Revelation of the circumstances of the accident vascular arterial ischemic brain in at term or near-term and referral]. / Circonstances de révélation de l'accident vasculaire cérébral ischémique artériel chez le nouveau-né à terme ou proche du terme et orientation des patients.

The neonatal arterial ischemic stroke is an emergency. Recurrent focal seizures, generally occurring in the first 24-72 hours after birth, are the commonest first clinical signs. When neonatal arterial ischemic stroke is suspected, optimal initial management involves careful supportive care including treatment of clinical and frequent or prolonged subclinical seizures, correction of the possible metabolic disorders and their prevention. Contrary to hypoxic ischemic encephalopathy, therapeutic hypothermia is not indicated. This newborn requires emergent transfer to a neonatal intensive care unit for the confirmation of the diagnosis by means of a specialized neonatal transport team.

[Neonatal arterial ischemic stroke: Review of the current guidelines]. / Accidents vasculaires cérébraux ischémiques artériels néonatals : synthèse des recommandations.

Neonatal arterial ischemic stroke (NAIS) is a rare event that occurs in approximately one in 5000 term or close-to-term infants. Most affected infants will present with seizures. Although a well-recognized clinical entity, many questions remain regarding diagnosis, risk factors, treatment, and follow-up modalities. In the absence of a known pathophysiological mechanism and lack of evidence-based guidelines, only supportive care is currently provided. To address these issues, a French national committee set up by the French Neonatal Society (Société française de néonatologie) and the national referral center (Centre national de référence) for arterial ischemic stroke in children drew up guidelines based on an HAS (Haute Autorité de santé [HAS]; French national authority for health) methodology. The main findings and recommendations established by the study group are: (1) among the risk factors, male sex, primiparity, caesarean section, perinatal hypoxia, and fetal/neonatal infection (mainly bacterial meningitis) seem to be the most frequent. As for guidelines, the study group recommends the following: (1) the transfer of neonates with suspected NAIS to a neonatal intensive care unit with available equipment to establish a reliable diagnosis with MRI imaging and neurophysiological monitoring, preferably by continuous video EEG; (2) acute treatment of suspected infection or other life-threatening processes should be addressed immediately by the primary medical team. Persistent seizures should be treated with a loading dose of phenobarbital 20mg/kg i.v.; (3) MRI of the brain is considered optimal for the diagnosis of NAIS. Diffusion-weighted imaging with apparent diffusion coefficient is considered the most sensitive measure for identifying infarct in the neonatal brain. The location and extent of the lesions are best assessed between 2 and 4 days after the onset of stroke; (4) routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocysteinemia, the Lp(a) test, the MTHFR thermolabile variant should not be considered in neonates with NAIS. Testing for FV Leiden can be performed only in case of a documented family history of venous thromboembolic disease. Testing neonates for the presence of antiphospholipid antibodies should be considered only in case of clinical events arguing in favor of antiphospholipid syndrome in the mother; (5) unlike childhood arterial ischemic stroke, NAIS has a low 5-year recurrence rate (approximately 1 %), except in those children with congenital heart disease or multiple genetic thrombophilia. Therefore, initiation of anticoagulation or antithrombotic agents, including heparin products, is not recommended in the newborn without identifiable risk factors; (6) the study group recommends that in case of delayed motor milestones or early handedness, multidisciplinary rehabilitation is recommended as early as possible. Newborns should have physical therapy evaluation and ongoing outpatient follow-up. Given the risk of later-onset cognitive, language, and behavioral disabilities, neuropsychological testing in preschool and at school age is highly recommended.

[Accidental out-of-hospital deliveries]. / Accouchements inopinés extrahospitaliers.

Unexpected out-of-hospital delivery accounts for 0.5% of the total number of delivery in France. The parturient is placed under constant multiparametric monitoring. Fetus heart rate is monitored thanks to fetal doppler. A high concentration mask containing a 50-to-50 percent mix of O(2) and NO performs analgesia. Assistance of mobile pediatric service can be required under certain circumstances such as premature birth, gemellary pregnancy, maternal illness or fetal heart rate impairment. Maternal efforts should start only when head reaches the pelvic floor, only if the rupture of the membranes is done and the dilation is completed. The expulsion should not exceed 30 min. Episiotomy should not be systematically performed. A systematic active management of third stage of labour is recommended. Routine care such as warming and soft drying can be performed when the following conditions are fulfilled: clear amniotic liquid, normal breathing, crying and a good tonus. Every 30 seconds assessment of heart rate, breathing quality and muscular tonus then guide the care. The redaction of birth certificate is a legal obligation and rests with the attending doctor.

[Delivery room management: What's new in 2010 recommendations?]. / Réanimation du nouveau-né en salle de naissance : qu'apportent les recommandations de 2010 ?

For apneic or bradycardic babies born at term, it is best to begin ressuscitation in the delivery room with air rather than 100% oxygen. Administration of supplementary oxygen should be regulated by blending oxygen and air, and the concentration delivered should be guided by oximetry. Preterm babies less than 32 weeks gestation may not reach the same arterial blood oxygen saturations in air as those achieved by term babies. Therefore, blended oxygen and air should be given guided by pulse oximetry. Detection of exhaled carbon dioxide in addition to clinical assessment is recommended as the most reliable method to confirm placement of a tracheal tube in neonates. If presented with a floppy, apnoeic baby born through meconium, it is reasonable to rapidly inspect the oropharynx to remove potential secretions. Tracheal intubation and suction may be useful. Therapeutic hypothermia should be considered for infants born at term or near-term with evolving moderate to severe hypoxic-ischemic encephalopathy, with protocol and follow-up coordinated through a regional perinatal system. For preterm babies of less than 28 weeks gestation delivery room temperatures should be at least 26 °C. They should be completely covered in a food-grade plastic bag up to their necks, without drying, immediately after birth. If the heart rate of a newly born baby is not detectable and remains undetectable for 10 min, it is then appropriate to consider stopping resuscitation. Simulation should be used as a methodology in resuscitation education.

Mortality in out-of-hospital premature births.

AIM: To determine whether the mortality for out-of-hospital (OOH) premature births was higher than for in-hospital premature births and identify additional risk factors. PATIENTS AND METHODS: A historical cohort study of a consecutive series of live-born, OOH, births of 24-35 weeks gestation cared for by two Transport Teams working in and around Paris, France 1994-2005. Matching with in-hospital births was according to gestational age, antenatal steroid use, the mode of delivery and nearest year of birth. RESULTS: Eighty-five OOH premature births were identified, of whom 83 met inclusion criteria, and 132 matching in-hospital premature births were selected. There was 18% mortality in the OOH group compared with 8% for the in-hospital group [p = 0.04, OR 2.9, (CI 95% 1.0-8.4)]. Variables significantly associated (p < 0.05) with the OOH birth were HIV infection, lower maternal age and endo-tracheal intubation, lack of medical follow-up during pregnancy, low temperature and low birth weight. CONCLUSIONS: Mortality was more than twice as high in out-of-hospital deliveries than for in-hospital matched controls. Hypothermia was an important associated risk factor. Measures such as oxygen administration to maintain an appropriate saturation for gestational age, the provision of polyethylene plastic wraps and skin-to-skin contact are recommended.

[National evaluation of knowledge and practice of cardiopulmonary resuscitation of children and infants in the field]. / Prise en charge préhospitalière de l'arrêt cardiaque de l'enfant et du nourrisson: enquête nationale de pratique.

INTRODUCTION: After the publication of new recommendations for cardiopulmonary resuscitation (2005 guidelines and 2006 French recommendations), we conducted a study amongst EMS teams concerning their approach with children and infants, nationwide. The objective was to measure the level of knowledge of guidelines and practice. METHODS: The online questionnaire was offered to emergency physicians belonging to the French emergency database, between November 1st and December 15th 2007. Incomplete questionnaires were excluded from the study. We recorded: profile of personnel, knowledge of guidelines, basic CPR and advanced CPR parameters. RESULTS: Four hundred and thirty-nine questionnaires were analyzed. Personnel was aged under 40 in 50.2 %, with 2-5 years experience in prehospital emergency care (57.6 %); 51,3 % declared having had training in pediatric CPR. A minority of subjects declared knowing the 2005 Guidelines (35 %), more the French 2006 recommendations (62.5 %). Basic CPR: transition age child/adult known in 30.3 %. Compression/ventilation ratio: 30/2 for one rescuer in 50.2 % (child), 46.5 % (infant); 15/2 for two or more rescuers in 57.6 % (child), 48 % (infant). AED age for use (1 year old) known in 59.8 %. Advanced CPR: epinephrine dose known in 89.3 % (intravenous) and 34.3 % (tracheal). External shock known in 57.2 %. CONCLUSION: This study emphasizes the lack of knowledge, especially with regard to first aid. Formations will be developed.

Obstetric interventions for babies born before 28 weeks of gestation in Europe: results of the MOSAIC study.

OBJECTIVE: To describe obstetric intervention for extremely preterm births in ten European regions and assess its impact on mortality and short term morbidity. DESIGN: Prospective observational cohort study. SETTING: Ten regions from nine countries participating in the 'Models of Organising Access to Intensive Care for Very Preterm Babies in Europe' (MOSAIC) project. POPULATION: All births from 22 to 29 weeks of gestation (n = 4146) in 2003, excluding terminations of pregnancy. METHODS: Comparison of three obstetric interventions (antenatal corticosteroids, antenatal transfer and caesarean section for fetal indication) rates at 22-23, 24-25 and 26-27 weeks to that at 28-29 weeks and the association of the level of intervention with pregnancy outcome. MAIN OUTCOME MEASURES: Use of antenatal corticosteroids, antenatal transfer and caesarean section by two-week gestational age groups as well as a composite score of these three interventions. Outcomes included stillbirth, in-hospital mortality and intraventricular haemorrhage (IVH) grades III and IV and/or periventricular leucomalacia (PVL) and bronchopulmonary dysplasia (BPD). RESULTS: There were large differences between regions in interventions for births at 22-23 and 24-25 weeks. Differences were most pronounced at 24-25 weeks; in some regions these babies received the same care as babies of 28-29 weeks, whereas elsewhere levels of intervention were distinctly lower. Before 26 weeks and especially at 24-25 weeks, there was an association between the composite intervention score and mortality. No association was observed at 26-27 weeks. For survivors at 24-25 weeks, the intervention score was associated with higher rates of BPD, but not with IVH or PVL. CONCLUSIONS: There are large differences between European regions in obstetric practices at the lower limit of viability and these are related to outcome, especially at 24-25 weeks.

[Air or oxygen for neonatal resuscitation at birth?]. / Réanimation du nouveau-né en salle de naissance : faut-il encore utiliser de l'oxygène pur ?

Most of the contemporary guidelines on newborn resuscitation are based on experience but lack scientific evidence. The use of 100% oxygen is one of the more evident. Today, these practices are questioned, particularly for the resuscitation of moderately depressed full-term or near-term newborns. Results of recent meta-analysis of trials that compared ventilation with room air versus pure oxygen at birth suggest current practices should be revisited. On the basis of these data, air can be the initial gas to use for these babies. Large-scale trials, including preterm and cause and/or severity of initial asphyxia, must now be undertaken before the publication of new guidelines for these populations.

[Intrapartum and postdelivery management of infants born to mothers with meconium-stained amniotic fluid]. / Prise en charge périnatale des enfants nés avec un liquide méconial.

Since a decade, some studies had discussed preventive and curative treatment of infants born to mothers with meconium-stained amniotic fluid. Today amnio-infusion, formerly proposed, is reconsidered in countries where midwives and obstetricians carefully monitor the fetal heart rate tracing during labor. Actually routine intrapartum oropharyngeal and nasopharyngeal suctioning, before and after shoulders delivery, followed by tracheal suction, are not recommended for infants born to mothers with meconium stained amniotic fluid.

[Effects of nasal continuous positive airway pressure ventilation in infants with severe acute bronchiolitis]. / Place de la ventilation non invasive nasale dans la prise en charge des broncho-alvéolites sévères.

OBJECTIVE: Usefulness of nasal continuous positive airway pressure (NCPAP) in severe acute bronchiolitis has been checked. The objective of this descriptive study was to evaluate the feasibility, safety and risk factors of NCPAP failure. POPULATION AND METHODS: One hundred and forty-five infants were hospitalised in our intensive care unit during the 2 last epidemics (2003-2004, 2004-2005). Among them, 121 needed a respiratory support, either invasive ventilation (N=68) or NCPAP (N=53). RESULTS: General characteristics were similar during the 2 periods. Percentage of NCPAP failure, defined by tracheal intubation requirement during the stay in paediatric intensive care unit, was quite similar during the 2 periods (25%), but number of NCPAP increased twofold. Whatever the evolution was in the NCPAP group, we observed a significant decrease in respiratory rate (60+/-16 vs 47.5+/-13.7 cycle/min., P<0.001) and PaCO2 (64.3+/-13.8 vs 52.6+/-11.7 mmHg, P=0.001) during NCPAP. Only PRISM calculated at day 1 and initial reduction of PaCO2 were predictive of NCPAP failure. Percentage of ventilator associated pneumonia was similar (22%) between the invasive ventilation group and infants who where intubated because of failure of NCPAP. Duration of respiratory support and stay were reduced in the NCPAP group (P<0.002). CONCLUSION: NCPAP appears to be a safe alternative to immediate intubation in infants with severe bronchiolitis.

[Neonatal resuscitation in delivery room: new advances]. / Aspects récents de la prise en charge du nouveau-né en salle de naissance.

The need for resuscitation of a distressed newborn in delivery room is more and more easily predictable. The two principal reasons are improvement of obstetrical survey and best perinatal regionalisation. Perinatal asphyxia and premature labour, especially before 32 weeks of gestational age, are the more frequent situation needing resuscitation at birth. A good survey of pregnancy and labor, verification of availability and efficiency of care devices and material in the delivery room are essential. In all guidelines respiratory resuscitation is today the priority in the first minutes. Non invasive positive pressure ventilation and early use of exogenous surfactant are the recent advances for the care of very premature baby in delivery room. Having a neonatal ventilator and pulse oximetry monitoring is recommended and can improve results. For the pregnant woman and the baby, maternal transfer if no contra-indications exist and when it is possible, is preferred to postnatal transportation in case of very premature labor or high risk pregnancy. In all the other situations neonatal transport must be strictly organised and realised by well-trained pediatric team, with adapted material and in the best conditions for security and comfort. The goal is to prevent any rupture until arrival in the referring neonatal intensive car unit.