Management of imported malaria in the emergency department: Adequacy compared to guidelines, and impact of the SARS-CoV-2 pandemic.

OBJECTIVES: Adequacy of imported malaria management with respect to guidelines in emergency departments (ED) is low. We aimed to identify factors associated with this non-compliance, and a potential impact of the SARS-CoV-2 pandemic. PATIENTS AND METHODS: Patients presenting with imported malaria at the ED of the hospital of Melun (France), from January 1, 2017 to February 14, 2022 were retrospectively included. RESULTS: Among 205 adults and 25 children, biological criteria of severity were fully assessed in 10% of cases; lactates (40%) and blood pH (21%) levels were the main missing variables. Of 74 patients (32%) with severe malaria, 13 were misclassified as uncomplicated malaria. The choice and dosage of treatment were adequate in 85% and 92% of cases, respectively. Treatment conformity was lower in severe malaria cases than in non-severe malaria cases (OR 0.15 [95% CI 0.07-0.31]), with oral treatment in 17 patients with severe malaria; conformity was higher in the intensive care unit (OR 4.10 [95% CI 1.21-13.95]). Patients with severe malaria were more likely to start treatment within 6hours than patients with uncomplicated malaria (OR 1.97 [95% CI 1.08-3.43]), as were patients infected by P.falciparum compared to other species (OR 4.63 [95% CI 1.03-20.90]). Consulting during the SARS-CoV-2 pandemic was the only organizational factor associated with a lower probability of adequate management (OR 0.42 [95% CI 0.23-0.75]). CONCLUSION: Initial evaluation of malaria severity and time to treatment administration could be improved. These have been adversely impacted by the SARS-CoV-2 pandemic.

Triage practices in stroke units: Physicians' perceptions and ethical issues.

OBJECTIVE: We aimed to explore acute stroke admission decisions and to discuss ethical issues in triage practices in stroke units (SUs) in France. METHODS: In this study, 337 questionnaires were sent to physicians involved in acute admission to SUs in Île-de-France (neurologists and physicians from emergency medical services). The questionnaires comprised questions about physicians' perceptions of the reasonable allocation of SU beds and admission criteria for patients in SU in clinical vignettes illustrating complex situations. RESULTS: In total, 162 questionnaires were fully completed. There were some discrepancies in perceptions and reporting practices between emergency physicians and neurologists concerning patient admission criteria. Triage choices were more frequently declared by emergency physicians than by neurologists and were related to the difficulty of obtaining a positive response for the admission of certain complex patients (particularly those with comorbidities). CONCLUSIONS: Despite recommendations stating that all patients with stroke should be admitted to SUs, this study has shown that triage practices exist in stroke admission decisions. The triage depends on the role and perceptions of each physician in acute stroke management. These decisions suggest reflections on the applicability of distributive justice theories and on ethical issues in triage practices in medicine.

[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.

[Evaluation of duration for direct admission dispatch process in an urban area]. / Evaluation des durées de recherche de places en service spécialisé par la régulation d'un Samu en milieu urbain.

OBJECTIVE: In France, when physicians in ambulances take care of patients, they report medical status to the dispatch centre. Then the dispatching physician search for the available and appropriate hospital service to agree in directly receiving the patient. We attempted to evaluate this direct admission dispatch, in a urban area, with many health care facilities. STUDY DESIGN: Prospective evaluation. PATIENTS AND METHODS: All the files for out of hospital interventions with a dispatch process were included. Data collected and analysed were: main pathologies, started time and end time of direct admission dispatch process and number of services called before finding the right place. RESULTS: 959 patients files were included, 849 could be analysed. The average duration of direct admission dispatch process is 10 (+/-13) minutes. Traumatology speciality shows a longer dispatch process than medicine disease (p < 0.001), and this time increased during summer (p < 0.05). The other parameters did not influence this duration. CONCLUSION: The average duration of direct admission dispatch process is acceptable. The increased duration of direct admission dispatch process in some pathology during summer may induce a risk for the patients. This problem will be improved only when the management of the available bed for emergency traumatology, will be implemented a regional coordination.

[Laboratory testing measurement of FIO2 delivered by Boussignac CPAP system with an input of 100% oxygen]. / Mesure sur banc d'essai des FIO2 délivrées par la CPAP Boussignac alimentée en oxygène pur.

INTRODUCTION: CPAP (Continuous Positive Airway Pressure) is one of the treatments of the cardiogenic acute pulmonary edema (cAPE). Among the out-of-hospital used devices, Boussignac CPAP (Vygon) shows a good technical usability, but no analysis of delivered FIO2 is available. OBJECTIVE: To measure the FIO2 delivered to patient, using Boussignac CPAP with an input of 100 vol % oxygen. Type of study. - Measurement in a laboratory testing. MATERIAL AND METHOD: Measurement of delivered FIO2 in a three parameters environment: expiratory positive airway pressure (EPAP), respiratory rate (RR) and required oxygen flow (ROF). Laboratory test: 100 vol % oxygen input, with a ball-type flow regulator for oxygen 0-30 l x min(-1) (Mediline), Boussignac CPAP valve with manometer (Vygon), Michigan test lung, ventilator César (Taema), oxygen analysis (Servomex) with paramagnetic sensor, with a response time < 10 s, pneumotachographe (Fleisch v 2). RESULTS: Under 10 cmH2O EPAP, the required oxygen flow is < or = 30 l x min(-1). Measured FIO2 ranges from 70 to 100 vol %, for a volume per minute < or = 15 l x min(-1) except for a EPAP at 2.5 cmH2O with a rate = 10 c min(-1) and a tidal volume (VT) at 1500 ml where the measured FIO2 is 60 vol %. For a volume per minute > 15 l x min(-1) and < 20 l x min(-1), measured FIO2 ranges from 59 to 83 vol % depending on the variations of RR and VT. CONCLUSION: Boussignac CPAP with 100 vol % oxygen input, delivers high levels of FIO2, especially for volume per minute values usually met in cAPE. The needed oxygen flow is lower than what is usually required by other CPAP flow generators using the venturi effect that may be used in out-of-hospital medical care.