Procedural Sedation and Analgesia in Trauma Patients in an Out-of-Hospital Emergency Setting: A Prospective Multicenter Observational Study.

BACKGROUND: The quality of procedural analgesia and sedation among trauma patients has not been studied much in the prehospital setting. The main objective of this study was to characterize the quality of procedural analgesia sedation practices in prehospital settings in trauma patients. METHODS: This was an open-label observational prospective multicenter study (January 01, 2012-December 31, 2013). We included all consecutive trauma victims undergoing a potentially painful procedure on the accident scene. The primary endpoint was the procedural pain intensity. RESULTS: Data for 210 patients aged 11 to 98 years were analyzed. The most common lesions were limb fractures or dislocations. The most common procedures were limb realignment and splinting. Overall, 25 different drug combinations [with paracetamol [acetaminophen], non-steroidal anti-inflammatory drugs, nefopam, opioids, loco-regional anesthesia, Equimolar Mixture of Oxygen/Nitrous Oxide (EMONO), sedative drugs] were used by the emergency medical services (EMS). One hundred seventeen patients (55%) received either one or two sedative drugs (among ketamine, propofol, and midazolam), 171 patients (81%) received morphine that was combined with a sedative drug in 54% of cases. During the procedure, 95 patients, 45% [95% Confidence Interval (CI) 39-52] experienced intense to severe pain. Among patients who received sedative drugs, 27% (32/117) had intense to severe pain vs. 68% (63/93) in patients who did not, that is, 40% difference [95% CI 33.8-47.0]. Seventeen patients (8%) experienced 18 adverse events of which 6 were respiratory adverse events. A deep sedation occurred in 17 patients. No center had any specific protocols for procedural sedation analgesia. CONCLUSION: Procedural sedation-analgesia was inadequate in almost half of the trauma patients in the out-of-hospital setting. The reasons of these failures were probably multiple. The non-administration of a sedative drug despite an indication or non-adapted doses, in the context of a lack of specific protocols, was certainly one of them.

Adverse Events With Ketamine Versus Ketofol for Procedural Sedation on Adults: A Double-blind, Randomized Controlled Trial.

OBJECTIVES: The goal of our study was to compare the frequency and severity of recovery reactions between ketamine and ketamine-propofol 1:1 admixture ("ketofol"). METHODS: We performed a multicentric, randomized, double-blind trial in which adult patients received emergency procedural sedations with ketamine or ketofol. Our primary outcome was the proportion of unpleasant recovery reactions. Other outcomes were frequency of interventions required by these recovery reactions, rates of respiratory or hemodynamic events, emesis, and satisfaction of patients as well as providers. RESULTS: A total of 152 patients completed the study, 76 in each arm. Compared with ketamine, ketofol determined a 22% reduction in recovery reactions incidence (p < 0.01) and less clinical and pharmacologic interventions required by these reactions. There was no serious adverse event in both groups. Rates in hemodynamic or respiratory events as well as satisfaction scores were similar. Significantly fewer patients experienced emesis with ketofol, with a threefold reduction in incidence compared with ketamine. CONCLUSION: We found a significant reduction in recovery reactions and emesis frequencies among adult patients receiving emergency procedural sedations with ketofol, compared with ketamine.

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.).

A study comparing care between nurses and doctors in the French prehospital setting: the case of hypoglycemia.

INTRODUCTION: The objective of this study was to compare the quality of care between French nurses and physicians in the prehospital management of hypoglycemic patients. METHODS: Response times, concordance with medical protocols/recommendations, quality of medical records, and percentage of hospitalized patients were evaluated. RESULTS: A total of 33 patients were treated for hypoglycemia by the nurse group and 41 by the physician group. The groups were similar in terms of response rates (mean time of 00:08 ± 00:06 minutes for nurses and 00:10 ± 00:09 minutes for doctors). For 51 patients not requiring hospitalization, the proportion was similar in each group (47.1% and 52.9% for nurses and doctors, respectively). The nurse group showed significantly higher mean scores for concordance with recommendations (P < .001) and quality of medical records (P = .005). DISCUSSION: In the management of hypoglycemic patients, the quality of care of an emergency ambulance team composed of nurses was comparable to that of doctors.

[Yanomami children's nutritional status in the middle Rio Negro, Brazilian Amazônia]. / O estado nutricional de crianças Yanomami do Médio Rio Negro, Amazônia.

The nutritional status of 290 Yanomami Amerindians children, from birth to about six year-olds, living in the middle Rio Negro, Brazilian Amazonia, has been studied in 1998 and 1999 using the weight-for-height. All of them were of low stature. Twenty malnourished (7%), defined as below two standard deviations of NCHS' data, have been observed. Five of them showed a severe malnutrition (

O estado nutricional de crianças Yanomami do Médio Rio Negro, Amazonia / Yanomami children's nutritional status in the middle Rio Negro, Brazilian Amazônia

The nutritional status of 290 Yanomami Amerindians children, from birth to about six year-olds, living in the middle Rio Negro, Brazilian Amazonia, has been studied in 1998 and 1999 using the weight-for-height. All of them were of low stature. Twenty malnourished (7), defined as below two standard deviations of NCHS' data, have been observed. Five of them showed a severe malnutrition (