A Short Intervention and an Interactive e-Learning Module to Motivate Medical and Dental Students to Enlist as First Responders: Implementation Study.

BACKGROUND: Prompt and proficient basic life support (BLS) maneuvers are essential to increasing the odds of survival after out-of-hospital cardiac arrest. However, significant time can elapse before the arrival of professional rescuers. To decrease these delays, many countries have developed first responder networks. These networks are composed of BLS-certified lay or professional rescuers who can be dispatched by emergency medical communication centers to take care of those who experience out-of-hospital cardiac arrest. Many systems are, however, limited by a relatively low number of active first responders, and first-year medical and dental students may represent an almost untapped pool of potential rescuers. On top of providing an enhanced BLS coverage to the population, this could also help medical students be better prepared to their future role as certified health care providers and address societal expectations regarding health care students. OBJECTIVE: Our objective was to describe the impact of a short motivational intervention followed by a blended BLS course (e-learning and practice session) designed to motivate first-year medical and dental students to enlist as first responders. METHODS: A short, web-based, motivational intervention presenting this project took place, and first-year University of Geneva, Faculty of Medicine students were provided with a link to the study platform. Those who agreed to participate were redirected to a demographic questionnaire before registering on the platform. The participants were then asked to answer a second questionnaire designed to determine their baseline knowledge prior to following an interactive e-learning module. Upon completion, a web-based booking form enabling them to register for a 1-hour practice session was displayed. These sessions were held by senior medical students who had been trained and certified as BLS instructors. The participants who attended these practice sessions were asked to answer a postcourse questionnaire before receiving the certificate enabling them to register as first responders. RESULTS: Out of the 529 first-year students registered at University of Geneva, Faculty of Medicine on January 14, 2021, 190 (35.9%) initially agreed to participate. Moreover, 102 (19.3%) attended the practice sessions, and 48 (9.1%) had completed all training and enlisted as first responders on the dedicated platform, Save a Life, at 6 months (July 14, 2021). Postcourse confidence in resuscitation skills was associated with a higher likelihood of registering as first responder (P=.03). No association was found between prior BLS knowledge and the probability of registering to a practice session (P=.59), of obtaining a course completion certificate (P=.29), or of enlisting as first responder (P=.56). CONCLUSIONS: This study shows that a motivational intervention associated with a short BLS course can convince medical students to enlist as first responders. Further studies are needed to understand the rather low proportion of medical students finally registering as first responders. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/24664.

Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest.

The objective of this study was to identify the key elements used by prehospital emergency physicians (EP) to decide whether or not to attempt advanced life support (ALS) in asystolic out-of-hospital cardiac arrest (OHCA). From 1 January 2009 to 1 January 2017, all adult victims of asystolic OHCA in Geneva, Switzerland, were retrospectively included. Patients with signs of "obvious death" or with a Do-Not-Attempt-Resuscitation order were excluded. Patients were categorized as having received ALS if this was mentioned in the medical record, or, failing that, if at least one dose of adrenaline had been administered during cardiopulmonary resuscitation (CPR). Prognostic factors known at the time of EP's decision were included in a multivariable logistic regression model. Included were 784 patients. Factors favourably influencing the decision to provide ALS were witnessed OHCA (OR = 2.14, 95% CI: 1.43-3.20) and bystander CPR (OR = 4.10, 95% CI: 2.28-7.39). Traumatic aetiology (OR = 0.04, 95% CI: 0.02-0.08), age > 80 years (OR = 0.14, 95% CI: 0.09-0.24) and a Charlson comorbidity index greater than 5 (OR = 0.12, 95% CI: 0.06-0.27) were the factors most strongly associated with the decision not to attempt ALS. Factors influencing the EP's decision to attempt ALS in asystolic OHCA are the relatively young age of the patients, few comorbidities, presumed medical aetiology, witnessed OHCA and bystander CPR.

Differences in Basic Life Support Knowledge Between Junior Medical Students and Lay People: Web-Based Questionnaire Study.

BACKGROUND: Early cardiopulmonary resuscitation and prompt defibrillation markedly increase the survival rate in the event of out-of-hospital cardiac arrest (OHCA). As future health care professionals, medical students should be trained to efficiently manage an unexpectedly encountered OHCA. OBJECTIVE: Our aim was to assess basic life support (BLS) knowledge in junior medical students at the University of Geneva Faculty of Medicine (UGFM) and to compare it with that of the general population. METHODS: Junior UGFM students and lay people who had registered for BLS classes given by a Red Cross-affiliated center were sent invitation links to complete a web-based questionnaire. The primary outcome was the between-group difference in a 10-question score regarding cardiopulmonary resuscitation knowledge. Secondary outcomes were the differences in the rate of correct answers for each individual question, the level of self-assessed confidence in the ability to perform resuscitation, and a 6-question score, "essential BLS knowledge," which only contains key elements of the chain of survival. Continuous variables were first analyzed using the Student t test, then by multivariable linear regression. Fisher exact test was used for between-groups comparison of binary variables. RESULTS: The mean score was higher in medical students than in lay people for both the 10-question score (mean 5.8, SD 1.7 vs mean 4.2, SD 1.7; P<.001) and 6-question score (mean 3.0, SD 1.1 vs mean 2.0, SD 1.0; P<.001). Participants who were younger or already trained scored consistently better. Although the phone number of the emergency medical dispatch center was well known in both groups (medical students, 75/80, 94% vs lay people, 51/62, 82%; P=.06), most participants were unable to identify the criteria used to recognize OHCA, and almost none were able to correctly reorganize the BLS sequence. Medical students felt more confident than lay people in their ability to perform resuscitation (mean 4.7, SD 2.2 vs mean 3.1, SD 2.1; P<.001). Female gender and older age were associated with lower confidence, while participants who had already attended a BLS course prior to taking the questionnaire felt more confident. CONCLUSIONS: Although junior medical students were more knowledgeable than lay people regarding BLS procedures, the proportion of correct answers was low in both groups, and changes in BLS education policy should be considered.

Emergency physician's dispatch by a paramedic-staffed emergency medical communication centre: sensitivity, specificity and search for a reference standard.

BACKGROUND: Some emergency medical systems (EMS) use a dispatch centre where nurses or paramedics assess emergency calls and dispatch ambulances. Paramedics may also provide the first tier of care "in the field", with the second tier being an Emergency Physician (EP). In these systems, the appropriateness of the decision to dispatch an EP to the first line at the same time as the ambulance has not often been measured. The main objective of this study was to compare dispatching an EP as part of the first line emergency service with the severity of the patient's condition. The secondary objective was to highlight the need for a recognized reference standard to compare performance analyses across EMS. METHODS: This prospective observational study included all emergency calls received in Geneva's dispatch centre between January 1st, 2016 and June 30th, 2019. Emergency medical dispatchers (EMD) assigned a level of risk to patients at the time of the initial call. Only the highest level of risk led to the dispatch of an EP. The severity of the patient's condition observed in the field was measured using the National Advisory Committee for Aeronautics (NACA) scale. Two reference standards were proposed by dichotomizing the NACA scale. The first compared NACA≥4 with other conditions and the second compared NACA≥5 with other conditions. The level of risk identified during the initial call was then compared to the dichotomized NACA scales. RESULTS: 97'861 assessments were included. Overall prevalence of sending an EP as first line was 13.11, 95% CI [12.90-13.32], and second line was 2.94, 95% CI [2.84-3.05]. Including NACA≥4, prevalence was 21.41, 95% CI [21.15-21.67], sensitivity was 36.2, 95% CI [35.5-36.9] and specificity 93.2 95% CI [93-93.4]. The Area Under the Receiver-Operating Characteristics curve (AUROC) of 0.7507, 95% CI [0.74734-0.75397] was acceptable. Looking NACA≥5, prevalence was 3.09, 95% CI [2.98-3.20], sensitivity was 64.4, 95% CI [62.7-66.1] and specificity 88.5, 95% CI [88.3-88.7]. We found an excellent AUROC of 0.8229, 95% CI [0.81623-0.82950]. CONCLUSION: The assessment by Geneva's EMD has good specificity but low sensitivity for sending EPs. The dichotomy between immediate life-threatening and other emergencies could be a valid reference standard for future studies to measure the EP's dispatching performance.

Symptom-Based Dispatching in an Emergency Medical Communication Centre: Sensitivity, Specificity, and the Area under the ROC Curve.

BACKGROUND: Measuring the performance of emergency medical dispatch tools used in paramedic-staffed emergency medical communication centres (EMCCs) is rarely performed. The objectives of our study were, therefore, to measure the performance and accuracy of Geneva's dispatch system based on symptom assessment, in particular, the performance of ambulance dispatching with lights and sirens (L&S) and to measure the effect of adding specific protocols for each symptom. Methods: We performed a prospective observational study including all emergency calls received at Geneva's EMCC (Switzerland) from 1 January 2014 to 1 July 2019. The risk levels selected during the emergency calls were compared to a reference standard, based on the National Advisory Committee for Aeronautics (NACA) scale, dichotomized to severe patient condition (NACA ≥ 4) or stable patient condition (NACA < 4) in the field. The symptom-based dispatch performance was assessed using a receiver operating characteristic (ROC) curve. Contingency tables and a Fagan nomogram were used to measure the performance of the dispatch with or without L&S. Measurements were carried out by symptom, and a group of symptoms with specific protocols was compared to a group without specific protocols. Results: We found an acceptable area under the ROC curve of 0.7474, 95%CI (0.7448-0.7503) for the 148,979 assessments included in the study. Where the severity prevalence was 21%, 95%CI (20.8-21.2). The sensitivity of the L&S dispatch was 87.5%, 95%CI (87.1-87.8); and the specificity was 47.3%, 95%CI (47.0-47.6). When symptom-specific assessment protocols were used, the accuracy of the assessments was slightly improved. Conclusions: Performance measurement of Geneva's symptom-based dispatch system using standard diagnostic test performance measurement tools was possible. The performance was found to be comparable to other emergency medical dispatch systems using the same reference standard. However, the implementation of specific assessment protocols for each symptom may improve the accuracy of symptom-based dispatch systems.

A Short Intervention Followed by an Interactive E-Learning Module to Motivate Medical Students to Enlist as First Responders: Protocol for a Prospective Implementation Study.

BACKGROUND: In Geneva, Switzerland, basic life support (BLS) maneuvers are provided in only 40% of out-of-hospital cardiac arrests (OHCAs) cases. As OHCA outcomes are markedly improved when BLS maneuvers are swiftly applied, a "first-responder" system was introduced in 2019. When emergency dispatchers identify a possible OHCA, first responders receive an alert message on a specific app (Save-a-Life) installed on their smartphones. Those nearest to the victim and immediately available are sent the exact location of the intervention. First-year medical students only have limited knowledge regarding BLS procedures but might nevertheless need to take care of OHCA victims. Medical students responding to out-of-hospital emergencies are off-duty in half of these situations, and offering junior medical students the opportunity to enlist as first responders might therefore not only improve OHCA outcomes but also foster a greater recognition of the role medical students can hold in our society. OBJECTIVE: Our aim is to determine whether providing first-year medical students with a short intervention followed by an interactive e-learning module can motivate them to enlist as first responders. METHODS: After obtaining the approval of the regional ethics committee and of the vice-dean for undergraduate education of the University of Geneva Faculty of Medicine (UGFM), 2 senior medical students will present the project to their first-year colleagues at the beginning of a lecture. First-year students will then be provided with a link to an interactive e-learning module which has been designed according to the Swiss Resuscitation Council's first aid guidelines. After answering a first questionnaire and completing the module, students will be able to register for practice sessions. Those attending and successfully completing these sessions will receive a training certificate which will enable them to enlist as first responders. The primary outcome will be the proportion of first-year medical students enlisting as first responders at the end of the study period. Secondary outcomes will be the proportion of first-year medical students electing to register on the platform, to begin the e-learning module, to complete the e-learning module, to register for practice sessions, to attend the practice sessions, and to obtain a certificate. The reasons given by medical students for refusing to participate will be analyzed. We will also assess how comfortable junior medical students would feel to be integrated into the first responders system at the end of the training program and whether it affects the registration rate. RESULTS: The regional ethics committee (Req-2020-01143) and the UGFM vice-dean for undergraduate education have given their approval to the realization of this study, which is scheduled to begin in January 2021. CONCLUSIONS: This study should determine whether a short intervention followed by an interactive e-learning module can motivate first-year medical students to enlist as first responders. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/24664.

Evolution of Bystander Intention to Perform Resuscitation Since Last Training: Web-Based Survey.

BACKGROUND: Victims of out-of-hospital cardiac arrest (OHCA) have higher survival rates and more favorable neurological outcomes when basic life support (BLS) maneuvers are initiated quickly after collapse. Although more than half of OHCAs are witnessed, BLS is infrequently provided, thereby worsening the survival and neurological prognoses of OHCA victims. According to the theory of planned behavior, the probability of executing an action is strongly linked to the intention of performing it. This intention is determined by three distinct dimensions: attitude, subjective normative beliefs, and control beliefs. We hypothesized that there could be a decrease in one or more of these dimensions even shortly after the last BLS training session. OBJECTIVE: The aim of this study was to measure the variation of the three dimensions of the intention to perform resuscitation according to the time elapsed since the last first-aid course. METHODS: Between January and April 2019, the two largest companies delivering first-aid courses in the region of Geneva, Switzerland sent invitation emails on our behalf to people who had followed a first-aid course between January 2014 and December 2018. Participants were asked to answer a set of 17 psychometric questions based on a 4-point Likert scale ("I don't agree," "I partially agree," "I agree," and "I totally agree") designed to assess the three dimensions of the intention to perform resuscitation. The primary outcome was the difference in each of these dimensions between participants who had followed a first-aid course less than 6 months before taking the questionnaire and those who took the questionnaire more than 6 months and up to 5 years after following such a course. Secondary outcomes were the change in each dimension using cutoffs at 1 year and 2 years, and the change regarding each individual question using cutoffs at 6 months, 1 year, and 2 years. Univariate and multivariable linear regression were used for analyses. RESULTS: A total of 204 surveys (76%) were analyzed. After adjustment, control beliefs was the only dimension that was significantly lower in participants who took the questionnaire more than 6 months after their last BLS course (P<.001). Resisting diffusion of responsibility, a key element of subjective normative beliefs, was also less likely in this group (P=.001). By contrast, members of this group were less afraid of disease transmission (P=.03). However, fear of legal action was higher in this group (P=.02). CONCLUSIONS: Control beliefs already show a significant decrease 6 months after the last first-aid course. Short interventions should be designed to restore this dimension to its immediate postcourse state. This could enhance the provision of BLS maneuvers in cases of OHCA.

Evaluation of a Prehospital Rotation by Senior Residents: A Web-Based Survey.

The added value of prehospital emergency medicine is usually assessed by measuring patient-centered outcomes. Prehospital rotations might however also help senior residents acquire specific skills and knowledge. To assess the perceived added value of the prehospital rotation in comparison with other rotations, we analyzed web-based questionnaires sent between September 2011 and August 2020 to senior residents who had just completed a prehospital rotation. The primary outcome was the perceived benefit of the prehospital rotation in comparison with other rotations regarding technical and non-technical skills. Secondary outcomes included resident satisfaction regarding the prehospital rotation and regarding supervision. A pre-specified subgroup analysis was performed to search for differences according to the participants' service of origin (anesthesiology, emergency medicine, or internal medicine). The completion rate was of 71.5% (113/158), and 91 surveys were analyzed. Most senior residents found the prehospital rotation either more beneficial or much more beneficial than other rotations regarding the acquisition of technical and non-technical skills. Anesthesiology residents reported less benefits than other residents regarding pharmacological knowledge acquisition and confidence as to their ability to manage emergency situations. Simulation studies should now be carried out to confirm these findings.

Effect of noninvasive ventilation on intubation risk in prehospital patients with acute cardiogenic pulmonary edema: a retrospective study.

OBJECTIVE: The aim of this study was to assess the effect of prehospital noninvasive ventilation for acute cardiogenic pulmonary edema on endotracheal intubation rate and on ICU admission rate. METHODS: We carried out a retrospective study on patients' prehospital files between 2007 and 2010 (control period), and between 2013 and 2016 (intervention period). Adult patients were included if a diagnosis of acute cardiogenic pulmonary edema was made by the prehospital physician. Exclusion criteria were a Glasgow coma scale score less than 9 or any other respiratory diagnosis. We analyzed the association between noninvasive ventilation implementation and endotracheal intubation or ICU admission with univariable and multivariable regression models. The primary outcome was prehospital endotracheal intubation rate. Secondary outcomes were admission to an ICU, prehospital intervention length, and 30-day mortality. RESULTS: A total of 1491 patients were included. Noninvasive ventilation availability was associated with a significant decrease in endotracheal intubation rate (2.6% in the control versus 0.7% in the intervention period), with an adjusted odds ratio (OR) of 0.3 [95% confidence interval (CI), 0.1-0.7]. There was a decrease in ICU admissions (18.6% in the control versus 13.0% in the intervention period) with an adjusted OR of 0.6 (95% CI, 0.5-0.9). There was no significant change in 30-day mortality (11.2% in the control versus 11.0% in the intervention period, P = 0.901). CONCLUSION: In our physician-staffed prehospital system, use of noninvasive ventilation for acute cardiogenic pulmonary edema decreased both endotracheal intubation and ICU admission rates.

Improvement of out-of-hospital cardiac arrest survival rate after implementation of the 2010 resuscitation guidelines.

OBJECTIVE: The implementation of cardiopulmonary resuscitation guidelines, updated every five years, appears to improve patient survival rates after Out-Of-Hospital Cardiac Arrest (OHCA). The aim of this study is: 1) to measure the level of improvement in the prognosis of OHCA patient survival rates for the years 2009 and 2010 and the following two years 2011 and 2012; and 2) correlate the improvement in prognosis with the updated 2010 Advanced Cardiovascular Life Support (ACLS) Guidelines. METHOD: We performed a retrospective observational study based on Geneva's OHCA register that includes data from January 1, 2009 to December 31, 2012. We compared the evolution of prognostic factors that influenced survival at hospital discharge between the periods before and after the implementation of the 2010 guidelines. We then compared the survival rates between each period. Finally, we adjusted the effects on survival in the second period to prognostic factors not linked with the care provided by Emergency Medical Services (EMS) teams, using a multivariable logistic regression model. Changes in advanced resuscitation treatment provided by EMS personnel were also examined. RESULTS: 795 OHCA were resuscitated between 1st January, 2009 and 31st December, 2012. The prognosis of patient survival at the time of hospital discharge rose from 10.33% in 2009-2010 to 17.01% in 2011-2012 (p = 0.007). After making adjustments for the effect of improved survival rates on the second period with factors not related to care provided by EMS teams, the odds ratio (OR) remains comparable (OR = 1.87, 95% CI [1.08-3.22]). Measured changes in treatment provided by EMS personnel were minor. CONCLUSIONS: Survival rate for OHCA patients improved significantly in 2011-2012. This study suggests that it was probably the improvement in the quality of care provided during CPR and post-cardiac arrest care that have contributed to the increase in survival rates at the time of hospital discharge.

Multi-organ injuries due to a lightning strike: a case report highlighting the importance of a multi-disciplinary approach.

The interdisciplinary management of patients with multiple organ injuries after lightning strike is of paramount importance. Cutaneous burns can be associated to other organ injuries requiring emergency and life-support treatment. We report the case of a lightning strike victim who presented with burns as well as cardiologic and neurologic complications.

[Normobaric oxygen therapy in acute medical care: myths versus reality]. / Oxygénothérapie normobare en médecine aiguë: entre mythes et réalité.

Oxygen adiministration for both medical and traumatic emergencies is regarded as an essential component of resuscitation. However, many recent studies suggest that the use of oxygen should be more restrictive. Detrimental effects of normobaric oxygen therapy in patients suffering from hypercapnic respiratory diseases have been demonstrated, especially because of the suppression of the hypoxic drive. Apart from this particular situation, correction of hypoxemia is still a widely accepted treatment target, although there is growing evidence that hyperoxemia could be harmful in acute coronary syndromes and cardio-respiratory arrests. In other pathologies, such as stroke or hemorragic shock, the situation is still unclear, and further studies are needed to clarify the situation. Generally speaking, oxygen therapy should from now on be goal-directed, and early monitoring of both pulse oximetry and arterial blood gases is advised.

Traumatic injuries after mechanical cardiopulmonary resuscitation (LUCAS2): a forensic autopsy study.

AIM: The aim of our study was to compare traumatic injuries observed after cardiopulmonary resuscitation (CPR) by means of standard (manual) or assisted (mechanical) chest compression by Lund University Cardiopulmonary Assist System, 2nd generation (LUCAS2) device. METHODS: A retrospective study was conducted including cases from 2011 to 2013, analysing consecutive autopsy reports in two groups of patients who underwent medicolegal autopsy after unsuccessful CPR. We focused on traumatic injuries from dermal to internal trauma, collecting data according to a standardised protocol. RESULTS: The study group was comprised of 26 cases, while 32 cases were included in the control group. Cardiopulmonary resuscitation performed by LUCAS2 was longer than manual CPR performed in control cases (study group: mean duration 51.5 min; controls 29.4 min; p = 0.004). Anterior chest lesions (from bruises to abrasions) were described in 18/26 patients in the LUCAS2 group and in 6/32 of the control group. A mean of 6.6 rib fractures per case was observed in the LUCAS2 group, but this was only 3.1 in the control group (p = 0.007). Rib fractures were less frequently observed in younger patients. The frequency of sternal factures was similar in both groups. A few trauma injuries to internal organs (mainly cardiac, pulmonary and hepatic bruises), and some petechiae (study 46%; control 41 %; p = 0.79) were recorded in both groups. CONCLUSION: LUCAS™2-CPR is associated with more rib fractures than standard CPR. Typical round concentric skin lesions were observed in cases of mechanical reanimation. No life-threatening injuries were reported. Petechiae were common findings.

[Hemorrhagic shock]. / Choc hémorragique.

Shock is a life threatening condition. The management of an hemorrhagic shock, whether traumatic or not, requires early identification of the bleeding source and adequate hemodynamic support. The diagnosis accuracy is based on clinical, hemodynamic, radiologic and biochemical findings which also allow appraisal of the treatment efficiency. Treatment should be goal-oriented with rapid hemorrhage control by surgery, interventional radiology or drug support. Circulatory resuscitation is aimed to restore adequate tissue perfusion and oxygenation and should be closely monitored.

Prehospital emergency physician activation of interventional cardiology team reduces door-to-balloon time in ST-elevation myocardial infarction.

QUESTION UNDER STUDY: To explore whether early activation of an interventional cardiology team, by prehospital emergency physicians, reduces door-to-balloon time (DTBT) in patients with ST-elevation myocardial infarction (STEMI) diagnosed with prehospital ECG. DESIGN: before-after comparison. SETTING: emergency department (ED) of an urban teaching hospital with a catheterisation laboratory open continuously. STUDY SUBJECTS: patients with STEMI diagnosed in the prehospital setting or in the ED within 12 hours of symptoms. INTERVENTION: a paging system or "STEMI alarm", activated by prehospital physicians, which simultaneously notified both the catherisation laboratory and cardiology teams before the patient's arrival to the ED. OUTCOME MEASURES: DTBT and the proportion of patients with DTBT <90 minutes. RESULTS: A total of 196 patients were included; 77 before and 119 after implementation of the "STEMI alarm". Between the two periods, median DTBT decreased from 109 to 76 minutes (p <0.001) and the proportion of patients treated within 90 minutes increased from 36% to 66% (p <0.001). During intervention, the STEMI alarm was activated in 67 patients (56%). In these cases the median DTBT was 50 minutes, with 96% within 90 minutes. The alarm was inappropriately activated in 9 cases (11%). CONCLUSIONS: Catheterisation laboratory activation by a prehospital emergency physician markedly reduces DTBT in STEMI patients.

[Somatic and psychiatric emergencies: building a mutual view]. / Urgences médicales somatiques et psychiatriques: pour une vision commune.

The prevalence of behavioural disorders is high among patients admitted to urban Accident and Emergency Departments. These disorders are not necessarily related to the reason for consultation and emergency physicians (EP) should be able to detect these patients and refer them to a psychiatrist when required. On the other hand, the frequent comorbid somatic disorders among patients attending an emergency psychiatric unit should raise concern from psychiatrists and prompt the need for EP advice. Due to the complex relationship between somatic and psychiatric disorders, a close collaboration between psychiatrists and EPs is crucial for efficient and patient care, as well as developing teaching and research.

Factors influencing emergency delays in acute stroke management.

OBJECTIVE: Early admission to hospital with minimum delay is a prerequisite for successful management of acute stroke. We sought to determine our local pre- and in-hospital factors influencing this delay. PATIENTS AND METHODS: Time from onset of symptoms to admission (admission time) was prospectively documented during a 6-month period (December 2004 to May 2005) in patients consecutively admitted for an acute focal neurological deficit presented at arrival and of presumed vascular origin. Mode of transportation, patient's knowledge and correct recognition of stroke symptoms were assessed. Physicians contacted by the patients or their relatives were interviewed. The influence of referral patterns on in-hospital delays was further evaluated. RESULTS: Overall, 331 patients were included, 249 had an ischaemic and 37 a haemorrhagic stroke. Forty-five patients had a TIA with neurological symptoms subsiding within the first hours after admission. Median admission time was 3 hours 20 minutes. Transportation by ambulance significantly shortened admission delays in comparison with the patient's own means (HR 2.4, 95% CI 1.6-3.7). The only other factor associated with reduced delays was awareness of stroke (HR 1.9, 95% CI 1.3-2.9). Early in-hospital delays, specifically time to request CT-scan and time to call the neurologist, were shorter when the patient was referred by his family or to a lesser extent by an emergency physician than by the family physician (p < 0.04 and p < 0.01, respectively) and were shorter when he was transported by ambulance than by his own means (p < 0.01). CONCLUSIONS: Transportation by ambulance and referral by the patient or family significantly improved admission delays and early in-hospital management. Correct recognition of stroke symptoms further contributed to significant shortening of admission time. Educational programmes should take these findings into account.

[Public access defibrillation]. / Ombres et lumières de l'accès public a la défibrillation.

Placement of automated external defibrillators (AED) in public facilities and training of the lay persons in basic life support-defibrillation (BLS-D) was recommended by the American Heart Association for the treatment of out-of-hospital cardiac arrest (OHCA). Immediate use of AED result in increase of survival to hospital discharge. Many observation and much less randomized trials describe clinical efficacy of this approach. However, "negative" trials have also been published and some recent data suggest that public access defibrillation (PAD) will have a minimal impact on population survival. In this article various PAD strategies were briefly reviewed. In our opinion installation of AED in public places should be based on the long-term study of local OHCA demography and preceded by widespread BLS training of lay population.

[Panic disorders: differential diagnosis and care in emergencies]. / Troubles paniques: du diagnostic différentiel vers une prise en charge urgente.

Despite the high prevalence of panic disorders in patients in primary-care settings, this condition is frequently under-recognised and under-treated. After the description of DSM-IV diagnosis criteria of panic disorders, this paper underline the importance of an adequate somatic and psychiatric differential diagnosis. Even if cognitive-behavioural therapy is the best studied psychotherapeutical approach, several efficacious psychodynamic psychotherapies were also described. High-potency benzodiazepines provide a rapid efficacy with beneficial effects during the first days of treatment. However, benzodiazepines should be avoided in the long term, because of the development of tolerance and dependence. Antidepressants (SSRI, venlafaxine) are effective in preventing panic attacks, especially in improving anticipatory anxiety and avoidance behaviour.