Effect of the 1-h bundle on mortality in patients with suspected sepsis in the emergency department: a stepped wedge cluster randomized clinical trial.

PURPOSE: The efficacy of the 1-h bundle for emergency department (ED) patients with suspected sepsis, which includes lactate measurement, blood culture, broad-spectrum antibiotics administration, administration of 30 mL/kg crystalloid fluid for hypotension or lactate ≥ 4 mmol/L, remains controversial. METHODS: We carried out a pragmatic stepped-wedge cluster-randomized trial in 23 EDs in France and Spain. Adult patients with Sepsis-3 criteria or a quick sequential organ failure assessment (SOFA) score ≥ 2 or a lactate > 2 mmol/L were eligible. The intervention was the implementation of the 1-h sepsis bundle. The primary outcome was in-hospital mortality truncated at 28 days. Secondary outcomes included volume of fluid resuscitation at 24 h, acute heart failure at 24 h, SOFA score at 72 h, intensive care unit (ICU) length of stay, number of days on mechanical ventilation or renal replacement therapy, vasopressor free days, unnecessary antibiotic administration, and mortality at 28 days. 1148 patients were planned to be analysed; the study period ended after 873 patients were included. RESULTS: 872 patients (mean age 66, 42% female) were analyzed: 387 (44.4%) in the intervention group and 485 (55.6%) in the control group. Median SOFA score was 3 [1-5]. Median time to antibiotic administration was 40 min in the intervention group vs 113 min in the control group (difference - 73 [95% confidence interval (CI) - 93 to - 53]). There was a significantly higher rate, volume, and shorter time to fluid resuscitation within 3 h in the intervention group. There were 47 (12.1%) in-hospital deaths in the intervention group compared to 61 (12.6%) in the control group (difference in percentage - 0.4 [95% CI - 5.1 to 4.2], adjusted relative risk (aRR) 0.81 [95% CI 0.48 to 1.39]). There were no differences between groups for other secondary endpoints. CONCLUSIONS: Among patients with suspected sepsis in the ED, the implementation of the 1-h sepsis bundle was not associated with significant difference in in-hospital mortality. However, this study may be underpowered to report a statistically significant difference between groups.

Injuries caused by defensive bullet launchers and resource utilization during the French yellow vests protests: A retrospective study.

BACKGROUND: In 2018, the French "Yellow Vest" social protest movement spread with weekly demonstrations resulting in confrontations between protesters and law enforcement. Non-lethal weapons, such as defensive bullet launchers (DBL) were used, and significant injuries have been reported through media, leading to public controversy regarding their use. These injuries are not well-known to civilian emergency physicians. The aim of this study is to describe the injuries caused by DBL among Emergency Department (ED) patients during these demonstrations and to identify the characteristics that required specialized care and hospital admission. METHODS: A multicenter retrospective study was conducted in 7 EDs of academic hospitals in Paris, France. Adult ED patients who presented with DBL injuries during "yellow vest" strikes between November 2018 and May 2019 were included. The primary outcome was the rate of DBL patients requiring hospital admission. We also compared the characteristics of the injuries and the care provided between the admitted patients and other DBL patients. RESULTS: 152 patients were included. 17% were admitted to hospital, with 19% of them being transferred to intensive care units. 49% of all patients had head, face, eye or neck injuries including 4 cases of intracranial hemorrhage, 1 carotide dissection, 1 laryngeal edema, 1 pneumencephalus. 11% of all patients presented with multiple wounds, and 28% had fractures (77% of admitted patients vs 18%, p < 0.001). Surgery was required for 20% of all patients (62% of admitted patients vs 10%, p < 0.001). Maxillofacial surgery was performed on 38% of admitted patients, orthopedic surgery on 25%, and neurosurgery on 13%. No death were reported. CONCLUSION: The use of DBL during the "yellow vest" civil strikes was associated with a high rate of head, face, eye or neck injuries among injured ED patients. Hospital admission was associated with a higher rate of fractures, with most of them requiring maxillofacial, orthopedic and neurosurgeries.

Accuracy of Emergency Department Clinical Findings for Diagnosis of Coronavirus Disease 2019.

STUDY OBJECTIVE: We seek to describe the medical history and clinical findings of patients attending the emergency department (ED) with suspected coronavirus disease 2019 (COVID-19) and estimate the diagnostic accuracy of patients' characteristics for predicting COVID-19. METHODS: We prospectively enrolled all patients tested for severe acute respiratory syndrome coronavirus 2 by reverse-transcriptase polymerase chain reaction in our ED from March 9, 2020, to April 4, 2020. We abstracted medical history, physical examination findings, and the clinical probability of COVID-19 (low, moderate, and high) rated by emergency physicians, depending on their clinical judgment. We assessed diagnostic accuracy of these characteristics for COVID-19 by calculating positive and negative likelihood ratios. RESULTS: We included 391 patients, of whom 225 had positive test results for severe acute respiratory syndrome coronavirus 2. Reverse-transcriptase polymerase chain reaction result was more likely to be negative when the emergency physician thought that clinical probability was low, and more likely to be positive when he or she thought that it was high. Patient-reported anosmia and the presence of bilateral B lines on lung ultrasonography had the highest positive likelihood ratio for the diagnosis of COVID-19 (7.58, 95% confidence interval [CI] 2.36 to 24.36; and 7.09, 95% CI 2.77 to 18.12, respectively). The absence of a high clinical probability determined by the emergency physician and the absence of bilateral B lines on lung ultrasonography had the lowest negative likelihood ratio for the diagnosis of COVID-19 (0.33, 95% CI 0.25 to 0.43; and 0.26, 95% CI 0.15 to 0.45, respectively). CONCLUSION: Anosmia, emergency physician estimate of high clinical probability, and bilateral B lines on lung ultrasonography increased the likelihood of identifying COVID-19 in patients presenting to the ED.

Blood product needs and transfusion timelines for the multisite massive Paris 2015 terrorist attack: A retrospective analysis.

OBJECTIVE: Hemorrhage is the leading cause of death after terrorist attack, and the immediacy of labile blood product (LBP) administration has a decisive impact on patients' outcome. The main objective of this study was to evaluate the transfusion patterns of the Paris terrorist attack victims, November 13, 2015. METHODS: We performed a retrospective analysis including all casualties admitted to hospital, aiming to describe the transfusion patterns from admission to the first week after the attack. RESULTS: Sixty-eight of 337 admitted patients were transfused. More than three quarters of blood products were consumed in the initial phase (until November 14, 11:59 PM), where 282 packed red blood cell (pRBC) units were transfused along with 201 plasma and 25 platelet units, to 55 patients (16% of casualties). Almost 40% of these LBPs (134 pRBC, 73 plasma, 8 platelet units) were transfused within the first 6 hours after the attack. These early transfusions were massive transfusion (MT) for 20 (6%) of 337 patients, and the average plasma/red blood cell ratio was 0.8 for MT patients who received 366 (72%) of 508 LBPs.The median time from admission to pRBC transfusion was 57 (25-108) minutes and 208 (52-430) minutes for MT and non-MT patients, respectively. These same time intervals were 119 (66-202) minutes and 222 (87-381) minutes for plasma and 225 (131-289) minutes and 198 (167-230) minutes for platelets. CONCLUSION: Our data suggest that improving transfusion procedures in mass casualty setting should rely more on shortening the time to bring LBP to the bedside than in increasing the stockpile. LEVEL OF EVIDENCE: Epidemiological study, Therapeutic IV.

Analysis of the medical response to November 2015 Paris terrorist attacks: resource utilization according to the cause of injury.

PURPOSE: The majority of terrorist acts are carried out by explosion or shooting. The objective of this study was first, to describe the management implemented to treat a large number of casualties and their flow together with the injuries observed, and second, to compare these resources according to the mechanism of trauma. METHODS: This retrospective cohort study collected medical data from all casualties of the attacks on November 13th 2015 in Paris, France, with physical injuries, who arrived alive at any hospital within the first 24 h after the events. Casualties were divided into two groups: explosion injuries and gunshot wounds. RESULTS: 337 casualties were admitted to hospital, 286 (85%) from gunshot wounds and 51 (15%) from explosions. Gunshot casualties had more severe injuries and required more in-hospital resources than explosion casualties. Emergency surgery was required in 181 (54%) casualties and was more frequent for gunshot wounds than explosion injuries (57% vs. 35%, p < 0·01). The types of main surgery needed and their delay following hospital admission were as follows: orthopedic [n = 107 (57%); median 744 min]; general [n = 27 (15%); 90 min]; vascular [n = 19 (10%); median 53 min]; thoracic [n = 19 (10%); 646 min]; and neurosurgery [n = 4 (2%); 198 min]. CONCLUSION: The resources required to deal with a terrorist attack vary according to the mechanism of trauma. Our study provides a template to estimate the proportion of various types of surgical resources needed overall, as well as their time frame in a terrorist multisite and multitype attack. FUNDING: Assistance Publique-Hôpitaux de Paris.