First Description of a Helicopter-Borne ECPR Team for Remote Refractory Out-of-Hospital Cardiac Arrest.

Introduction: Access time to extracorporeal cardiopulmonary resuscitation (ECPR) refractory out of hospital cardiac arrest (OHCA) is a crucial factor. In our region, some patients are not eligible to this treatment due to the impossibility to reach the hospital with reasonable delay (ideally 60 min). In order to increase accessibility for patients far from ECPR centers, we developed a helicopter-borne ECPR-team which is sent out to the patient for ECPR implementation on the scene of the OHCA.Methods: We conducted a retrospective monocentric study to evaluate this strategy. The team is triggered by the local emergency medical service and heliborne on the site of the OHCA. All consecutive patients implemented with ECPR by our heliborne ECPR team from January 2014 to December 2017 were included. We analyzed usual CA characteristics, different times (no-flow, low-flow, time between OHCA and dispatch…), and patient outcome.Results: During this 4-year study period, 33 patients were included. Mean age was 43.9 years. Mean distance from the ECPR-team base to OHCA location was 41 km. Mean low-flow time was 110 minutes. Five patients survived with good neurological outcome; 6 patients developed brain death and became organ donors.Conclusion: These results show the possibility to make ECPR accessible for patients far from ECPR centers. Survival rate is non negligible, especially in the absence of therapeutic alternative. An earlier trigger of the ECPR-team could reduce the low-flow time and probably increase survival. This strategy improves equity of access to ECPR and needs to be confirmed by further studies.

[Out-of-hospital management of elderly patients for trauma injury]. / Prise en charge préhospitalière de la traumatologie de la personne âgée : quelles spécificités ?

Elderly patients should benefit from maximum care in cases of serious trauma, starting with pre-hospital care. A proper evaluation of the gravity of the trauma is an essential element in the management. The elderly are at risk of "under-triage", which can result in inappropriate hospital admission and delayed trauma care. Particular attention must be paid to "common" trauma, because such trauma is often associated with a potentially serious outcome in elderly patients. The Vittel criteria offer an important tool to estimate the level of gravity and to help in patient triage. The kinetic of the accident is important in identifying serious trauma. Emergency medical services with physicians on board must be the norm in cases of severe trauma, irrespective of the age of the patient. The literature clearly indicates the benefit of an aggressive strategy in elderly trauma patients, thus justifying direct admission in a trauma center in cases of real or potentially serious trauma. There is no difference in pre-hospital care management between elderly and younger trauma patients. Analgesia must be a priority. When a self-assessment of pain intensity is impossible, specific scales for pain can be used, such as Algoplus(®). Morphine titration is the recommended strategy for analgesia in the pre-hospital setting and the same protocol must be used for both the elderly and younger patients. Locoregional anaesthesia should be used when possible in this setting, in particular the ilio-facial block. Age is not a criterion for a non-resuscitation order in trauma patients. The decisions of limitation of therapeutic, if they were not anticipated, will be discussed after admission, according to the principles of the current legislation.

[Observatory of the elderly over 80 years supported by the mobile emergency and resuscitation service]. / Observatoire du sujet âgé de plus de 80 ans pris en charge en urgence par le service mobile d'urgence et de réanimation.

Emergency medical services (EMS) received an increasing number of calls for patients aged 80 and older. The goal of the present study was to evaluate outcome and functional dependence of patients aged 80 and older who EMS managed in the prehospital theater. This prospective study was conducted over 1 year (September 2007-August 2008), all consecutive patients aged 80 and older managed by a medical team during the study period were included. Characteristics of patients, including previous health status and functional dependence, were recorded on-the scene by the attending physician. Three-month mortality was recorded, as well as ADL score. Data are expressed as mean values±standard deviations, medians and interquartile ranges (IQRs), and percentages and compared using univariate and multivariate analysis. P<0.05 was considered the threshold for significance. Five hundred twenty-three patients were included. Mean age was 86 ± 5. Median ADL index was 2 (IQR 0-9), and 63% of patients were living at home. At 3 months, the survival rate was 66% (n=273) and the proportion of patients living at home was 64% (P=0.9), the median ADL index of survivors was 2 (IQR 0-8) vs 1 (IQR 0-6) initially for this subpopulation, P=0.01. Our study confirms utility and efficacy of full access of elderly persons to advanced life support especially for self-patients and not restricted based on aging per se. The development and daily use of tools for rapid assessment of autonomy should enable practitioners to innovate and thus, adapt their management.

[Results of a national survey about the use of sedation scales in emergency prehospital medicine]. / Résultats d'une enquête nationale évaluant l'utilisation des scores de sédation en médecine préhospitalière.

The primary goal of sedation in emergency prehospital care is to guarantee the security of the mechanically ventilated patients by optimising their adaptation to the respirator. If the French prehospital guidelines are well codified, their applicability in routine clinical practice seem to be rather empirical. The aim of this national survey was to evaluate the use of the clinical sedation scales by the prehospital physicians. This prospective and clinical practice survey was begun in January 2005. An anonymous questionnaire was sent to the physicians working in the 377 Mobile Intensive Care Unit of the 105 French Emergency Medical Service System. The total response rate from physicians was 28% (n=497). Only 29% of the physicians (n=145) declared to use a sedation scale for a mechanically ventilated patient. The Ramsay score was used in 97% of the cases (n=141).The principal reasons given by the physicians for not using the sedation scales were their ignorance in 57% of the cases (n=200) and the systematic choice of a deep sedation in 42% of the cases (n=147). For 18% of them (n=62), the use of sedation scores was considered too complicated. The final results show that the utilisation ratio of the sedation scores is very low in emergency prehospital medicine and suggest that an effort toward improving the use of sedation in prehospital emergency medicine is necessary.

[Prehospital management by EMS of a potential non-heart-beating donor]. / Prise en charge par le Smur d'un patient en arrêt cardiaque en vue d'un prélèvement d'organe à coeur arrêté

After their prehospital management by EMS system and on-scene declaration of death, some patients are potential non-heart-beating donors. We report the case of refractory cardiac arrest, transferred to the hospital assisted by chest compression device. Time factor might be an important brake on prehospital recruitment. Future networks should attempt to shorten the time intervals.

A quality control programme for acute myocardial infarction management in out-of-hospital critical care medicine.

This study, conducted over two time periods, aimed to evaluate the effectiveness of the diffusion of data, implementation of correctives measures and updated protocols in reducing time to reperfusion in acute myocardial infarction (AMI) management in the out-of-hospital setting. Mean (SD) time to hospital admission and to arterial puncture improved (58 (13) vs 67 (18) min, p = 0.03; and 82 (16) vs 95 (29) min, p = 0.02). The study, performed according to quality control programme methodology, showed that the chronology of AMI management could be improved by appropriate interventions and monitoring of intervention times.

[The tako-tsubo syndrome: therapeutic stakes]. / Le syndrome de tako-tsubo: enjeu thérapeutique.

The authors report the case of 2-old-caucasian women in the pre- and interhospital setting, who presented chest pain with ST segment elevation. Coronary angiography did not show any significant coronary lesion, ventriculography revealed typical aspect of tako-tsubo. It resolved in a short time, with normalisation of the left ventricule function. The tako-tsubo syndrome, or transient left ventricular apical ballooning syndrome, first described by Japanese physicians, is more and more frequently observed in caucasian patients. This cardiomyopathy associates an apical transient dysfunction without any significant coronary lesion. This syndrome is usually observed in elderly women, occurs frequently after acute emotional or physical stress. The clinical presentation looks like an acute coronary syndrome, with chest pain, electrocardiographic changes and moderate cardiac enzymes release. Coronary angiography shows no significant coronary disease and ventriculography a systolic dysfunction with akinesia of middle and apical segments, leading apical ballooning, and basale hyperkinesia. These abnormalities are transient, with quick favorable outcome. The aetiopathegenia is still uncertain. The differential diagnosis with an acute coronary syndrome with thrombosis is not yet possible. Clinical or biological criteria allowing early diagnosis would lead to optimize the therapeutic management.

[Faisability of foetal monitoring in prehospital care]. / Faisabilité du monitorage du rythme cardiaque foetal par cardiotocographe en Smur.

The use of mobile monitoring system for foetal cardiotachometry has never been evaluated in the prehospital care. The aim of the survey was to evaluate the faisability of this device. Twenty-five patients were enrolled, mostly within the context of interhospital transfer because of threatening premature delivery (n = 20). Foetal monitoring was effective for 64 % of the patients during initial physical examination and for 52 % during transport by ambulance. Prehospital treatment was improved in one case of eclampsia after on-scene fetal monitoring. Cardiotocography can be easily performed in the prehospital setting.

[Haemorrhagic shock after severe blunt shoulder trauma]. / Choc hémorragique après traumatisme fermé de l'épaule.

The management of severe injured patients requires life-threatening lesions research, especially potential haemorrhagic lesions. The haemorrhagic shock is a rare but serious complication of shoulder girdle traumas. We report in this study the clinical and paraclinical signs that lead us to take care from such evolution.

[Survey on the use of mannitol in prehospital care in Paris area]. / Enquête sur l'utilisation du mannitol en réanimation préhospitalière en Ile-de-France.

OBJECTIVE: To evaluate the use of mannitol in prehospital care in Paris area. STUDY DESIGN: Survey using telephone interviews. METHODS: Emergency physicians on duty in the 37 emergency departments in charge of prehospital care in Paris area were called by one investigator. They were asked to answer a questionnaire about their own use of mannitol in the prehospital setting. RESULTS: Ninety-six questionnaires were recorded. Physicians were anaesthesiologists (9%) or emergency physicians (87%). In three departments, mannitol was not available in the ambulances. Thirty-five per cent (n = 34) reported no use of mannitol and 17% (n = 16) just once. Fourteen physicians (15%) did not want to use it. The reasons for not using mannitol were lack of knowledge about efficacy for five, need for previous brain imaging for seven or neurosurgeon's agreement before using mannitol for three. For those who had already used mannitol or were ready to use it, the main indication was increased intracranial pressure with clinical signs of brain herniation after severe brain injury for 92% of physicians. Thirty-one % reported not knowing the dose of mannitol, 33% having a memorandum immediately available and among those who answered the question, 63% gave a value compatible with guidelines. CONCLUSION: A significant percentage of physicians tacking part in the French prehospital care system, do not follow published guidelines on the use of mannitol. Actions improving implementation of those guidelines should be supported.

[Changes in reperfusion strategies in the acute phase of myocardial infarction from 1988 to 2001]. / Evolution des stratégies de reperfusion en phase aiguë d'infarctus du myocarde entre 1988 et 2001.

The objective of this study was to evaluate the evolution of therapeutic strategies in the course of myocardial infarction. Two successive periods were studied: 1988/96 (700 patients) and 1996/2001 (700 patients). The following parameters were compared: patient characteristics, management methods, and results on the hospital morbidity and mortality. The patient characteristics were little changed, in terms of age and sex, with a drop in the frequency of anterior infarcts during the second period (46 vs 51%, p = 0.0001). The average delay to admission remained stable over both periods, 186 vs 189 min. During the second period, primary angioplasty was favoured (66 versus 44%, p = 0.0001), associated with a wider use of stents (47 against 4%, p = 0.0001) and anti GP IIb/IIIa (24 against 0.5%, p = 0.0001). In the acute phase, TIMI3 reperfusion was obtained in 81% of cases (88/96 period) against 88% during the second period (p = 0.02). The hospital mortality was reduced by 1.2% (8.9 against 7.7%, NS). Without cardiogenic shock, the mortality was comparable between the two groups (5%), whereas it diminished in the small group of patients (5%) in cardiogenic shock, from 76 to 66% (NS). Haemorrhagic complications were reduced, but the rate of symptomatic reocclusion remained stable (2.5%). With multivariate analysis, the independent predictive mortality factors were identical in the two groups: age and cardiogenic shock on admission. Currently, TIMI3 reperfusion is possible in close to 90% of patients in the acute phase of infarction. Our efforts should focus on earlier management, especially for older patients, too often excluded without reason, and for those in cardiogenic shock, which constitutes a therapeutic quest for the future. The theory of angioplasty facilitated by anti GP IIb/IIIa and/or prehospital thrombolysis must be evaluated scientifically with the goal of early and efficient reperfusion for the greatest number of patients.

[Out-of hospital management of elderly patients]. / Prise en charge préhospitalière médicalisée des personnes âgées.

OBJECTIVE: To evaluate prehospital management of elderly patients, agreement between prehospital and hospital diagnosis and to observe clinical course during hospitalization. TYPE OF STUDY: Retrospective study. PATIENTS AND METHOD: Out-of hospital patients of 65-year-old or more were included. Apart from demographic data, were collected: reasons for call, medicalization length, SAPS score, prehospital management, destination, prehospital and hospital diagnosis and patients evolution. Three groups were defined: G1 (65-74), G2 (75-84), G3 (> 84 year old). Statistical analysis was done by an Anova for quantitative data and by a Chi squared test for qualitative data. RESULTS: Two hundred and seventy-one patients were included (mean age 80 +/- 8 years, 43% of men). Eighty-two per cent of interventions were followed by a medicalized transport. Twelve per cent of patients died in the field. Forty-four per cent were hospitalised in intensive care unit, but patients of more than 84 year-old were significantly less often admitted in intensive care unit. There was no difference between the three groups in term of degree medicalization during transport. Eight per cent of patients required tracheal intubation in the field. Prehospital diagnoses were in agreement with reason for call in 61% of patients and with in-hospital diagnosis in 85% of patients. Fifty three per cent of patients came back home after hospitalisation. CONCLUSION: Analysis of elderly patient evolution after hospitalisation confirms the idea that the age should not influence the decision and the degree of prehospital medicalization.