[Implementation of a massive transfusion protocol in an emergency department]. / Mise en place d'un protocole de transfusion massive dans un service d'urgences.

We present here the massive transfusion protocol implemented in our institution in 2013. It will improve our management of critical massive bleeding, a situation which is rare in in our hospital, but carries a high mortality risk.

Intracranial subdural hematoma following spinal anesthesia: case report and review of the literature.

Postdural puncture headaches represent one of the main complications of spinal anesthesia. Sometimes, they can reveal the presence of an intracerebral hemorrhage or intracranial subdural hematoma. Atypical postdural puncture headaches or secondary alterations of a typical headache, and particularly the disappearance of its postural character, must prompt to search for another cause. Early diagnosis and careful and rapid management are mandatory. We here report the case of a 53-year-old woman who presented with an intracranial subdural hematoma following spinal anesthesia for hallux valgus surgery performed 48 hours earlier. The implications of such a diagnosis are then discussed, in the light of the existing literature.

Effectiveness of intubating laryngeal mask airway (ILMA Fastrach) used by nurses during out of hospital cardiac arrest resuscitation.

OBJECTIVE: ILMA Fastrach is a recognized alternative to classic laryngoscopic intubation. In this study, we evaluated the success rate of intubation with Fastrach, used by emergency nurses who have no experience of field intubation. METHODS: Twelve untrained nurses used Fastrach during 71 out of hospital cardiac arrests (OHCAs). Each step time of resuscitation was recorded. RESULTS: Fastrach effective ventilation was obtained in 97%. Rate of successful intubation was 86%. CONCLUSIONS: ILMA Fastrach is a good alternative to classical laryngoscopic intubation by untrained nurses, even in difficult conditions such as OHCAs.

A protocol of trauma care in the emergency service including MDCT imaging.

Trauma is the principal cause of young peo ple's death. Care should be appropriate to the severity of the injuries and involves a multidisciplinary team around the clock. In this article, we examine a protocol of care based on ATLS (Advanced Trauma Life Support) recom mendations, including advances in imaging technology, which have greatly increased quality care in our institu tion. The protocol is based on patient stability and on injury mechanisms. The challenge is to avoid wasting time in the definitive treatment of lesions. Multi-detector computed tomogra phy (MDCT) has brought complete and rapid imaging in stable traumas but it shouldn't delay immediate surgical operations. When patients are unstable despite reanima tion, three important x-rays are taken right on the stretch er (pelvis, neck, and chest) before going into surgery. The head of the trauma team makes a decision on the pertinence of such procedure.

Tramadol, an alternative to morphine for treating posttraumatic pain in the prehospital situation.

In this randomized, double-blinded, parallel-group study, we compared the efficacy of tramadol and morphine administered IV for the management of pain in trauma patients in the prehospital situation. One-hundred-five patients were randomly allocated to receive tramadol (Group T) or morphine (Group M). The initial dose was 100 mg tramadol in Group T and 5 mg morphine (body weight < or = 70 kg) or 10 mg morphine (body weight >70 kg) in Group M; this could be increased to 200 mg in Group T and 15 or 20 mg in Group M if necessary. Pain intensity was assessed with four-point verbal rating scales. Sedation, physiologic data, and adverse events were also recorded. Analgesia was similar in both groups; the 95% confidence interval for the difference between the decrease in pain intensity observed with tramadol or morphine was -0.26 to 0.30, which was within the predefined equivalence range (-0.50 to 0.50). Neither sedation scores nor physiologic data differed between groups. Tramadol is an acceptable alternative to morphine in the prehospital trauma setting.

A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group.

BACKGROUND: Clinical trials have not shown a benefit of high doses of epinephrine in the management of cardiac arrest. We conducted a prospective, multicenter, randomized study comparing repeated high doses of epinephrine with repeated standard doses in cases of out-of-hospital cardiac arrest. METHODS: Adult patients who had cardiac arrest outside the hospital were enrolled if the cardiac rhythm continued to be ventricular fibrillation despite the administration of external electrical shocks, or if they had asystole or pulseless electrical activity at the time epinephrine was administered. We randomly assigned 3327 patients to receive up to 15 high doses (5 mg each) or standard doses (1 mg each) of epinephrine according to the current protocol for advanced cardiac life support. RESULTS: In the high-dose group, 40.4 percent of 1677 patients had a return of spontaneous circulation, as compared with 36.4 percent of 1650 patients in the standard-dose group (P=0.02); 26.5 percent of the patients in the high-dose group and 23.6 percent of those in the standard-dose group survived to be admitted to the hospital (P=0.05); 2.3 percent of the patients in the high-dose group and 2.8 percent in the standard-dose group survived to be discharged from the hospital (P=0.34). There was no significant difference in neurologic status according to treatment among those discharged. High-dose epinephrine improved the rate of successful resuscitation in patients with asystole, but not in those with ventricular fibrillation. CONCLUSIONS: In our study, long-term survival after cardiac arrest outside the hospital was no better with repeated high doses of epinephrine than with repeated standard doses.