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.

Accidental Falls↗

PubMed2005

[Faisability of foetal monitoring in prehospital care].

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.

Adult↗

PubMed2004

[Survey on the use of mannitol in prehospital care in Paris area].

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.

Ambulances↗

PubMed2003

[Prehospital sedation: practical application].

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Emergency Medical Services↗

PubMed2003

[Out-of hospital management of elderly patients].

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.

Age Factors↗

PubMed2003

[Changes in reperfusion strategies in the acute phase of myocardial infarction from 1988 to 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.

Aged↗

PubMed2002

[Exposure of French emergency medical personnel to violence].

OBJECTIVES: Evaluate the problem of violence in French EMS system and characterize assaults. STUDY DESIGN: Multicentric, descriptive, open study. PATIENTS AND METHODS: A questionnaire was given to a sample of prehospital care providers in Paris area. People were asked about assaults during their careers, typology of the assaults and consequences. Results are presented in percentage and means. RESULTS: Two hundred seventy-six questionnaires were returned. One or more assaults were recounted by 23% (61/271) of the sample (median of 8 +/- 7 years experience on the job). The injuries were bruises in 40% (17/43), wounds in 9% (4/43) and fractures in 2% (1/43). Only 4% of assaults were followed by sick leave, 15% by a complaint. After the assaults, 4% (2/45) reported having got therapy against post-traumatic stress disorder. Eighty-eight per cent reported verbal threat and 41% physical threat. Thirteen per cent (25/200) were threatened with a knife and 12% (23/200) with a gun. Only 9% (24/270) had a formal training for management of violence. CONCLUSION: Formal training in the management of violent encounters and prevention of post-traumatic stress should be developed.

Adult↗

PubMed2002

Succinylcholine improves the time of performance of a tracheal intubation in prehospital critical care medicine.

BACKGROUND AND OBJECTIVE: The study aimed to evaluate and improve airway management in the prehospital setting, i.e. physicians working on board ambulances. A quality control programme focusing on anaesthesia was instituted to improve the time taken to perform endotracheal intubation. METHODS: All consecutive patients requiring tracheal intubation were prospectively analysed before (first period) and after the training programme focusing on anaesthetic protocols for tracheal intubation (second period). The number of attempts at laryngoscopy, the time taken to achieve tracheal intubation, the difficulties encountered and the related complications of the anaesthetic technique were recorded. At the end of the first period, the results were reported to the whole staff of the unit and the anaesthesia protocols were then modified by introducing succinylcholine into the induction sequence, as part of a training programme. RESULTS: Two-hundred-and-eighty patients were evaluated (97 in the first period, 183 in the second). All patients were successfully intubated in both periods. The percentage of difficult intubations (as assessed by the physician) was lower in the second period (20 versus 35%, respectively; P < 0.01). The success rate at the first attempt was significantly higher (74% [68-80] 95% CI versus 55% [45-65] 95% CI, P < 0.01) and the duration of intubation was significantly shorter in the second period than in the first (1.4 +/- 3.2 vs. 4.1 +/- 6.7 min, respectively; P < 0.001). The incidence of complications (hypoxaemia, laryngospasm, bronchospasm) was lower in the second period (15 versus 31%, P < 0.01). CONCLUSIONS: The time to perform tracheal intubation can be improved by the introduction of succinylcholine into the prehospital anaesthetic protocol. Rapid sequence induction should be taught as a way of improving tracheal intubation in the prehospital setting.

Adult↗

PubMed2001

Intubating trauma patients before reaching hospital -- revisited.

Endotracheal intubation is widely used for airway management in a prehospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome in adult patients. The benefits, in term of outcomes of invasive airway management before reaching hospital, remain controversial. However, inadequate airway management in this patient population is the primary cause of preventable mortality. An increase in intubation failures and in the rate of complications in trauma patients should induce us to improve airway management skills at the scene of trauma. If the addition of emergency physicians to a prehospital setting is to have any influence on outcome, further studies are merited. However, it has been established that sedation with rapid sequence intubation is superior in terms of success, complications and rates of intubation difficulty. Orotracheal intubation with planned neuromuscular blockade and in-line cervical alignment remains the safest and most effective method for airway control in patients who are severely injured.

Air Ambulances↗

PubMed2001

Out-of-hospital thrombolytic therapy during cardiopulmonary resuscitation in refractory cardiac arrest due to acute myocardial infarction.

Out-of-hospital thrombolytic therapy was administrated to a 53-year-old woman with confirmed acute myocardial infarction and refractory cardiac arrest. Standard advanced cardiac life support measures were performed by an out-of-hospital critical care team but they were unsuccessful. Thrombolytic therapy was given as a rescue therapy after prolonged cardiopulmonary resuscitation. The patient recovered a sinus rhythm and circulation 20 minutes after a bolus infusion of tissue plasminogen activator and was fit to be transported to the hospital. Reversal of arterial occlusion was confirmed at the hospital. There was no sequelae related to thrombolytic therapy and the patient was finally discharged 21 days later. This is the first published report of out-of-hospital thrombolytic therapy during cardiopulmonary resuscitation for a patient with refractory cardiac arrest due to acute myocardial infarction.

Ambulatory Care↗

PubMed2000

[Management of severe head-injured patients in the first 24 hours. Resuscitation and initial diagnostic strategy].

Limitation of secondary insults after severe head injury is a permanent concern during the early phase of head trauma management. The objectives are to maintain mean arterial pressure between 80 and 100 mmHg, to avoid hypoxaemia, and to maintain arterial PCO2 near to 35 mmHg. Volume loading can be necessary to improve arterial pressure, and is carried out with isotonic critalloid (NaCl 9/1000) or colloids, with the exclusion of all hypotonic solutions (Ringer lactate or glucose). The use of catecholamines is reserved for patients with unstable haemodynamics despite an adequate volume loading. The rapid sequence induction is recommended for endotracheal intubation and is followed by continuous analgesia-sedation to keep patient-ventilator dysynchrony, but without compromising haemodynamic objectives. Mannitol is used in case of life-threatening intracranial hypertension. Conversely, specific treatment of intracranial hypertension, especially hypocapnia, is not recommended. Initial diagnostic procedures include cerebral tomodensitometry (TDM). However, TDM may be delayed in case of haemorrhage, which requires a rapid treatment. Intrahospital transport for additional explorations risks secondary insults, and thus requires close monitoring to detect and treat in due time all adverse events. This monitoring includes invasive arterial blood pressure assessment, use of continuous capnography and repeated arterial blood gas measurements. The usefulness of transcranial Doppler for initial management of head-trauma patients needs further evaluation.

Brain Injuries↗

PubMed1999

A quality control program for acute pain management in out-of-hospital critical care medicine.

STUDY OBJECTIVE: This study was conducted to evaluate a quality control program for improving pain treatment in the out-of-hospital setting. METHODS: Pain was evaluated for all patients at the beginning (T(0)) and the end (T(end)) of out-of-hospital management. During the first part of the study (part 1, n=108), the administration and choice of analgesics was left to the physician's discretion. Pain protocols were then modified to encourage the use of opioids. The effectiveness of this new pain management was analyzed (part 2, n=105) using pain scales and quality of relief. RESULTS: Seventy percent of patients who expressed meaningful pain did not request analgesia, and 36% did not receive any analgesia in part 1 in contrast to 7% in part 2 of the study. The verbal rating scale and visual analog scale scores were substantially improved at T(end) versus T(0) in both periods, but the improvement was greater in part 2 (mean visual analog scale score at T(end) was 29.3+/-23 mm [+/-SD]) than in part 1 (38.6+/-25 mm). The percentage of patients who expressed satisfactory relief increased in part 2 (67% versus 49% in part 1). The mean dose of intravenous morphine was 7.2+/-6 mg. Adverse effects were rare and minor. CONCLUSION: This program focusing on pain treatment plus implementation of pain protocols (with intravenous morphine) improved pain management in the field.

Adult↗

PubMed1998

Systemic pressure-flow reactivity to norepinephrine in rabbits: impact of endotoxin and fluid loading.

OBJECTIVE: This study aimed to evaluate the impact of fluid loading on hemodynamics and vascular hypocontractility to norepinephrine (NE) in an endotoxic shock model. DESIGN: Mean arterial pressure (MAP), aortic blood flow velocity (AoV, 20 MHz Doppler) and aortic conductance (AoC = AoV/MAP) were studied during 180 min (T0-T180) in 41 anesthetized and ventilated rabbits. INTERVENTIONS: Shock was induced by a 600 micrograms/kg bolus injection of endotoxin. Fluid loading (20 ml/kg colloids) was infused from T90 to T120. Dose-response curves to NE were performed at T0, T60 and T120 in endotoxic and non-endotoxic animals with or without fluid loading. MEASUREMENTS AND RESULTS: Endotoxin decreased pressure (-23%, p < 0.05) and flow (-42%, p < 0.05) corresponding to a decrease in conductance (-19%, p < 0.05). Fluid loading did not improve hypotension but markedly increased systemic flow (+51%, p < 0.01), corresponding to a hyperkinetic syndrome. Vascular reactivity to NE was impaired after endotoxin at T60 since the pressure response to NE was depressed (p < 0.01) and flow did not decrease. In non-fluid-loaded groups, the pressure response to NE recovered at T120, with no reduction in flow. In fluid-loaded endotoxic animals, however, the pressure response to NE was still impaired at T120 (p < 0.05), but with a decrease in flow. CONCLUSIONS: Fluid loading transformed the hypodynamic profile of endotoxic shock into a hyperdynamic state without improving blood pressure. Depressed vascular reactivity to NE was observed in both hyperdynamic and hypodynamic states, suggesting that a reduced vascular reactivity does not necessarily imply systemic vasodilation.

Animals↗

PubMed1998

[Taking care of acute pain in pre-hospital medicine].

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Analgesia↗