F. Berthier

Comparative study of methods of measuring acute pain intensity in an ED

The best one-dimensional method for routine self-assessment of acute pain intensity in a hospital emergency department is unknown. In this study, an 11-point numerical rating scale (NRS), a simple verbal rating scale describing five pain states (VRS), and a visual analogue scale (VAS) were presented successively on admission to 290 patients with acute pain (200 with and 90 without trauma). VAS and NRS were closely correlated for both traumatic (r = .795) and nontraumatic pain (r = .911). The VAS could not be used with 19.5% of patients with trauma and the VRS with 11% of patients without trauma, whereas the NRS could be used with 96% of all patients. The NRS proved more reliable for patients with trauma, giving equivalent results to those with the VAS for patients without trauma. These two scales showed better discriminant power for all patients. Thus, the NRS would appear to be the means for self-evaluation of acute pain intensity in an emergency department.

Score predicting imminent delivery in pregnant women calling the emergency medical service.

Objective To develop a telephone score predicting imminent delivery. Methods Prospective multicenter (n=38) study including pregnancies of 33 weeks or more amenorrhea (n=3.499). Values in points were assigned to risk factors (Coxs model) and the score tested on a validation cohort and receiver operating characteristic curves. Results Risk was increased if the caller was panicking or declared delivery to be imminent (+3 points), if the pregnant woman could not be spoken to herself (+3), was aged 26–35 (+3) years, was having frequent contractions (from +4 to +8), had the urge to push (+2 to +6 depending on starting time), had a history of rapid or home delivery (+2), or had not been followed up during pregnancy (+8). Nulliparous women (−7) or those on tocolytic treatment (−3) were less at risk. The score is reproducible and relevant. Conclusion Score predicting imminent delivery scoring during calls is a valid means of assessing risk of delivery.

Noninvasive ventilation use in French out-of-hospital settings : a preliminary national survey

OBJECTIVE The objective of our study was to describe noninvasive ventilation (NIV) practices (pressure support ventilation and continuous positive airway pressure) in French out-of-hospital mobile intensive care units (SMUR) and their compliance with national consensus guidelines. METHOD Online inquiry into practices of NIV among managers of French SMUR. Analyzed data include types of NIV devices and use of NIV. RESULTS Upon 218 SMUR referenced within the SAMU de France database, 118 questionnaires (54%) were processed. Noninvasive ventilation equipment: 91% of the SMUR with at least one type of NIV device (continuous positive airway pressure only=82%; pressure support ventilation only=59%; both=50%) but frequently not with recommended devices. Use of NIV: for acute cardiogenic pulmonary edema, practices were compliant with recommendations in 80% of cases, although there was still room for improvement. For other pathologies, practices were very heterogeneous, not always properly assessed, and frequently not compliant with recommendations. CONCLUSION To conclude, NIV use in the out-of-hospital setting in France seems to meet current recommendations for acute cardiogenic pulmonary edema but not for other pathologies. This could be improved by the use of written procedures, conduction of further studies, and promotion of compliance through education.

The Effect of Work Shift Configurations on Emergency Medical Dispatch Center Response

Abstract Objective. It has been proved that emergency medical dispatch centers (EMDC) save lives by promoting an appropriate allocation of emergency medical service resources. Indeed, optimal dispatcher call duration is pivotal to reduce the time gap between the time a call is placed and the delivery of medical care. However, little is known about the impact of work shift configurations (i.e., work shift duration and work shift rotation throughout the day) and dispatcher call duration. Thus, the objective of our study was to assess the effect of work shift configurations on dispatcher call duration. Methods. During a 1-year study period, we analyzed the dispatcher call durations for medical and trauma calls during the 4 different work shift rotations (day, morning, evening, and night) and during the 10-hour work shift of each dispatcher in the EMDC of Nantes. We extracted dispatcher call durations from our advanced telephone system, configured with CC Pulse + (Genesys, Alcatel Lucent), and collected them in a custom designed database (Excel, Microsoft). Afterward, we analyzed these data using linear mixed effects models. Results. During the study period, our EMDC received 408,077 calls. Globally, the mean dispatcher call duration was 107 ± 45 seconds. Based on multivariate linear mixed effects models, the dispatcher call duration was affected by night work shift and work shift duration greater than 8 hours, increasing it by about 10 ± 1 seconds and 4 ± 1 seconds, respectively (both p < 0.001). Conclusion. Our study showed that there was a statistically significant difference in dispatcher call duration over work shift rotation and duration, with longer durations seen over night shifts and shifts over 8 hours. While these differences are small and may not have clinical significance, they may have implications for EMDC efficiency.

Assessment of oxidative stress after out-of-hospital cardiac arrest

INTRODUCTION Pathophysiology of cardiac arrest corresponds to a whole body ischemia-reperfusion. This phenomenon is usually associated with an oxidative stress in various settings, but few data are available on cardiac arrest in human. The aim of the present study was to evaluate different oxidative stress markers in out-of-hospital cardiac arrest (OHCA) patients treated with therapeutic hypothermia. MATERIALS AND METHODS We conducted a prospective study assessing oxidative stress markers (thiobarbituric acid reactive species, carbonyls, thiols, glutathione, and glutathione peroxidase) in OHCA patients treated with therapeutic hypothermia. Measurements were performed during the 4 days after admission and compared between good and poor outcome patients according to Cerebral Performance Category. RESULTS Thirty-four patients were included, 10 good and 24 poor outcomes at 6 months. Thiobarbituric acid reactive species were higher in the poor outcome group on admission and when therapeutic hypothermia was reached. The other markers were not different between groups. No markers seemed modified by the use of therapeutic hypothermia in each group. CONCLUSIONS After OHCA, good outcome patients exhibit lower oxidative stress markers than poor outcome patients. Thiobarbituric acid reactive species appears to be an early prognostic parameter. Oxidative stress markers seem not mitigated by therapeutic hypothermia.

Parcours de soins des patients régulés par le Samu Centre 15 de Nantes et arrivant avec des signes de gravité aux urgences

Mots clés : Gravité ; Régulation ; Dyspnée Introduction.— L’étude réalisée a pour but d’évaluer le parcours de soins des patients se présentant avec des signes de gravité aux urgences du CHU de Nantes. Matériel et méthode.— Tous les patients priorisés 1 par l’Infirmière d’Orientation et d’Accueil pendant un mois sont inclus. Pour chacun, les paramètres vitaux à l’arrivée aux urgences sont notés, puis comparés aux données des bandes sonores (pour tous les patients régulés par le Samu Centre 15) afin de comprendre pourquoi ils n’ont pas bénéficié d’une prise en charge spécifique. Résultats.— Sur cette période, 12 500 appels sont traités par le Samu Centre 15, 4952 patients sont admis aux urgences dont 225 priorisés 1 par l’IOA : 122 patients sont adressés par la régulation. Le sex-ratio est de 1,44, la moyenne d’âge de 54 23 ans. Le mode de transport est un véhicule de secours et d’assistance aux victimes (VSAV) (53 %), une ambulance privée (43 %) ou un véhicule privé (4 %). Les patients arrivent majoritairement sur la tranche horaire de 8 à 20 h (p = 0,02). Les motifs principaux d’admission sont la douleur (EVA 8) (24,6 %), la détresse respiratoire aiguë (12,3 %) et le trouble de la conscience (score de Glasgow < 8) (9,8 %). Vingt-cinq pour cent (n = 30) présentent des paramètres vitaux nécessitant une prise en charge immédiate. 11,5 % sont hospitalisés en réanimation ou soins intensifs et 3 patients décèdent aux urgences. Parmi ces 30 patients, 13 auraient nécessité l’envoi d’un Smur pour une détresse respiratoire (91 %). Sept fois sur 10 le régulateur n’a pas parlé à la victime. Dans 2 cas : le Smur est indisponible. Dans 6 cas sur les 13, le régulateur est rassuré par une tierce personne (médecin. . .), dans 4 cas, il n’est pas possible d’isoler d’explications et dans un cas, il s’agit d’une surcharge de travail à la régulation. Conclusion.— Un patient tous les 3 jours arrive aux urgences avec des signes de détresse vitale malgré un contact avec la régulation. La régulation de ces détresses (principalement respiratoires) nécessite d’écouter la victime parler ou respirer, même en présence d’un paramédical sur place. Une EPP après mise en place d’une fiche d’aide à la régulation est envisagée.