Laurent Domanski

Out-of-hospital cardiac arrest phone detection: those who most need chest compressions are the most difficult to recognize.

UNLABELLED Dispatcher-assisted cardiopulmonary resuscitation increases the likelihood of survival and thus is highly recommended. However, the detection rate of out-of-hospital cardiac arrest (OHCA) is very different from one system to another, and early recognition of cardiac arrest in the dispatch centre remains challenging. The aim of this study was to assess the provision of dispatcher-assisted cardiopulmonary resuscitation in the main French dispatch centre. METHODS In the Paris Fire Brigade, each patient over 15 years of age who presented an OHCA from 15 to 31 May 2012 was prospectively included. Field data and tape recordings of emergency calls were studied by three experienced physicians, to assess the rate (and delay) of OHCA recognition and chest compression initiation, and identify the causes of unrecognized OHCA. RESULTS Among 82 consecutive calls for detectable cardiac arrest, the dispatcher recognized 50/82 (61%). The median times from call to OHCA recognition and from call to chest compression initiation were, respectively, 2 min 23s (1 min 51 s to 3 min 7s) and 3 min 37s (2 min 57 s to 5 min). The main causes of non-recognition of OHCA were the absence or incomplete assessment of breathing and the presence of agonal breathing. No cardiac arrest was missed when the dispatcher followed the local dispatch algorithm; this included the gesture of putting the hand on the abdomen and measuring the breathing frequency. Hospital admission with a beating heart was paradoxically 18% for detected cardiac arrest and 47% for undetected cardiac arrest (p=0.007). This paradox could be explained by the relation between agonal breathing and, on the one hand, good prognosis of OHCA and, on the other hand, difficulties in recognizing OHCA. CONCLUSION The improvement of cardiac arrest recognition in the dispatch centre seemed mandatory, as the cardiac arrests of better immediate prognosis were not well detected. The measurement of OHCA recognition and CPR initiation by phone should be encouraged in dispatch centres as a key to initiating corrective measures.

Difficulties of triage in mass casualties incident

We read with deep interest the article by Mahaluxmivala [1]. We appreciate the work of the authors on the article. However, the data about infection of Table 1 are inconsistent with that in Results. From Table 1, infection was recorded in 2 patients in group 1, 5 patients in group 2 and 6 patients in group 3. But from Results, infection was noted in 4 patients in group 1, 5 patients in group 2 and 1 patient in group 3. This makes us confused. We do not know clearly about patient demographics. In brief, we think a corrigendum should be made; otherwise the inconsistency about the data of infection makes readers more difficult to extract the data. Nonetheless, the flaw cannot lessen this article’s complete value and we thoroughly enjoyed reading the paper with respect.

French military general practitioner: ultrasound practice

Objectives Ultrasound has been used in the field and in emergency departments for more than two decades. In a military setting, its use has grown rapidly as it has gained widespread acceptance among emergency physicians and as the range of diagnostic and triage applications has continued to expand. Technological changes have enabled ultrasound devices to become accessible to general practitioners (GP), and it could be of particular interest for military GPs in isolated environments. We have investigated both the training of French military GPs in the area of ultrasonography and the use of ultrasound devices, in daily practice and abroad, in isolated military settings. Methods In 2011, a questionnaire was sent to all 147 in-the-field GPs of the French southeast regional military health service. The questionnaire evaluated the training of military GPs in ultrasonography, the use of ultrasound in France in daily practice, and during military operations in isolated environments abroad during 2010. Results The response rate was 52%. On the one hand, half the responding GPs had been specially trained in ultrasound, mainly (97%) in military institutes. On the other hand, only a quarter of doctors used ultrasound in daily practice. Among those GPs performing ultrasound examinations in France, 75% used it in 2010 during isolated operations abroad. Ultrasound examinations performed in such an austere environment were retrospectively declared useful to guide clinical reasoning (41% of examinations carried out), diagnosis (21%) and decision making as regards evacuation (11%). Conclusions The challenge for the future is to make ultrasound courses mandatory for all military GPs going on overseas operations, to develop daily practice, and to investigate effective triage systems, combining both ultrasound imagery and physical examination.

Stroke: prospective evaluation of a prehospital management process based on rescuers under medical direction☆☆☆

BACKGROUND Improving access to thrombolytic therapy for patients with ischemic stroke is challenging. We assessed a prehospital process based on firemen rescuers under strict medical direction, aimed at facilitating thrombolysis of eligible patients. METHODS This was a prospective observational study conducted over 4 months in Paris, France. Prehospital patients with suspected stroke were included after telephone consultation with a physician. If the time since the onset of symptoms was less than 6 hours, patients were transported directly to a neurovascular unit (NVU); if symptom onset was more than 6 hours ago, they were transported to an emergency department (ED). Confirmation of stroke diagnosis, the rate of thrombolysis, and the time intervals between the call and hospital arrival and imaging were assessed. Comparison used Fisher exact test. RESULTS Of the 271 patients transported to an NVU, 218 were diagnosed with a stroke (166 with ischemic stroke), 69 received thrombolytic therapy, and the mean stroke-thrombolysis interval was 150 minutes. Of 64 patients admitted to the ED, 36 patients had a stroke (ischemic, 24). None were thrombolysed. Globally, 36% of ischemic strokes were thrombolysed (27% of all strokes diagnosed). The mean interval call-hospital was 65 minutes (ED vs NVU, P = .61). The interval call-imaging was 202 minutes (interquartile range, 105.5-254.5) for ED and 92 minutes (interquartile range, 77-116) for NVU (P < .001). CONCLUSIONS The prehospital management of stroke by rescuers, under strict medical direction, seemed to be feasible and effective for selection of patients with stroke in an urban environment and may improve the access to thrombolysis.

Field Triage Protocol in Elderly Trauma Patients: What Level of Care?

We would like to congratulate Gage and colleagues for their study investigating compliance with out-of-hospital trauma guidelines. They addressed a fundamental question being debated: what level of care for elderly patients with trauma?This is a crucial topic: the continued increase in average life expectancy has created an explosion in the population of individuals 75 years and older; concomitant with this aging of the population, there has been an increase in the number of older trauma patients. And adherence to prehospital triage protocols represents a fundamental component of a wellfunctioning trauma system. Moreover, the ethical issue of appropriateness of elderly trauma care is challenging. Gage and colleagues showed that, in contradiction with clear field triage guidelines, older age was associated with transport to the lower level of trauma care. The reasons for this were unclear but perhaps involved perceptions among prehospital providers that little can be done to alter outcomes for elderly trauma patients, inability of triage criteria, or even patient preferences. However, we do not totally agree with the authors when they stated, in the discussion section of the article, that “the advantage of transporting older trauma patients to a level I trauma center has not been clearly shown in the literature either.” Actually, they leave out a fair amount of data that strongly suggests that elderly trauma patients may benefit from early and aggressive care, ideally in specialized trauma centers, and that older age per se should not be considered a contraindication to the delivery of high-level trauma care. Trauma centers have been purported to positively influence the outcomes of elderly trauma patients. Battistella and coauthors observed that despite higher than expected mortality after discharge, aggressive management of elderly trauma patients was justified by favorable long-term outcomes. In a level I trauma center, they observed that despite a lower than expected long-term survival rate after discharge, at least 42% of trauma patients aged 75 years and older were

Rationale of plasma-to-RBC ratios.

Critical Care Medicine www.ccmjournal.org e245 The authors reply: We thank Tourtier et al (1) for their insightful comments. Although we mostly agree, we feel that a slight clarification is in order. The main finding of our investigation (2) is that an analysis of the effect of high plasma ratios in trauma patients must account for not just “what” blood components are given but, importantly, also “when” they are given. Hence, findings of previous studies on the importance of plasma in trauma may have been exaggerated due to survival bias. That said, on account of the comparably small sample size of our study and the limited variation of plasma use in the trauma patients at our hospital, our results do not strictly support the notion that it is not important to maintain a high plasma ratio in critically bleeding trauma patients and only that there is a need for a careful, time-dependent statistical analysis. At the same time, we fully agree with the authors that the prospective data from the Prospective, Observational, Multicenter, Major Trauma Transfusion study (3) are highly interesting and look forward to further prospective and hopefully also randomized trials on this subject. However, we also feel it is important to note that although it seems both clinically and biologically plausible that plasma ratios have the strongest impact during the first 6 hours of arrival in the hospital, it is also likely that it is during this period, that is, when the majority of trauma patients dies, that the effects of survival bias are of the biggest concern. We, therefore, insist that one must be careful in the interpretation of any observational analysis of this subject. Rationale of Plasma-to-RBC Ratios To the Editor: We would like to congratulate Halmin et al (1) for their retrospective monocentric cohort study of the association between plasma-to-RBC ratios and risk of death in trauma patients. They have collected detailed data on 741 transfused trauma patients, allowing the characterization of individual transfusion therapy hour by hour, with the goal of assessing the effects of plasma use on survival. The time-dependent analyses, which contribute to eliminate the effect of survivor bias, showed no evidence of an increased risk of death in massively transfused patients receiving a lower plasma ratio. These conclusions argue that the observed survival differences between patients receiving high and low ratios in the first 24 hours may simply be due to the fact that survivors live long enough to receive component therapy (survivor bias) (2). This was corroborated by Ho et al (3) (mathematical modeling). But both Halmin et al and Ho et al have composed with retrospective data. We would like to go further into the debate appeared about the optimal rate and time of transfusion as well as the precise ratios of various products. Recently, a prospective multicenter study was designed to minimize the effect of survival bias (detailed real-time data collection methods and analysis strategies adapted) (4). The major findings were that patients did not receive a constant ratio during the period of active resuscitation and that early infusion of higher plasma and platelet ratios was associated with decreased mortality within 6 hours of admission, during which 81% of the hemorrhagic deaths had occurred. The protective association between higher transfusion ratios and in-hospital mortality appeared strongest within 6 hours and diminished over time. After 24 hours, plasma and platelet ratios were unassociated with mortality, when competing risks from nonhemorrhagic causes prevailed (the primary causes of mortality shifted from exsanguination to head injury, respiratory distress, organ failure, and infection). These prospective data suggested strongly that the association between earlier and higher ratios of plasma and platelets and decreased in-hospital mortality exists and is concentrated in the first 6 hours in patients with substantial bleeding (patients with ratios lower than 1:2 were three to four times more likely to die than patients with ratios of 1:1 or higher). Whatever, we totally agree with Halmin et al (1) when they claimed that there is a need for an ability to discriminate trauma patient who will be in need of massive transfusion and where big amounts of plasma might be beneficial. Transfusion therapy guided by thromboelastometry is becoming an integral part of resuscitation at level 1 trauma centers around the world (5). This bedside testing modality may represent the future “gold standard” for guidance of blood component transfusions, but well-designed prospective clinical trials are needed in order to advance the topic in the future. The authors have disclosed that they do not have any potential conflicts of interest.