Mirko Ruscev

Prevalence and Management of Acute Pain in Prehospital Emergency Medicine

Abstract Background. Less is known about the prevalence of pain in prehospital emergency medicine than about pain in the emergency department. Objectives. To estimate the prehospital prevalence of pain and to identify the factors associated with oligoanalgesia. Methods. The mobile intensive care units of the emergency services of a Paris suburb conducted this prospective study. All consecutive patients aged 16 years or older who were able to self-assess pain were included around the clock over a period of 11 months in 2007. Results. Among the 2,279 included patients, 947 had acute pain (42% [95% confidence interval (CI) 40–44]). Pain was intense to severe in 64% of patients. Factors associated with acute pain were trauma (odds ratio [OR] = 2.9 [1.9–4.3]) and age under 75 years (OR = 2.2 [1.7–2.8]). Intense pain was significantly associated with pain of cardiac or traumatic origin. Among the 1,364 patients transported by the mobile units, 48% experienced acute pain (71% had intense to severe pain). An analgesic agent was administered to 73%. According to multivariate analysis, only gynecologic/obstetric emergencies were associated with inadequate treatment (OR = 0.2 [95% CI 0.1–0.6]). Overall, 51% of patients [46–56] experienced pain relief. The rate of pain relief was lowest in patients suffering from trauma or a gynecologic/obstetric disorder. Conclusion. In our studied population, pain in prehospital emergency medicine affects 42% of patients. However, the rate varies widely according to the origin of the pain. Pain management is inadequate, as only one in two patients experiences relief.

Out-of-hospital use of an automated chest compression device: facilitating access to extracorporeal life support or non–heart-beating organ procurement

OBJECTIVE The aim of the study was to assess the ease-of-use, safety, and usefulness of an automated external chest compression device for cardiopulmonary resuscitation. METHODS Adults with out-of-hospital cardiac arrest (OHCA) were included prospectively. The emergency medical services (EMS) in a large suburb northeast of Paris (France) recorded data for standard criteria for EMS care for CA and specific criteria on device use-application time, ease of application and use (visual analog scale score: 0, impossible; 5, very easy), technical incidents, and clinical complications. RESULTS We attended 4868 OHCA patients (January 2005 to April 2010) and used the device in 285 patients (6%) (212 males [74%], 73 females [26%]; median age, 56 [43-70] years). Results (medians with 25-75 percentiles) were as follows: time to apply device, 30 seconds (20-60); ease of application and activation, 5 (4-5) and 5 (5-5), respectively; duration of use, 30 (20-41) minutes; return to spontaneous circulation (ROSC), 76 patients (27%); and time to ROSC, 19 (12-32) minutes after placement. Twenty-seven patients (9%) with refractory CA benefited from extracorporeal life support. Overall, 32 patients were alive after 24 hours, 11 at 7 days, and 3 at 1 month. An additional 23 patients (8%) with refractory CA were selected for non-heart-beating kidney procurement. Ten patients were used to harvest kidneys and 15 were transplanted. There were 21 technical incidents (7%) and 19 clinical complications (7%). CONCLUSION The device was easy to use in routine emergency practice and of particular value in facilitating access to extracorporeal life support or non-heart-beating organ procurement. These uses should be itemized in all OHCA studies.

Information médicale : de l’hôpital à la ville. Que perçoit le médecin traitant ?

BACKGROUND The communication and circulation of medical information between hospitals and GPs play a central role in the quality of care. Numerous statutes, regulations, and clinical practice guidelines stress the need for such communication. We assessed how it really works. METHODS We conducted face-to-face interviews based on a standardized questionnaire with 50 GPs in the districts of Paris and Seine-Saint-Denis, to explore different aspects of their communication with hospitals: the communication channels, and the amount, content, and quality of the information received. RESULTS It appears that the overall quantity of communication is satisfactory but its quality and content vary according to the reasons for which the GP sent the patient to the hospital. GPs have a deep feeling that hospital staff physicians do not collaborate with them. CONCLUSION The proposed personal medical file may help resolve logistic obstacles to the circulation of medical information but it will not bridge the cultural gap that exists between the two pillars of the system of care: the hospital and the GP.

Chest Pain in an Out‐of‐Hospital Emergency Setting: No Relationship Between Pain Severity and Diagnosis of Acute Myocardial Infarction

Chest pain frequently prompts emergency medical services (EMS) call‐outs. Early management of acute coronary syndrome (ACS) cases is crucial, but there is still controversy over the relevance of pain severity as a diagnostic criterion.

Douleur aiguë de l’enfant dans l’aide médicale d’urgence: Évaluation des pratiques

Resume Objectif Evaluer les pratiques des medecins des Services mobiles d’urgence et de reanimation (Smur) en France concernant la prise en charge des douleurs aigues severes (DAS) de l’enfant. Methodes Une enquete a ete realisee a l’aide d’un questionnaire telephonique adresse aux medecins transporteurs de tous les Smurs (n = 360). Ce questionnaire evaluait: les modalites d’evaluation de la douleur, la definition d’une DAS, les objectifs therapeutiques, les modalites du traitement entrepris, la nature des morphiniques disponibles, la presence d’un protocole local d’analgesie et un avis sur les recommandations nationales. Resultats 359 Smur ont repondu au questionnaire. Huit pour cent des medecins savaient correctement definir une DAS et 10 % connaissaient les objectifs therapeutiques. La morphine etait utilisee de premiere intention par 47 % des medecins. Les posologies et les delais recommandes etaient suivis respectivement dans 7 et 13 % des cas. La morphine etait disponible dans 93 % des cas. Quarante-neuf pour cent des medecins ne connaissaient pas les recommandations et 63 % n’avaient aucun protocole antalgique local. Conclusion Nous avons mis en evidence un deficit de connaissance concernant la prise en charge des douleurs aigues severes de l’enfant. Un travail de formation est indispensable pour ameliorer la prise en charge de la douleur en prehospitalier.

Procedural Sedation and Analgesia in Trauma Patients in an Out-of-Hospital Emergency Setting: A Prospective Multicenter Observational Study

Abstract Background: The quality of procedural analgesia and sedation among trauma patients has not been studied much in the prehospital setting. The main objective of this study was to characterize the quality of procedural analgesia sedation practices in prehospital settings in trauma patients. Methods: This was an open-label observational prospective multicenter study (January 01, 2012–December 31, 2013). We included all consecutive trauma victims undergoing a potentially painful procedure on the accident scene. The primary endpoint was the procedural pain intensity. Results: Data for 210 patients aged 11 to 98 years were analyzed. The most common lesions were limb fractures or dislocations. The most common procedures were limb realignment and splinting. Overall, 25 different drug combinations [with paracetamol [acetaminophen], non-steroidal anti-inflammatory drugs, nefopam, opioids, loco-regional anesthesia, Equimolar Mixture of Oxygen/Nitrous Oxide (EMONO), sedative drugs] were used by the emergency medical services (EMS). One hundred seventeen patients (55%) received either one or two sedative drugs (among ketamine, propofol, and midazolam), 171 patients (81%) received morphine that was combined with a sedative drug in 54% of cases. During the procedure, 95 patients, 45% [95% Confidence Interval (CI) 39–52] experienced intense to severe pain. Among patients who received sedative drugs, 27% (32/117) had intense to severe pain vs. 68% (63/93) in patients who did not, that is, 40% difference [95% CI 33.8–47.0]. Seventeen patients (8%) experienced 18 adverse events of which 6 were respiratory adverse events. A deep sedation occurred in 17 patients. No center had any specific protocols for procedural sedation analgesia. Conclusion: Procedural sedation-analgesia was inadequate in almost half of the trauma patients in the out-of-hospital setting. The reasons of these failures were probably multiple. The non-administration of a sedative drug despite an indication or non-adapted doses, in the context of a lack of specific protocols, was certainly one of them.