Stéphane Travers

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.

Hemostatic dressings in civil prehospital practice: 30 uses of QuikClot Combat Gauze.

To report the use and describe the interest of hemostatic dressings in a civilian setting, we provided medical prehospital teams with QuikClot Combat Gauze (QCG) and asked physicians to complete a specific questionnaire after each use. Thirty uses were prospectively reported. The wounds were mostly caused by cold steel (n=15) and were primarily cervicocephalic (n=16), with 19/30 active arterial bleedings. For 26/30 uses, hemostatic dressing was justified by the inefficiency of other hemostasis techniques. Those 30 applications were associated with 22 complete cessations of bleeding, six decreases of bleeding, and ineffectiveness in two cases. The application of QCG permitted the removal of an effective tourniquet that was applied initially for three patients. No side-effects were reported. The provision of hemostatic dressings in civilian resuscitation ambulances was useful by providing an additional tool to limit bleeding while rapidly transporting the injured patient to a surgical facility.

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.

Research in prehospital emergency medicine: comparison by geographic origin of publications.

Department of Emergency Medicine, Fire brigade of Paris, Department of Emergency Medicine, University Hospital Lariboisière AP-HP, University Paris Diderot, Sorbonne Paris Cité, UMRS 942, Paris, Fire Bataillon of Marseille, SAMU 13, University Hospital La Timone AP-HM, Marseille, France and Central Bohemian Region, Emergency Medicine Service, Kladno, Czech Republic Correspondence to Jean-Pierre Tourtier, MD, Fire Brigade of Paris, Emergency Medical Service, 1 Place Jules Renard, 75017 Paris, France Tel: + 33 670 208 162; fax: + 33 156 796 754; e-mail: jeanpierre.tourtier@free.fr

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.

Usefulness of a multiplying factor in predicting the final number of victims during a mass casualty incident

Objective Whenever a mass casualty incident (MCI) occurs, it is essential to anticipate the final number of victims to dispatch the adequate number of ambulances. In France, the custom is to multiply the initial number of prehospital victims by 2–4 to predict the final number. However, no one has yet validated this multiplying factor (MF) as a predictive tool. We aimed to build a statistical model to predict the final number of victims from their initial count. Methods We observed retrospectively over 30 years of MCIs triggered in a large urban area. We considered three types of events: explosions, fires, and road traffic accidents. We collected the initial and final numbers of victims, with distinction between deaths, critical victims (T1), and delayed or minimal victims (T2–T3). The MF was calculated for each category of victims according to each type of event. Using a Poisson multivariate regression, we calculated the incidence risk ratio (IRR) of the final number of T1 as a function of the initial deaths and the initial T2–T3 counts, while controlling for potential confounding variables. Results Sixty-eight MCIs were included. The final number of T1 increased with the initial incidence of deaths [IRR: 1.8 (1.4–2.2)], the initial number of T2–T3 being greater than 12 [IRR: 1.6 (1.3–2.1)], and the presence of one or more explosion [IRR: 1.4 (1.1–1.8)]. Conclusion The MF seems to be an appealing decision-making tool to anticipate the need for ambulance resources. In explosive MCIs, we recommend multiplying T1 by 1.4 to estimate final count and the need for supplementary advanced life support teams.

Reply to Letter: The utility of electrocardiogram for evaluation of clinical cardiac arrest in neonatal resuscitation: Promises which need confirmation☆

We have read with interest the article by Koizumi et al. that ighlights the utility of the electrocardiogram (ECG) for the evalution of clinical cardiac arrest in neonatal resuscitation.1 The tools, hich include ECG, cardiac auscultation and pulse oximetry (PO), ffer a combination whose diagnostic sensitivity and specificity eserve further accurate assessment. The authors suggest intraospital care. We present here our experience of the extra-hospital ituation. Births are frequent (N = 300 in 2015 in our backup sysem) and take place without the use of any sophisticated technical quipment. The fastest teams on site are professional first responers in 85% of cases. They await the arrival of the medical team or a median duration of 20 min, with an interquartile range of 2–30 min; their newborn evaluation tools are those that evalute the clinical condition (Apgar, pulse palpation, etc.) associated ith pulse oximetry (PO). The use of the ECG has not been tested n newborns in our system but only in young children on the utomated external defibrillator (AED) screen in situations outide any ventricular fibrillation context. Its use has led to many alse positives due to the presence of electrical activity associated ith the perception of the first responder’s own finger pulse in lace of no pulse of the victim. Such misjudgment has been the ause of many hand-offs of victims requiring chest compressions data not published). Because of this, the completion of CPR withut interruption until the arrival of the medical team is the rule of humb. Recommendations for the care of newborns are based on the act that the heart rate is initially measured more quickly and preisely by listening to heart sounds with a stethoscope (at the cardiac pex) or by ECG than by seeking a palpable pulse.2 The ECG is faster nd more accurate, especially in the first two minutes of life. The erception of a pulse at the base of the umbilicus is reliable only if t exceeds 100 pulses per min.2 Given these data, we will start a study, first, to validate the uscultation of heart sounds by the first responders and, second, o study the possibility of exploiting the variation of the thoracic

Injuries induced using an active compression–decompression device (Cardiopump®) during resuscitation for out-of-hospital cardiac arrest: Observational study

Daniel Jost1,∗, Pascal Dang Minh1, Nicolas Genotelle1, Stephane Travers1, Olga Maurin1, Florence Dumas2, Michel Bignand1, Jean-Pierre Tourtier1 1 Fire Brigade of Paris, Paris, France 2 Sudden Death Expertise Center, Paris, France Purpose:Cardiopump® (CP) is a deviceusedbyprofessional rescuer teams to perform chest compression (CC) on out-of-hospital cardiac arrest (OHCA). It allowsperforming a compression followed by an active decompression, and has a gauge to assess the depth of the full compression and decompression. This study aimed to identify chest injuries induced by CC performed with CP. Materials andmethods:Prospectiveobservational study. Inclusion criteria: patients with non-traumatic OHCA>15 years, for whom CP was used. Collected data: epidemiological (age, gender, location, bystander, CPR duration), clinical (skin lesions linked to CP, rib fracture caused by CC, subcutaneous emphysema) and prognosis (return of spontaneous circulation (ROSC), “beating-heart” on arrival at the hospital). We performed uni and multivariate statistical analysis (logistic regression). Results: A total of 3385 patients were included in 2013. Of these, 590 (17%) had chest skin lesions, 121 (4%) rib fractures, and 30 (0.89%) suffered subcutaneous emphysema. Mean age of injured patients was comparable to that of non-injured (66±17 years vs 67±19, p =0.28), and so was their sex-ratio. Three logistic regression models were performed: 1. Skin lesions were linked to low-flow>30min (OR=3.1 [1.6–5.8]) and regurgitation (OR=2.1 [0.9–4.9]). 2. Rib fractures were linked to low-flow>60min (OR=7.1 [1.3–30.1]) and less frequent in OHCA at home (OR=0.38 [0.2–0.8]). 3. Subcutaneous emphysema was less frequent at home (OR=0.09 [0.01–0.48]. None of the other variableswas significantly linked to the occurrence of injury by CP. Conclusions: Chest injuries from CC performed with CP were frequent, and it was impossible to show their harmful effect on early patient outcome. A study should be conducted to compare the frequency and severity of lesions induced by CC performed by CP or no.

Utility of shock index calculation in hemorrhagic trauma.

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