Guideline-concordant administration of prothrombin complex concentrate and vitamin K is associated with decreased mortality in patients with severe bleeding under vitamin K antagonist treatment (EPAHK study).

International audienceINTRODUCTION: In vitamin K antagonist (VKA)-treated patients with severe hemorrhage, guidelines recommend prompt VKA reversal with prothrombin complex concentrate (PCC) and vitamin K. The aim of this observational cohort study was to evaluate the impact of guideline concordant administration of PCC and vitamin K on 7-day mortality. METHODS: Data from consecutive patients treated with PCC were prospectively collected in 44 emergency departments. Type of hemorrhage, coagulation parameters, type of treatment and 7-day mortality were recorded. Guideline-concordant administration of PCC and vitamin K (GC-PCC-K) were defined by at least 20 IU/kg factor IX equivalent PCC and at least 5 mg of vitamin K performed within a predefined time frame of 8 hours after admission. Multivariate analysis was used to assess the effect of appropriate reversal on 7-day mortality in all patients and in those with intracranial hemorrhage (ICH). RESULTS: Data from 822 VKA-treated patients with severe hemorrhage were collected over 14 months. Bleeding was gastrointestinal (32%), intracranial (32%), muscular (13%), and "other" (23%). In the whole cohort, 7-day mortality was 13% and 33% in patients with ICH. GC-PCC-K was performed in 38% of all patients and 44% of ICH patients. Multivariate analysis showed a two-fold decrease in 7-day mortality in patients with GC-PCC-K (odds ratio (OR) = 2.15 (1.20 to 3.88); P = 0.011); this mortality reduction was also observed when only ICH was considered (OR = 3.23 (1.53 to 6.79); P = 0.002). CONCLUSIONS: Guideline-concordant VKA reversal with PCC and vitamin K within 8 hours after admission was associated with a significant decrease in 7-day mortality

Glucocorticoids for acute urticaria: study protocol for a double-blind non-inferiority randomised controlled trial

INTRODUCTION: This study protocol describes a trial designed to investigate whether antihistamine alone in patients with acute urticaria does not increase the 7-day Urticaria Activity Score (UAS7) in comparison with an association of antihistamine and glucocorticoids and reduces short-term relapses and chronic-induced urticaria. METHODS AND ANALYSIS: This is a prospective, double-blind, parallel-group, multicentre non-inferiority randomised controlled trial. Two-hundred and forty patients with acute urticaria admitted to emergency department will be randomised in a 1:1 ratio to receive levocetirizine or an association of levocetirizine and prednisone. Randomisation will be stratified by centre. The primary outcome will be the UAS7 at day 7. The secondary outcomes will encompass recurrence of hives and/or itch at day 7; occurrence of spontaneous hives or itch for >6 weeks; patients with angioedema at day 7, and 2, 6, 12 and 24 weeks; new emergency visits for acute urticaria recurrences at days 7 and 14, and 3 months; Dermatology Life Quality Index at days 7 and 14, and 3 and 6 months; and Chronic Urticaria Quality of Life Questionnaire at 6 weeks. ETHICS AND DISSEMINATION: The protocol has been approved by the and will be carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. A steering committee will oversee the progress of the study. Findings will be disseminated through national and international scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03545464

Pre-hospital management protocols and perceived difficulty in diagnosing acute heart failure

Aim To illustrate the pre-hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre-hospital conditions. Methods and results A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre-hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point-of-care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST-elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12-lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point-of-care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non-invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST-elevation myocardial infarction, asthma, and stroke. Conclusions The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre-hospital conditions

Trials

BACKGROUND: Recent data suggest that 10-20% of injury patients will suffer for several months after the event from diverse symptoms, generally referred to as post-concussion-like symptoms (PCLS), which will lead to a decline in quality of life. A preliminary randomized control trial suggested that this condition may be induced by the stress experienced during the event or emergency room (ER) stay and can be prevented in up to 75% of patients with a single, early, short eye movement desensitization and reprocessing (EMDR) psychotherapeutic session delivered in the ER. The protocol of the SOFTER 3 study was designed to compare the impact on 3-month PCLS of early EMDR intervention and usual care in patients presenting at the ER. Secondary outcomes included 3-month post-traumatic stress disorder, 12-month PCLS, self-reported stress at the ER, self-assessed recovery expectation at discharge and 3 months, and self-reported chronic pain at discharge and 3 months. METHODS: This is a two-group, open-label, multicenter, comparative, randomized controlled trial with 3- and 12-month phone follow-up for reports of persisting symptoms (PCLS and post-traumatic stress disorder). Those eligible for inclusion were adults (>/=18 years old) presenting at the ER departments of the University Hospital of Bordeaux and University Hospital of Lyon, assessed as being at high risk of PCLS using a three-item scoring rule. The intervention groups were a (1) EMDR Recent Traumatic Episode Protocol intervention performed by a trained psychologist during ER stay or (2) usual care. The number of patients to be enrolled in each group was 223 to evidence a 15% decrease in PCLS prevalence in the EMDR group. DISCUSSION: In 2012, the year of the last national survey in France, 10.6 million people attended the ER, some of whom did so several times since 18 million visits were recorded in the same year. The SOFTER 3 study therefore addresses a major public health challenge. TRIAL REGISTRATION: Clinical Trials. NCT03400813 . Registered 17 January 2018 - retrospectively registered

Access to prehospital mobile medical team in Paris area

La prise en charge des urgences vitales préhospitalières en France, est du ressort des SMUR sous l’autorité des SAMU, seuls responsables de l’organisation des soins, du lieu de survenue jusqu’à l’hôpital. L’accessibilité de la population aux équipes médicales des SMUR n’avait jamais été évaluée. Au travers de l’analyse prospective d’une cohorte de 500 patients traumatisés crâniens graves, pris en charge par les SAMU/SMUR en Ile de France, l’apport d’outils SIG a permis d’identifier les caractéristiques d’accessibilité et de disponibilité de l’organisation territoriale des SMUR franciliens. Des territoires ont été identifiés potentiellement à risque, en raison d’une accessibilité des moyens SMUR supérieure à 30 minutes. Cependant, le critère d’accessibilité pris isolément, masque de fortes inégalités dans l’organisation territoriale des SMUR. La disponibilité d’un SMUR est un critère essentiel, rarement évalué. La prise en charge du traumatisme crânien grave illustre parfaitement la situation. La réflexion géographique et l’utilisation des outils SIG permettent de pouvoir évaluer et visualiser objectivement les atouts et faiblesses de l’organisation territoriale d’un système de santé et de proposer des modèles d’organisation pertinents.In France, the prehospital life threatning emergency are managed by mobile medical team (MMT) and an medical dispatcher service called SAMU. Access to medical mobile team, is a strong criterion but never has been estimated. Throughout a Paris regional study, who concerned five hundred severe traumatic head injury managed during two years by MMT, we perform, with tools GIS , an assessment of accessibility and availability to MMT in Paris area. We concluded that the SAMU organization made strong disparity in the area coverage

L’expédition française en Syrie et au Liban de 1860

The French expedition to Syria in 1860 is a military operation of the Second French Empire in the Ottoman Levant region. Responding to an international mandate issued by a conference of the European Powers (United Kingdom, France, Austria, Prussia, and Russia) with the participation of Ottoman Government, this expedition aims to put an end to the massacre of the Christian populations of the region. Christians and Muslims are in tense relations throughout the region and the Turkish administration is making little effort to calm events. In this context, an occupation was set up between 5 September 1860 and 5 June 1861 by 12,000 European soldiers. On their return the region is pacified and the troubles stopped. Yet this expedition is today very little known by the public. Why, while this term, described as "the first humanitarian expedition of history," was a complete success, everyone has forgotten. Perhaps because the media coverage of the events was slight. By analyzing the columns of the newspaper La Presse, a French newspaper of great importance in 1860, one realizes that far from being innocuous this expedition is popular. With almost constant media coverage, this popularity is measured. There are variations in media coverage in important moments, such as negotiation phases. The importance of rapid information is also confirmed when one looks at the nature of the information published in the daily columns. We realize that if this expedition is today largely unknown, it is not for lack of media coverage on the part of La Presse.L’expédition française en Syrie de 1860 est une opération militaire du Second Empire français dans la région du Levant ottoman. Répondant à un mandat international émis par une conférence des Puissances européennes (Royaume-Uni, France, Autriche, Prusse, et Russie) avec la participation de gouvernement ottoman, cette expédition a pour but de mettre fin au massacre des populations chrétiennes de la région. Chrétiens et musulmans sont en relation tendu dans toute la région et l’administration turque ne fait que peu d’effort pour calmer les évènements. Dans ce contexte une occupation est mise en place entre le 5 septembre 1860 et le 5 juin 1861 par 12 000 soldats européens. A leur retour la région est pacifié et les troubles arrêtés. Pourtant cette expédition est aujourd’hui très peu connue par le public. Pourquoi, alors que ce mandat, qualifié de « première expédition humanitaire de l’Histoire » fut une réussite complète, tout le monde l’a oublié. Peut-être parce que la couverture médiatique des évènements fut légère. En analysant les colonnes du journal La Presse, quotidien français de grande importance en 1860, on se rend compte que loin d’être anodine cette expédition est populaire. Avec une couverture médiatique quasi constante on mesure cette popularité. On note des variations de la couverture médiatique dans les moments d’importances, comme les phases de négociation. L’importance de l’information rapide est également confirmer lorsque l’on se penche sur la nature des informations publiées dans les colonnes du quotidien. On s’aperçoit que si cette expédition est aujourd’hui largement méconnue, ce n’est pas par manque de couverture médiatique de la part de La Presse

Prise en charge des traumatismes crâniens graves par le SAMU-SMUR Melun (évolution des pratiques entre 1997 et 2003)

But de l'étude : analyser l'impact des recommandations pour la pratique clinique sur la prise en charge thérapeutique et l'orientation des traumatismes crâniens graves (TCG). Méthode : étude monocentrique rétrospective d'analyse de dossiers cliniques de TCG pris en charge par le SAMU 77 - SMUR Melun en 1997 et 2003. Résultats : la prise en charge et l'orientation ont beaucoup changé entre 1997 et 2003. Le contrôle des voies aériennes supérieures est fait systématiquement avec une séquence rapide d'induction de l'anesthésie générale. La ventilation mécanique est systématiquement monitorée avec un capnographe. La pression artérielle systolique est optimisée avec l'utilisation d'amines pressives. Les indications de l'osmothérapie sont respectées. L'orientation primaire vers un centre spécialisé est systématique. Discussion - conclusion : les recommandations pour la pratique clinique ont été largement diffusées et ont eu un impact majeur sur la prise en charge des TCG en Seine et Marne. Il persiste encore le problème du délai trop long entre l'appel au SAMU et l'admission dans un centre spécialisé, faute d'une structure adaptée à la pris en charge des patients TCG.PARIS7-Xavier Bichat (751182101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Ruptures cardiaques et traumatismes fermés du thorax (analyse d'un cas de rupture de l'oreillette droite, d'un cas de rupture de l'auricule droit et revue de la littérature)

Les ruptures cardiaques lors des traumatismes fermés du thorax sont méconnues et sous-estimées. Elles sont l'une des deux premières causes de mortalité par traumatisme thoracique. Leur mortalité est proche de 85%, leur incidence allant de 0.1 à 5%. Le taux de survie pourrait être meilleur si le diagnostic était évoqué rapidement car un quart des victimes ont une durée de survie spontanée compatible avec une chirurgie de sauvetage. L'analyse de deux dossiers médicaux et la revue de la littérature nous permettent de dégager l'intérêt majeur de l'intervention d'une équipe SMUR sur le terrain possédant l'outil diagnostic le plus efficient : l'échographie. L'examen clinique et les autres examens paracliniques sont au mieux aussi sensibles pour des contraintes supérieures. L'échographie permet l'évocation du diagnostic devant un épanchement péricardique associé ou non à un hémothorax et orient le patient vers un centre médical adapté. Le seul traitement salvateur étant la chirurgieBlunt cardiac ruptures are unrecognised and underestimated. They are one of the two thirst causes of death by closed chest trauma. Their mortality is next to 85%, their incidence going to 0.1 to 5%. The survival rate might be better if the diagnosis has been evocated quickly since one quarter of the victims has a spontaneous survival time compatible with salvage surgery. The analysis of two cases and the review of literature allow to point out the major interest of a prehospital medical team intervention in the field with the most efficient diagnostic tool : echography. Clinic examination and the other paraclinic exams are at the best as sensible for more fetters. Echography allows the diagnostic evocation in the presence of hemopericardium plus or less hemothorax and leads the patient to adapted medical center. The only salvaging treatment is surgeryPARIS12-CRETEIL BU Médecine (940282101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF