Cet article propose de définir le rôle des professionnels de santé dans l’écosystème contre-terroriste français, sans les transformer en agents de sécurité ou de renseignement. Il s’inscrit dans un contexte marqué par une recrudescence des attentats et la nécessité pour le système de santé de se préparer à des menaces intentionnelles (NRBC-E, cyberattaques, attaques multisites). La médecine contre-terroriste ne doit pas être conçue comme une extension sécuritaire dans l’hôpital, mais comme une composante de la résilience sanitaire. L’enjeu est de former les professionnels à répondre efficacement aux crises tout en préservant les valeurs fondatrices du soin — compétences, coordination, éthique et humanité face aux victimes, comme le résume l’adage « On ne fait bien en crise que ce qu’on fait très bien au quotidien ».

Background:Septic shock may occur in the prehospital setting requiring a prehospital mobile intensive care unit (MICU) intervention. The prehospital MICU is equipped to deliver antibiotics and hemodynamic optimization on scene in order to implement effective treatment measures within the initial hour. The study objective is to assess the relationship between the duration of prehospital care and 30-day mortality among patients with septic shock who received MICU prehospital antibiotic and norepinephrine administration. Methods:From 2016, May, to 2021, March, patients with septic shock managed by a prehospital MICU of nine French hospital centers were retrospectively analyzed. Multivariate logistic regression and propensity score analysis with the inverse probability weighting (IPTW) method were used to assess the association between prehospital care duration and 30-day mortality. Results:Five-hundred and thirty patients were analyzed among which 341 (64%) were males, and the mean age was 70 ± 15 years old. The 3 main presumed sepsis origins were pulmonary, digestive, and urinary for 43%, 25%, and 17% of the patients, respectively. One-hundred and thirty-two patients (25%) received prehospital antibiotic and 155 (29%) norepinephrine administration with a median dose of 1.0 [0.5-2.0] mg.h-1 within the first prehospital hour. The 30-day mortality was 31%. The mean prehospital care duration was 71 ± 34 min. Multivariate logistic regression analysis revealed an association between prehospital care duration and 30-day mortality rate: adjusted odds ratio (aOR) = 1.01 [1.00-1.02], p = 0.017. Multivariate logistic regression adjusted on the same potential confounders reported an association between prehospital care duration < 60 min and 30-day mortality: aOR = 0.64 [0.41-0.99], p = 0.044. Log binomial regression weighted with the IPTW revealed an association between prehospital care duration < 60 min and 30-day mortality: aOR = 0.56 [0.46-0.67], p < 10-3. Conclusion:The present study reports the association between prehospital care duration and 30-day mortality among septic shock patients who received MICU prehospital antibiotic and norepinephrine administration.

Abstract Background International guidelines recommend early a bundle of care to reduce sepsis mortality. Among bundle of care, antibiotic therapy is all the additionally effective when early initiated, especially for the sicker patients, i.e., those with septic shock, for whom it should be started within the first hour. This study aims to examine the impact of prehospital antibiotics administration on 30-day mortality in patients with septic shock, as defined by Sepsis-2, cared for by a prehospital mobile intensive care unit (MICU). Methods We performed a nationwide observational cohort study in France using data from May 2016 to December 2021 including septic shock patients admitted to ICU after receiving prehospital care from a MICU. An emulate retrospective randomized controlled trial using a weighted Cox proportional hazards model was conducted to compare the efficacy of prehospital antibiotic administration versus no prehospital antibiotic administration on 30-day mortality. A secondary analysis assessed the association between prehospital antibiotic administration and 30-day mortality according to presumed septic shock origin. Results Among the 530 patients analyzed, 341 (64%) were males and the mean age was 70 ± 15 years. The 30-day mortality was 31%. The presumed origins of sepsis in the prehospital setting were primarily pulmonary, digestive, and urinary, with respective percentages of 43%, 25%, and 17%, respectively. One-hundred and thirty-two patients (25%) received prehospital antibiotic therapy, a 3rd generation cephalosporin for 98 patients (18%). The inverse probability of treatment weighting analysis emulating the target trial revealed that prehospital antibiotic administration was associated with a lower risk of 30-day mortality compared with no prehospital antibiotic administration: RR = 0.64, 95%CI [0.41–0.97]. The weighted logistic regression model showed a significant association between 30-day mortality and prehospital antibiotic administration for pulmonary origin: RRa = 0.80 [0.86–0.93], urinary origin: RRa = 0.89 [0.80–0.98], and unknown origin: RRa = 0.94 [0.86–0.99]. Conclusion The prehospital antibiotics administration is associated with a reduced risk of 30-day mortality among patients suffering from septic shock cared for by a prehospital MICU. The prehospital antibiotic treatment effect differs according to septic shock origin. However, prospective studies are necessary to validate these preliminary findings and to assess the supplementary effects of the bundle of care components.

Background: In order to reduce sepsis mortality, early treatment implementation and referral to the most appropriate ward (emergency department (ED) or intensive care unit (ICU) are recommended. This multicentre retrospective study aims to study the relationship between 30-day mortality and the admission mode to ICU or ED among patients with septic shock cared for by a prehospital mobile Intensive Care Unit (MICU). Methods: From May 2016 to December 2022, septic shock patients cared for by a prehospital MICU were retrospectively analysed. To assess the relationship between 30-day mortality rate and the admission mode, a multivariate logistic regression after Inverse Probability Treatment Weighting (IPTW) propensity score matching was performed. Results: Among the 587 patients analysed, pulmonary, urinary and digestive infections were the main sepsis aetiology: 42%, 26% and 17% respectively. The overall 30-day mortality rate was 30%. Three-hundred and twenty-seven patients (58%) were admitted to ICU and 260 (42%) to the ED. On matched population, the multivariate analysis including the followings potential confounders: prehospital fluid expansion, norepinephrine administration, antibiotic therapy, age, chronic obstructive pulmonary disease, chronic renal failure, diabetes mellitus, cancer history, hypertension, chronic heart failure, coronary artery disease, hospitalization in the previous 3 months, SAPS-2, management in rural area and prehospital duration, an aRR=1.05 [1.00-1.09] (p=0.025) between 30-day mortality and ED admission. Conversely, the multivariate analysis with the same confounders found aRR=0.90 [0.86-0.95] between 30-day mortality and ICU admission. Conclusion: This study highlighted a positive relationship between ED admission and 30-day mortality of patients in septic shock cared for by a prehospital MICU suggesting a possible negative effect of ED admission whereas a direct ICU admission may be beneficial.

OBJECTIVES:To investigate the effect of a 1-hour resuscitation bundle, including early antibiotics, hemodynamic optimization with fluids and vasopressors as needed, and hydrocortisone therapy as needed, implemented in a prehospital setting by a mobile ICU (MICU) team, on 28-day mortality in adults with septic shock. DESIGN:A multicenter, open-label, cluster-randomized study from May 09, 2016, to November 2, 2018. SETTINGS:Prehospital emergency ambulance in France. PATIENTS:Adults with suspected septic shock at the time of management by the prehospital MICU team. INTERVENTIONS:The 1-hour resuscitation bundle included antibiotics, up to 35 mL/kg of ideal body weight of isotonic saline administered within the first 60 minutes, norepinephrine if mean blood pressure (MBP) remained less than 65 mm Hg or if diastolic blood pressure remained less than 40 mm Hg, and 100 mg of IV hydrocortisone when MBP remained less than 65 mm Hg while the patient was receiving greater than or equal to 1.5 mg/hr of norepinephrine. MEASUREMENTS AND MAIN RESULTS:The primary outcome was 28-day all-cause mortality. Secondary outcomes included mortality rates in the ICU, at hospital discharge, and at 90 days, time alive free of vasopressor drugs, invasive mechanical ventilation, renal replacement therapy, and ICU and hospital lengths of stay. Of 398 participants, 17 did not consent; therefore, 381 participants (96%; mean age, 67 ± 15 yr) were analyzed. In total, 23 of 103 deaths (22%) occurred by 28 days in the 1-hour bundle arm and 76 of 278 deaths (27%) in the usual care arm (risk ratio, 0.81; 95% CI [0.61-1.08]; p = 0.16). The intracluster correlation coefficient was estimated at 0.005 ± 0.002. Secondary outcomes were similar between groups. CONCLUSIONS:The prehospital initiation of a 1-hour resuscitation bundle did not reduce 28-day all-cause mortality in adults with septic shock. Imbalances in patient enrollment between centers and a small difference in care provided between the groups may explain these results. TRIAL REGISTRATION NUMBER:NCT02473263 (http://clinicaltrials.gov/).

BACKGROUND:Pediatric emergency departments face overcrowding, often driven by non-urgent consultations. Telephone triage, supported by clinical decision support systems (CDSSs), offers a potential solution to improve decision accuracy and reduce unnecessary visits. However, pediatric-specific CDSSs are scarce and underexplored. OBJECTIVE:This study aimed to evaluate the impact of a pediatric-specific CDSS, PED-IA, on decision-making accuracy, confidence, and response time. METHODS:PED-IA is an ontology-based CDSS featuring a rule-driven inference engine and a dynamic interface that guides practitioners through structured clinical reasoning. A crossover study was conducted with 51 practitioners who had to answer clinical cases with and without the CDSS. Decision accuracy, confidence, and response times were measured, and satisfaction was assessed through questionnaires. RESULTS:The CDSS significantly improved decision accuracy from 52.9 % to 76.0 % (+23.1 %, p < 0.01) and increased confidence levels by 0.65 points on a 10-point scale (p < 0.01). Residents benefited the most, with an improved accuracy (odds ratio of 3.70 [2.15, 6.36]). Response times increased by an average of 261.8 s per case (p < 0.01). Practitioners expressed high satisfaction, with 88.2 % finding the system useful for decision-making and 84.3 % believing it could reduce stress in clinical practice. CONCLUSION:The PED-IA CDSS significantly enhances triage decision accuracy and user confidence, making it a promising system for clinical practice and medical education. Practitioners viewed the system positively and identified its long-term time-saving potential. Future works should focus on refining system ergonomics and exploring hybrid models that combine data-driven and logic-based approaches to improve usability and adaptability.

BACKGROUND:Telephone triage could limit admissions to emergency departments. However, telephone triage is challenging in pediatrics due to nonspecific symptoms, reliance on parental description, and emotional distress. Clinical decision support systems (CDSSs) could improve the accuracy and quality of telephone triage. Despite proven benefits, current CDSSs are not well suited to the nuances of pediatrics. This study aims to develop a CDSS for pediatric emergency telephone triage. METHODS:We developed a formal knowledge base (KB) for pediatric telephone triage inspired by the ontology model and implemented a generic medical reasoning system that mimics the clinical reasoning used in pediatric emergency triage. The CDSS is built in three layers (a knowledge layer, a Python-based decision layer, and a web interface layer) and provides real-time recommendations. We assessed its accuracy on 96 fictitious clinical cases. RESULTS:The CDSS uses an ontology-oriented KB that includes 303 concepts and 1780 axioms and a generic algorithm that provides recommendations based on user input, exploring and updating decisions continuously. It demonstrated 100 % internal validity compared to written recommendations and 77.1 % accuracy compared to a trio of experts. The 22.9 % discrepancies were due to experts using additional elements not documented in the written recommendations (11.5 %) or experts making different decisions despite consistent rules in the textual recommendations (10.4 %), emphasizing the challenges of standardized guidelines in this narrow but complex field. DISCUSSION/CONCLUSION:The CDSS provides explainable and interpretable recommendations designed to alleviate healthcare professionals' cognitive load so that they can focus on complex clinical situations. Future improvements involve enriching the KB, enhancing user interaction with patient-friendly language, and combining this knowledge-based approach with data-driven approaches.

Background The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). Methods Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports. Results Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39–3.95], 2.08 [1.33–3.25] and 2.22 [1.38–3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively. Conclusion A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.

Background and importance Prolonged emergency medical services' response times (EMS-RT) are associated with poorer outcomes in out-of-hospital cardiac arrest (OHCA). The patient access time interval (PATI), from vehicle stop until contact with patient, may be increased in areas with low socioeconomic status (SES). Objectives The objective of this study is to identify predictors of prolonged EMS-RT intervals, and to evaluate associations with clinical outcomes in OHCAs occurring in the largest metropolitan area in France. Design Using the Utstein-style, prospectively implemented, population-based SDEC registry for OHCAs, we conducted a multicenter, region-wide, retrospective cohort study of EMS dispatches for OHCA cases occurring in the 124 cities of the Greater Paris area, France, between January 1, 2017 and December 31, 2018. Settings and participants Adult, nontraumatic, EMS-assessed, non-EMS witnessed OHCAs. Exposure Geographic location and scene-level SES. Outcome measures and analysis The primary outcome was the EMS-RT interval, from activation until arrival at patient's side. As secondary outcomes, we evaluated patient access outcomes of: (1) dispatch-to-patient contact interval ('EMS-RT'); and (2) vehicle scene arrival-to-patient contact interval (PATI); and patient clinical outcomes of: (1) death; and (2) unfavorable neurological status, both at 30 days. Area-level SES was assessed at census tract level using the European Deprivation Index (EDI; continuous, and divided into quintiles, Q5 = most deprived). We fitted multilevel mixed-effects regression models to identify predictors of patient access outcomes, and their association with clinical outcomes. Main results We included 4082 cases; the median EMS-RT was 10.85 min (interquartile range [8.87-13.15]), and 138 (3.4%) survived to hospital discharge. Independent predictors of increased EMS-RT and PATI were age >65, female sex, residential location, occurrence at elevated floors, arrest unwitnessed by a bystander, and low EDI (all P < 0.018). After multivariable analysis, an overall EMS-RT interval >8 min was associated with higher mortality and poorer neurological status at hospital discharge (both P < 0.001). Conclusion In OHCA cases occurring in the Greater Paris metropolitan area, after adjustment for scene characteristics, EMS delays until patient contact were longer in neighborhoods of low SES, and were associated with poorer clinical outcomes.

Abstract Purpose Respiratory dysfunction is one of the most frequent symptoms observed during sepsis reflecting hypoxemia and/or acidosis that may be assessed by the ROX index (ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate). This study aimed to describe the relationship between the prehospital ROX index and 30-day mortality rate among septic shock patients cared for in the prehospital setting by a mobile intensive care unit (MICU). Methods From May 2016 to December 2021, 530 septic shock patients cared for by a prehospital MICU were retrospectively analysed. Initial ROX index value was calculated at the first contact with MICU. A Cox regression analysis after propensity score matching was performed to assess the relationship between 30-day mortality rate and a ROX index ≤ 10. Results Pulmonary, digestive and urinary sepsis were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality reached 31%. Cox regression analysis showed a significant association between 30-day mortality and a ROX index ≤ 10: adjusted hazard ratio of 1.54 [1.08–2.31], p < 0.05. Conclusions During the prehospital stage of septic shock patients cared for by a MICU, ROX index is significantly associated with 30-day mortality. A prehospital ROX ≤ 10 value is associated with a 1.5-fold 30-day mortality rate increase. Prospective studies are needed to confirm the ability of prehospital ROX to predict sepsis outcome since the prehospital setting.