Background Epinephrine increases the chances of return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA), especially when the initial rhythm is non-shockable. However, this drug could also worsen the post-resuscitation syndrome (PRS). We assessed the association between epinephrine use during cardiopulmonary resuscitation (CPR) and subsequent intensive care unit (ICU) mortality in patients with ROSC after non-shockable OHCA. Methods We used data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing OHCA data located in the Greater Paris area, France) between May 2011 and December 2021. All adults with ROSC after medical, cardiac and non-cardiac causes, non-shockable OHCA admitted to an ICU were included. The mode of death in the ICU was categorized as cardiocirculatory, neurological, or other. Results Of the 2,792 patients analyzed, there were 242 (8.7%) survivors at hospital discharge, 1,004 (35.9%) deaths from cardiocirculatory causes, 1,233 (44.2%) deaths from neurological causes, and 313 (11.2%) deaths from other etiologies. The cardiocirculatory death group received more epinephrine (4.6 ± 3.8 mg versus 1.7 ± 2.8 mg, 3.2 ± 2.6 mg, and 3.5 ± 3.6 mg for survivors, neurological deaths, and other deaths, respectively; p < 0.001). The proportion of cardiocirculatory death increased linearly ( R 2 = 0.92, p < 0.001) with cumulative epinephrine doses during CPR (17.7% in subjects who did not receive epinephrine and 62.5% in those who received > 10 mg). In multivariable analysis, a cumulative dose of epinephrine was strongly associated with cardiocirculatory death (adjusted odds ratio of 3.45, 95% CI [2.01–5.92] for 1 mg of epinephrine; 12.28, 95% CI [7.52–20.06] for 2–5 mg; and 23.71, 95% CI [11.02–50.97] for > 5 mg; reference 0 mg; population reference: alive at hospital discharge), even after adjustment on duration of resuscitation. The other modes of death (neurological and other causes) were also associated with epinephrine use, but to a lesser extent. Conclusions In non-shockable OHCA with ROSC, the dose of epinephrine used during CPR is strongly associated with early cardiocirculatory death. Further clinical studies aimed at limiting the dose of epinephrine during CPR seem warranted. Moreover, strategies for the prevention and management of PRS should take this dose of epinephrine into consideration for future trials.

Context: Deciding on "termination of resuscitation" (TOR) is a dilemma for any physician facing cardiac arrest. Due to the lack of evidence-based criteria and scarcity of the existing guidelines, crucial arbitration to interrupt resuscitation remains at the practitioner's discretion.Aim: Evaluate with a quantitative method the existence of a physician internal bias to terminate resuscitation.Method: We extracted data concerning OHCAs managed between January 2013 and September 2021 from the Re ' AC registry. We conducted a statistical analysis using generalized linear mixed models to model the binary TOR decision. Utstein data were used as fixed effect terms and a random effect term to model physicians personal bias towards TOR.Results: 5,144 OHCAs involving 173 physicians were included. The cohort's average age was 69 (SD 18) and was composed of 62% of women. Median no-flow and low-flow times were respectively 6 (IQR [0,12]) and 18 (IQR [10,26]) minutes. Our analysis showed a significant (p < 0.001) physician effect on TOR decision. Odds ratio for the "doctor effect" was 2.48 [2.13-2.94] for a doctor one SD above the mean, lower than that of dependency for activities of daily living (41.18 [24.69-65.50]), an age of more than 85 years (38.60 [28.67-51.08]), but higher than that of oncologic, cardiovascular, respiratory disease or no-flow duration between 10 to 20 minutes (1.60 [1.26-2.00]).Conclusions: We demonstrate the existence of individual physician biases in their decision about TOR. The impact of this bias is greater than that of a no-flow duration lasting ten to twenty minutes. Our results plead in favor developing tools and guidelines to guide physicians in their decision.

La sarcoïdose est une granulomatose systémique de cause inconnue et de pronostic très hétérogène. Alors qu’environ la moitié des patients ont une résolution spontanée de la maladie, certains vont développer une forme « dangereuse » engageant le pronostic vital ou fonctionnel immédiat ou à plus long terme, avec une mortalité pouvant atteindre 6 %. La littérature comporte peu d’information sur les motifs d’hospitalisation en urgence des patients atteints de sarcoïdose. L’objectif principal de notre étude était de décrire les causes d’hospitalisation non programmée dans la sarcoïdose. Il s’agissait d’une étude rétrospective monocentrique, incluant les patients hospitalisés entre le 01/01/2017 et le 07/07/2020 dans les services de pneumologie, réanimation ou médecine interne de l’hôpital Avicenne dans les 14 jours suivant une consultation aux urgences, ou avec un pneumologue du service ou un avis téléphonique. Les patients ont été sélectionnés à partir du registre PMSI (diagnostic principal ou associé de sarcoïdose). Au total, 458 patients ont été hospitalisés sur cette période avec un diagnostic de sarcoïdose, dont 144 (31,4 %) hospitalisés de façon non programmée (hommes : 53 %, âge à l’admission : 56 ± 14 ans). Les principaux motifs d’hospitalisation en urgence étaient les suivants : détérioration respiratoire non infectieuse (n = 13, 9 %), infection respiratoire (n = 25, 16,7 %), infection extra-respiratoire (n = 4, 2,8 %), suspicion d’atteinte cardiaque (n = 12, 8,3 %), atteinte rénale avec ou sans hypercalcémie (n = 7, 4,5 %), poussée d’hypertension pulmonaire (n = 8, 5,6 %), hémoptysie compliquant une aspergillose pulmonaire chronique (n = 4, 2,8 %), atteinte du système nerveux central (n = 5, 3,5 %), atteinte oculaire sévère (n = 2, 1,4 %), atteinte laryngée (n = 1, 0,7 %) et autres (n = 63, X %). La durée moyenne de séjour était de 7,97 ± 7,45 jours. Vingt-huit (19 %) patients ont nécessité un séjour en réanimation. Le taux de mortalité hospitalière était de 3,5 %. Le suivi après l’hospitalisation était de 31 ± 18 mois au terme duquel la survie globale était de 76 % (IC95 % = 67,4 %–85,6 %). Près d’un tiers des hospitalisations des patients avec un diagnostic de sarcoïdose dans notre centre de référence sont faites en urgence. Les causes sont variées, mais la principale est respiratoire. La mortalité de cette population de patients est non négligeable.

Angioedema (AE) can lead to frequent use of the emergency department (ED). The morbidity and mortality of AE is important given the frequent upper airway involvement. Histaminergic and bradykinin AE are different. In ED, the diagnostic approach and therapeutic action must be systematic and standardized in order not to forget a bradykinin angioedema. Histaminergic AEs, associated with superficial urticaria, are the most common and are sometimes associated with anaphylaxis, requiring immediate epinephrine treatment. They can be allergic (mediated by IgE) and are then associated with anaphylaxis or not allergic, and clinically result in acute or chronic urticaria associated with angioedema. Bradykinin AE, with rare incidence, can also require ED use, particularly angiotensin converting enzyme inhibitor (ACE-I) AE, given their large administration and their clinical involvement of the face, tongue, and larynx, which provide ED visits. Emergency specific treatments mainly include icatibant and Cl-inhibitor concentrate. They should be administered as soon as possible because antiallergic treatments are ineffective. Expert's advice from the reference center for bradykinin angioedema can improve treatment by better diagnostic and by organizing the provision of emergency specific treatments.

Involuntary psychiatric hospitalization (IPH) is a heavy and complex psychiatric exception measure. In the Seine-Saint-Denis department (low medical density), the evaluation of the patient in psychiatric decompensation is the responsibility of the out-of-hours general practitioners (GP) mandated by the call center. Their feeling is the non-achievement of the procedure once the patient arrives at the emergency room. We aimed to evaluate the outcome of patients following a request for IPH from these GP.We conducted a retrospective study based on all requests for IPH received during 2016 at the Seine-Saint-Denis emergency medical call center. The characteristics of the call and the patient, as well as the decisions of the regulator and the GP were collected. The decision of hospitalization in the emergency room was sought for patients referred for IPH.Of the 7541 calls for decompensation, 539 were for an IPH. These calls occurred during non-working hours in 55 % of cases. A GP was involved in more than two-thirds of the cases and requested an IPH for 240/304 (79 %) patients. Patients were male in 56 % of cases with an average age of 40 (±16) years. IPH was confirmed for 132 (61 %) patients. This rate did not differ from the 65 % reported in the literature (Z-test, P=0.26). Voluntary hospitalization was performed for 37 (17 %) other patients.The IPH rate for patients referred by GP mandated by the call center was comparable to that following the requests of the attending physicians, validating their intervention in this critical context.

Les angioedèmes (AE) sont un motif de recours fréquent aux urgences. Leur morbimortalité n’est pas négligeable compte tenu de l’atteinte fréquente des voies aériennes supérieures. On distingue les AE histaminiques et bradykiniques. Aux urgences, la démarche diagnostique et la conduite à tenir doit être systématique et standardisée afin de ne pas méconnaître un potentiel AE bradykinique. Les AE histaminiques, accompagnés dans la plupart des cas d’une urticaire superficielle, sont de loin les plus fréquents et sont associés parfois à une anaphylaxie, ce qui nécessite alors un traitement par adrénaline immédiat. Ils peuvent être allergiques (médiés par les IgE) et sont alors associés à une anaphylaxie ou non allergiques, et se traduisent cliniquement par une urticaire aiguë ou chronique associée à l’AE. Les AE bradykiniques, d’incidence plus rare, sont également pourvoyeurs de recours aux urgences et particulièrement les AE secondaires aux inhibiteurs de l’enzyme de conversion de l’angiotensine compte tenu de leur importante prescription et de leurs atteintes cliniques de la face, de la langue et du larynx, elles-mêmes pourvoyeuses de recours aux urgences. Les traitements spécifiques d’urgence comprennent principalement l’icatibant et le concentré de C1-inhibiteur. Ils doivent être administrés le plus tôt possible devant l’inefficacité des traitements antiallergiques. Un avis auprès d’un expert du centre de référence pour les AE à kinines peut améliorer les prises en charge en aidant à la démarche diagnostique et en organisant la mise à disposition des traitements spécifiques d’urgence.

Background. - Involuntary psychiatric hospitalization (IPH) is a heavy and complex psychiatric exception measure. In the Seine-Saint-Denis department (low medical density), the evaluation of the patient in psychiatric decompensation is the responsibility of the out-of-hours general practitioners (GP) mandated by the call center. Their feeling is the non-achievement of the procedure once the patient arrives at the emergency room. We aimed to evaluate the outcome of patients following a request for IPH from these GP. Methods. - We conducted a retrospective study based on all requests for IPH received during 2016 at the Seine-Saint-Denis emergency medical call center. The characteristics of the call and the patient, as well as the decisions of the regulator and the GP were collected. The decision of hospitalization in the emergency room was sought for patients referred for IPH. Results. - Of the 7541 calls for decompensation, 539 were for an IPH. These calls occurred during nonworking hours in 55 % of cases. A GP was involved in more than two-thirds of the cases and requested an IPH for 240/304 (79 %) patients. Patients were male in 56 % of cases with an average age of 40 (+/- 16) years. IPH was confirmed for 132 (61 %) patients. This rate did not differ from the 65 % reported in the literature (Z-test, P = 0.26). Voluntary hospitalization was performed for 37 (17 %) other patients. Discussion. - The IPH rate for patients referred by GP mandated by the call center was comparable to that following the requests of the attending physicians, validating their intervention in this critical context.

Aims: Patients with suspected acute stroke need fast management. That is why, in France, a specific pathway has been set up for the management of those patients. It is named "neurovascular pathway". The aim of this study was to describe the initial diagnosis and care pathway of patients with suspected acute stroke in the French health system (prehospital and emergency department). Procedure: A short prospective observational study during 3 days in 35 emergency medical services (EMS) call centers, 27 physician-staffed EMS ambulances and 85 emergency departments in France, enrolling every patient over 18 with symptoms suggestive of an acute stroke. Patients were either or not managed in the neurovascular pathway. Results: From November 29 to December 1, 2016, 827 patients have been enrolled, mean age 68. Among them, 418 were diagnosed with an acute stroke, including 231 with acute ischemic stroke. The initial care was managed in the neurovascular pathway in 279 patients (44 %). The median time before seeing a physician was 3h49. It was significantly shorter in the neurovascular pathway (2 h 45 vs. 5 h 56; p < 0.001). Conclusion: In France, management of patients with suspected acute stroke follows a specific pathway in only half of the cases. This pathway needs to be promoted.

Objectif : Les patients présentant des signes d’accident vasculaire cérébral (AVC) nécessitent une prise en charge rapide. En France, il a été mis en place une filière « neurovasculaire » dédiée à ces patients. L’objectif de cette étude était de décrire la filière de prise en charge des patients présentant des signes évocateurs d’AVC dans le système de soins français. Méthodes : Étude prospective observationnelle de courte durée pendant trois jours dans 35 régulations Samu, 27 Smur et 85 services d’urgences en France, incluant tout patient de plus de 18 ans présentant un signe évocateur d’AVC ou d’accident ischémique transitoire (AIT). Les patients suivaient ou non la filière neurovasculaire définie au préalable. Résultats : Du 29 novembre au 1er décembre 2016, 827 patients ont été inclus, d’âge moyen 68 ans. Parmi eux, 418 avaient un AVC confirmé, dont 231 accidents ischémiques constitués. La filière UNVa été suivie pour 279 patients (44 %). Le délai médian de prise en charge médicale était de 3 heures 49. Pour les patients avec AVC confirmé, ce délai était significativement plus court dans la filière neurovasculaire (2 heures 45 vs 5 heures 56 ; p < 0,001). Conclusion : En France, la prise en charge dans une filière dédiée des patients suspects d’AVC n’est actuellement effective que dans la moitié des cas. Cette filière nécessite d’être promue.

La survenue d’un arrêt cardiaque intra-hospitalier, quiconstitue la forme la plus extrême de l’urgence vitaleintra-hospitalière (UVIH), constitue un évènementindésirable majeur qui concerne environ 1 à 5 patientspour 1000 admissions. Le pronostic de ces victimesest étroitement dépendant de la mise en œuvre d’unechaîne de survie intra-hospitalière efficace, dont l’élémentle plus important est le déclenchement immédiat dessecours. Chaque minute compte : tout retard engendrénotamment par une incertitude ou une hésitation surle système d’alerte diminue les chances de survie etaugmente les risques de séquelles.

Un retour d’expérience sur la direction médicale de crise (DMC) pendant la première phase de l’épidémie de Covid-19 a été effectué à l’Assistance publique–Hôpitaux de Paris (AP–HP), le plus important centre hospitalier universitaire européen. L’AP–HP s’est dotée d’un directeur médical de crise (DMC) AP–HP, de six DMC de groupes hospitaliers (GH) et d’un DMC pour chacun des 39 sites hospitaliers. Le pilotage s’est appuyé sur des réunions quotidiennes de crise AP–HP et de GH, des groupes de travail disciplinaires et des tableaux de bord quotidiens fiabilisés qui ont permis d’optimiser les actions. Des actions innovantes ont été mises en place : cellules de régulation des entrées et des sorties de réanimation, suivi des patients infectés à domicile, traçage des contacts, transferts interrégionaux de patients de réanimation. Les éléments clés de la réussite ont été les relations entre direction générale et DMC, l’articulation entre l’échelon central (AP–HP) et celui des GH, la mobilisation de tous les acteurs vers un objectif unique identifié et la mobilisation de l’ensemble des soignants, y compris les étudiants. Parmi les pistes d’amélioration soulignées, il convient de citer la généralisation des DMC hors AP–HP, conformément à la réglementation, le développement de la connaissance du mode de fonctionnement de crise, l’anticipation de la formation à la gestion de crise, la réalisation d’une information quotidienne de l’ensemble des acteurs des actions menées dans une crise de longue durée et la participation des représentants des usagers. La gestion de la recherche en temps de crise reste à inventer au niveau national, voire européen.

Feedback on the medical crisis management during the first phase of the COVID-19 epidemic was provided to the Assistance publique-Hopitaux de Paris (AP-HP), the largest university hospital center in Europe. The AP-HP has one AP-HP medical crisis director (DMC), 6 hospital group (HG) DMCs, and one DMC for each of the 39 hospital sites. Management was based on daily AP-HP and GH crisis meetings, disciplinary working groups and reliable daily dashboards, which enabled the optimization of actions. Innovative actions have been implemented: regulation units for intensive care unit entries and exits, follow-up of infected patients at home, contact tracing, and inter-regional transfers of critically-ill patients. The key elements of success were the relationship between General management, DMC, the articulation between the central level and those of the GH, the mobilization of all the actors towards a unique identified objective, and the mobilization of all the caregivers, including students. Among the highlighted avenues for improvement, it is worth mentioning the generalization of DMCs outside the AP-HP in accordance with the regulations, the development of knowledge of the crisis operating mode, the anticipation of training in crisis management, the provision of daily information to all those involved in actions carried out in a long-term crisis, and the participation of care-user representatives. The management of research in times of crisis remains to be invented at the national or even European level.

Introduction. - The United Nations Climate Conference (COP21) gathered in France for delegations from all around the world, with 20,000 delegates from 195 countries every day, including 150 heads of states during the first 48 hours. A specific medical cover was organized in a particular "post-attacks" context and with harsh constraints due to delimitation of an inner zone under the sole UN authority ("blue zone"). Objective. - To evaluate medical means involved and medical activity. Methods. - Medical cover was managed by SAMU 93 in collaboration with zonal SAMU and regional health agency for the entire site including the "blue zone". End-points: engaged workforce, number of visits, including transfers and medicalized transfers. Results. - In "France zone" (operational headquarters): an emergency physician dispatcher and an assistant for 20 days. In "blue zone": 20 rescuers, mobile intensive care unit H24 and two emergency physicians (consultations) 12/24 hours for 16 days. A total of 47 doctors, 25 nurses, 25 paramedics and 20 assistants participated in the medical service. This corresponded to three emergency physician full medical time equivalents (FMTE) for 16 days. Consultations performed: 1238 or 97/day resulting in 34 (3%) transfers including seven medicalized. Patients were 706 (57%) men and 495 (43%) women, with mean age of 43 +/- 1 years. Trauma patients were most numerous (20%). Conclusion. - Medical means involved were consistent for 16 days. The medical activity was sustained, but medicalized transfer rarely required. (C) 2019. Published by Elsevier Masson SAS

Abstract Issue The management of pre-hospital emergencies is a growing issue in developing countries, particularly because of the increase of both road accidents and cardio-vascular diseases. Description of the problem Numerous countries have tried or are currently trying to develop emergency response systems like the French SAMU but the outcome of those actions show a lot of difficulties. It is however proved that efficient care of serious pre-hospital medical emergencies significantly improves both patients’ mortality and morbidity. Results AP-HP, Greater Paris University Hospitals, has a strong experience of supporting the development of this model of care in countries with limited resources. Most of last 30 years’ experiments have been reviewed to understand what the essential prerequisites to succeed in setting up an emergency response system such as SAMU are. The analysis (5 criteria evaluation: efficiency, sustainability, effectiveness, impact, relevance) of past and present experiments in 28 countries showed that main issues are political (what are the priorities?), financial and societal (what does the population expect?). The question of medical resources is also crucial as the French model introduces medical regulation at all levels. Moreover, in France, such a system is built as a health care pathway with a predetermined orientation towards the appropriate and operational structure, which unfortunately is not the case in a lot of countries. Aside from those realized in China or in some Southern American countries, most of the projects so far don’t match all the evaluation criteria, particularly sustainability, as it is based both on stable funding and a strong reactivity of local hospitals. Lessons Future projects will have to fit with the local context. Strong commitments from partner countries must be made on the long term to have a real impact. Key messages There is no universal system easily duplicable. Some major prerequisites must be identified and implemented to succeed in the set-up of an efficient and sustainable EMSS.

Les directives académiques incitent les établissements scolaires (ES) à appeler d’emblée le SAMU pour tout enfant malade ou accidenté. Le nombre de ces appels nous a semblé en augmentation. L’objectif était d’étudier l’évolution des appels émanant des établissements scolaires et de les caractériser. Les appels émanant d’ES sont systématiquement identifiés à la prise d’appel au SAMU 93. Tous les appels pour des patients de moins de vingt ans ont été analysés, du 03/01/2011 au 27/01/2016. Date, âge, sexe du patient, motif de recours, décision médicale, orientation et devenir du patient (en cas d’envoi d’une équipe SMUR) étaient relevés. Au total, 12 379 (1,5 %) dossiers de régulation médicale émanaient d’ES, dont 10 656 pour des patients de moins de 20 ans qui ont été analysés : 5703 (54 %) garçons et 4881 (46 %) filles, d’âge médian 12 (8–15) ans. Le nombre d’appels a significativement augmenté avec le temps : médianes (IQ) de 155 (115–220) versus 208 (172–236) respectivement pour le premier et le dernier trimestre de la période étudiée soit une augmentation de 34 % en cinq ans. Le motif de l’appel était traumatologique pour 5397 (51 %) des appels. Les décisions prises en régulation étaient l’envoi d’un premier secours (n = 3486 ; 34 %), d’une ambulance (n = 3634 ; 36 %) cas et un conseil médical téléphonique (n = 1987 ; 20 %) ; un SMUR a été envoyé 471 (5 %) fois et le transport a été médicalisé 129 (1 %) fois. Finalement, 11 patients ont été admis en réanimation soit une admission pour 969 appels. Les appels émanant d’ES augmentaient. L’envoi d’un SMUR était rare et la médicalisation exceptionnelle. La stratégie de gestion de ces nombreux appels reste à codifier. Academic guidelines encourage schools to call SAMU immediately for any sick or injured child. The number of these calls seemed to be increasing. The aim was to study the evolution of calls coming from schools and to characterize them. Calls to the SAMU 93 coming from schools are systematically identified. All calls for patients under the age of 20 have been analyzed from 03/01/2011 to 27/01/2016. Date, age, sex, reason of the call, medical decision, orientation and outcome of the patient (in case of sending a mobile intensive care unit – MICU – with an emergency physician) were recorded. In total, 12,379 (1.5%) calls come from schools, of which 10,656 were for patients under 20 years old that were analyzed: 5703 (54%) boys and 4881 (46%) girls; median age 12 (8–15) years old. The number of calls significantly increased over time: median (IQ) of 155 (115–220) versus 208 (172–236) respectively for the first and the last quarter of the period studied, i.e. an increase of 34% in five years. The reason for the call was traumatic in 5397 (51%) cases. SAMU emergency physician decisions included first aid responders (N = 3486; 34%), ambulance (N = 3634; 36%) and medical advice (N = 1987; 2%); a MICU was sent in 471 (5%) cases and the transport was performed by MICU in 129 (1%) cases. Finally, 11 patients were admitted to intensive care unit, i.e. one admission for 969 calls. Calls from schools increased. The sending of a MICU was rare and medical management exceptionally required. The management strategy of these numerous calls has to be codified.

Background: Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. We compared chest compression fraction (CCF) between patients receiving endotracheal intubation (ETI) versus bag mask ventilation (BMV). Methods: We studied adult OHCA enrolled from our center in the CAAM trial. Primary exposures were ETI or BMV. Primary outcome was whole intervention CCF, adjusted for Utstein confounders. Secondary outcomes were per cycle CCF, no flow time associated (NFT) with ventilation, rhythms checks and mechanical chest compression device placement. Results: Of 2040 OHCA enrolled in the CAAM trial we analyzed 112 cases recruited by our center. Unadjusted CCF was 0.89 for ETI and 0.88 for BMV (p = 0.19). Compared with BMV, ETI achieved lower NFT associated with ventilations (32 vs 127s; p 0.001). ETI cases experienced higher NFT associated with rhythm checks (69.5 vs 42.5 s p = 0.02) and with mechanical chest compression placement (29 vs 20 s; p = 0.04). CCF was higher during the first cycle in BMV than in ETI patients (0.81 vs 0.74; p = 0.02). After correction for confounders we observed no difference in global intervention CCF between the ETI and BMV (Delta CCF [ETI-BMV] 0.301; [95%CI: 1.9 to 2.51]; p = 0.79). Conclusion: In our substudy whole intervention CCF among OHCA was not modified by ETI compared to BMV. In the ETI group we observed lower NFT associated with ventilations and higher NFT associated with mechanical chest compression devices placement. CCF was lower in the ETI group during the first cycle.

Introduction : Le taux d’occupation des lignes téléphoniques d’un Samu-Centre 15 conditionne la fluidité de la gestion des appels et donc sa capacité de répondre à l’urgence. La disponibilité des assistants de régulation médicale (ARM) et des médecins régulateurs est déterminante. Nous nous sommes interrogés sur l’impact du nombre d’ARM sur la prise en charge des appels d’un Samu-Centre 15. Méthodes : Le taux d’appels raccrochés (par l’appelant) après 15 secondes a été retenu comme critère de jugement principal. Il a été analysé en fonction de l’effectif « réel » d’ARM. L’effectif théorique d’ARM a été pris comme référence. Deux analyses ont été réalisées, la première portant sur 672 périodes d’un quart d’heure de la semaine 51 de l’année 2016 (en période d’épidémie de grippe) et la seconde sur 3 624 périodes d’une heure sur les cinq premiers mois de l’année 2017. Résultats : Sur la première période, le nombre médian d’appels raccrochés après 15 secondes était de 1 (0–3) par quart d’heure. Il variait de 0 (0–1) à 3 (1–5) selon l’effectif d’ARM auquel il était parfaitement inversement corrélé (p < 0,001). Sur la seconde période, le nombre médian d’appels raccrochés était de 4 (1–8) par heure. Il variait de 2 (1–6) à 10 (6–16) selon l’effectif d’ARM auquel il était parfaitement inversement corrélé (p < 0,001). Conclusion : Le taux d’appels raccrochés après 15 secondes était parfaitement corrélé à l’effectif (plus précisément au sous-effectif) d’ARM. Sur une année, le nombre estimé d’appels perdus ainsi était proche de 50 000 ! Prendre en considération l’effectif des ARM est une nécessité absolue.