OBJECTIVE:To provide guidelines for guidelines on adult patient intubation in emergency settings outside the operating room and intensive care unit. DESIGN:A consensus committee of 24 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation, SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence, SFMU) was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline developpement process was conducted independently of any industrial funding (e.g., pharmaceutical or medical device companies). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS:The aim of these expert panel guidelines is to evaluate adult patient intubation in emergency settings outside the operating room and intensive care unit. The experts studied questions within 5 domains. Each question was formulated according to the PICO (Population, Intervention, Comparison, Outcome) model, and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE® methodology. RESULTS:The experts' synthesis and the application of the GRADE® method yielded 32 recommendations for adult patient intubation in emergency settings outside the operating room and intensive care unit. Among the formalised recommendations, 5 have high levels of evidence (GRADE 1), and 12 have low levels of evidence (GRADE 2). For 15 recommendations, the GRADE method could not be applied, resulting in expert opinions. 4 questions did not find any response in the literature. After 4 rounds of scoring and amendment, strong agreement was reached for all the recommendations. CONCLUSIONS:There was strong agreement among experts for 36 recommendations to improve practices for adult patient intubation in emergency settings outside the operating room and intensive care unit.

AIMS:The rising popularity of endurance races underscores the need to explore the risks of sports-related sudden cardiac arrest (Sr-SCA). Although rare, Sr-SCA is significantly more prevalent in men than in women. The mechanisms underlying these sex differences remain unclear.We aimed to investigate the incidence rates, clinical characteristics, aetiologies, sex differences, and exercise performances among SCA cases during major endurance races in Paris over a 10-year period. METHODS AND RESULTS:We Analysed the Paris Sudden Death Expertise Centre Registry Data (Covering 2011-2024, excluding 2020). This included SCA cases from the half marathon, full marathon and 20 km Parisian race events. We calculated the incidence rates for men and women, with performance analyses focusing on acceleration patterns and the relative risk of SCA in the final kilometre. Among the 1.2 million participants, 17 SCA cases (88% male) were identified, yielding crude incidences of 16.9 and 5.7 per million for men and women, respectively. Sr-SCA was overrepresented in the final kilometres of short races. Men exhibited twice the acceleration rate that women did. Despite extensive medical investigations, no cause was identified in 47.1% of the cases, underscoring the idiopathic nature of Sr-SCA. After hospitalization, 88% (15/17) of the cases survived, all with excellent neurological outcomes [cerebral performance category (CPC) 1], except for one CPC 2. CONCLUSION:SCA incidences during endurance races are low, with male predominance, high survival rates, and a high proportion of unexplained cases. The male-specific acceleration in the final kilometre may suggest that physiological and behavioural factors influence SCA risk.

INTRODUCTION:As the 2024 Paris Olympic Games approach, it seemed relevant to analyze 25 past years of medical workload at the Stade de France to better predict future needs by identifying the determinants of workload levels. METHODS:Site : Stade de France, the largest French stadium, in the Greater Paris area. Inclusion : Events from 1998 to 2022. Parameters : Nature of event; level of event; competition finals; number of spectators, weather, and medical workload. End-points : Number of patient presentations. RESULTS:459 events were studied: 167 (36%) football matches, 142 (31%) rugby matches, 111 (24%) artistic performances, 26 (6%) athletics competitions, 11 (2%) motor sports competitions, and 2 (0.5%) other types of events. Median attending spectators: 72,057 [56,825-78,500]. Median patient presentations: 29 (15-59) or 5 (2-9) per 10,000 spectators. Median transports to hospital: 2 (1-3) per event, or 0.3 [0.1-0.5] per 10,000 spectators. Median medicalized transports to hospital: 0 [0-0] per event. The nature of the event, rugby (OR = 7.97 [1.65-46.80]), international event (0.18 [0.04-0.76]), and temperature (OR = 0.86 [0.77-0.96]) were associated with a greater frequency of high medical workload in multivariate analysis. CONCLUSION:Rugby matches, level of event, and outdoor temperature were independent determinants of medical workload. Number of spectators and duration of the event had no influence.

IMPORTANCE:The Olympic Games, as the world's largest sporting event, present significant logistical challenges for healthcare delivery, especially regarding emergency medical service (EMS) and emergency department (ED) preparedness. Evaluating their impact on emergency services supports better planning of future Olympic or other such events and helps align emergency healthcare provision with demand. Nevertheless, data on their real-world impact remain limited. OBJECTIVE:The objective of this study is to assess whether the 2024 Paris Olympic and Paralympic Games were associated with an increase in ED visits and EMS activity in the most exposed geographical areas. DESIGN, SETTING, AND PARTICIPANTS:This retrospective, population-based study analyzed routinely collected administrative data from all EDs and EMS dispatch centers in the departments of Paris (75) and Seine-Saint-Denis (93), which hosted most Olympic venues. Weekly ED visits, EMS calls (SAMU), and physician-staffed mobile ICU (MICU) dispatches were extracted from January 2019 through December 2024. Pandemic years (2020-2021) were excluded. MAIN OUTCOMES AND MEASURES:The primary outcome was the adjusted mean weekly number of ED visits during the core Olympic period (weeks 30-32). Secondary outcomes included call center activity and MICU dispatch volume. These were also analyzed during an extended period (weeks 27-35), encompassing the Paralympic Games. Data for 2019, 2022, and 2023 were standardized to 2024 levels using annual mean activity excluding Olympic weeks. RESULTS:Over 3.7 million ED visits were analyzed. During the core Olympic weeks, adjusted weekly ED visits were slightly lower in 2024 compared with previous years (-3.3%, -3.6%, and -0.9% vs 2019, 2022, and 2023 respectively). Conversely, EMS calls increased by approximately 10% and MICU dispatch activity by 5-8%. Mean patient age (47.4 years) remained stable, and no clinically meaningful differences were observed. CONCLUSIONS AND RELEVANCE:The 2024 Paris Olympic and Paralympic Games were not associated with an increase in ED utilization but with a slight increase in EMS calls and MICU activity. This study offers a baseline reference for futures large-scale international events with mass gathering.

Les Jeux Olympiques et Paralympiques de Paris 2024 ont été une réussite festive et organisationnelle historique. Une préparation minutieuse a été effectuée sur plusieurs années, impliquant une coordination entre les agences régionales de santé, le SAMU, les établissements de santé, et diverses associations de secours pour planifier la couverture sanitaire préhospitalière. Le système préhospitalier mis en place répondait à un triple défi : (1) assurer les soins courants de la population en dehors des sites olympiques, (2) renforcer les sites olympiques en cas de dépassements des structures sanitaires, et (3) prendre en charge une éventuelle situation sanitaire exceptionnelle. Le SAMU zonal a joué un rôle moteur dans la coordination interservices, tandis que des moyens importants ont été mobilisés pour prévenir les situations sanitaires exceptionnelles telles que les conséquences d’une canicule ou les attentats terroristes. Malgré une légère augmentation de la charge de travail pour les services d’urgence et les équipes de régulation pendant la période des Jeux Olympiques, l’impact global sur les structures sanitaires a été modéré. Ce retour d’expérience a mis en évidence l’importance de standardiser et d’harmoniser les référentiels pour les évènements à venir, tout en renforçant la formation et les exercices pratiques des personnels. La coordination interservices, les dispositifs de secours bien dimensionnés et les outils de communication simples, inspirés de la gestion COVID, sont des éléments clés pour améliorer la réponse sanitaire lors des prochains grands évènements internationaux.

Background: While extensive evidence linking human immunodeficiency virus (HIV) infection to acute myocardial infarction (AMI), several studies have also suggested an association between HIV and presumed sudden cardiac death (PSCD). Our objective was to evaluate the association between HIV and PSCD compared to AMI. Understanding whether HIV confers differential risks for distinct cardiovascular outcomes is essential to guide prevention strategies and risk stratification in this population. Methods: The study design was a case-control study. We combined data from the large prospective population-based Paris Sudden Death Expertise Center Registry on PSCD and from the French National Health Insurance (SNDS) database. The SNDS database contains comprehensive data on all reimbursements for health-related expenditures and detailed medical information on all admissions to French public and private hospitals. In this study, adult patients with PSCD that occurred between 2011 and 2020 in Paris and the 3 adjacent departments were matched with AMI controls. We identified HIV patients in the 2 populations. We used a logistic regression to estimate the association between HIV and PSCD compared to HIV and AMI, adjusted for confounders. Results: In this study, 22,510 PSCD patients (60% men, age 71 (17) years) were matched with 22,510 AMI controls (60% men, age 72 (17) years). Among them, 245 (1%) and 104 (1%) had a positive HIV status preceding PSCD and AMI respectively. The odds of PSCD was 97% higher than the odds of AMI in HIV patients (adjusted odds-ratio, 1.97; 95% confidence interval: 1.55–2.49). Conclusions: Our findings, based on big data analysis, strongly suggest a significant association between HIV status and PSCD, also among patients without a history of AMI. The underlying mechanisms still remain incompletely defined and further studies are needed.

INTRODUCTION:Obtaining vascular access is crucial in critically ill patients. The EZ-IO® device is easy to use and has a high insertion success rate. Therefore, the use of intraosseous vascular access (IOVA) has gradually increased. AIM:We aim to determine how IOVA was integrated into management of vascular access during out-of-hospital cardiac arrest (OHCA) resuscitation. METHODS:Analysing the data from the OHCA French registry for events occurring between 1 January 2013 and 15 March 2021, we studied: demography, circumstances of occurrence and management including vascular access, delays and evolution. The primary outcome was the rate of IOVA implantation. RESULTS:Among the 7156 OHCA included in the registry, we analysed the 3964 (55%) who received cardiopulmonary resuscitation. The vascular access was peripheral in 3122 (79%) cases, intraosseous in 775 (20%) cases and central in 12 (<1%) cases. The use of IOVA has increased linearly (R2 = 0.61) during the 33 successive trimesters studied representing 7% of all vascular access in 2013 and 33% in 2021 (p = 0.001). It was significantly more frequent in traumatic cardiac arrest: 12% versus 5%; p < 0.0001. The first epinephrine bolus occurred significantly later in the IOVA group, at 6 (4-10) versus 5 (3-8) min; p < 0.0001. Survival rate in the IOVA group was significantly lower, at 1% versus 7%; p < 0.0001. CONCLUSION:The insertion rate of IOVA significantly increased over the studied period, to reach 30% of all vascular access in the management OHCA patients. The place of the intraosseous route in the strategy of venous access during the management of prehospital cardiac arrest has yet to be determined.

BACKGROUND In cardiac arrest (CA), time is directly predictive of patients' prognosis. The increase in mortality resulting from delayed cardiopulmonary resuscitation has been quantified minute by minute. Times reported in CA management studies could reflect a timestamping bias referred to as "digit preference". This phenomenon leads to a preference for certain numerical values (such as 2, 5, or 10) over others (such as 13). Our objective was to investigate whether or not digit preference phenomenon could be observed in reported times of the day related to CA management, as noted in a national registry. METHODS We analyzed data from the French National Electronic Registry of Cardiac Arrests. We analyzed twelve times-of-the-day corresponding to each of the main steps of CA management reported by the emergency physicians who managed the patients in prehospital settings. We postulated that if CA occurred at random times throughout the day, then we could expect to see events related to CA management occurring at a similar rate each minute of each hour of the day, at a fraction of 1/60. We compared the fraction of times reported as multiples of 15 (0, 15, 30, and 45 - on the hour, quarters, half hour) with the expected fraction of 4/60 (i.e. 4 × 1/60). MAIN RESULTS A total of 47,211 times-of-the-day in relation to 6131 CA were analyzed. The most overrepresented numbers were: 0, with 3737 occurrences (8% vs 2% expected, p < 0.0001) and 30, with 2807 occurrences (6% vs 2% expected, p < 0.0001). Times-of-the-day as multiples of 15 were overrepresented (22% vs 7% expected, p < 0.0001). CONCLUSION Prospectively collected times were considerably influenced by digit preference phenomenon. Studies that are not based on automatic time recordings and that have not evaluated and considered this bias should be interpretated with caution.

Les douleurs périnéales du post-partum diminuent spontanément jusqu’à 18 mois en post accouchement.Les déchirures périnéales sévères (3e et 4e degré), l’épisiotomie, la primiparité et l’allaitement sont des facteurs de risque de dyspareunies du post-partum.Le mode d’accouchement n’est pas un facteur de risque de dyspareunie.Aucune technique n’a fait la preuve de son efficacité dans la prise en charge des dyspareunies du post-partum. La neurostimulation électrique transcutané et la luminothérapie semblent améliorer les dyspareunies du post-partum.Un tiers des femmes présentent un prolapsus stade 2 au 3e trimestre de grossesse. Il persiste en post-partum dans la grande majorité des cas mais le plus souvent de façon asymptomatique.Les principaux facteurs de risque de prolapsus du post-partum sont l’accouchement par voie vaginal et l’accouchement instrumental par forceps.La prise en charge doit être globale associant règles hygiénodiététiques, utilisation de pessaire et rééducation périnéale en premier lieu. La prise en charge chirurgicale doit être différée après l’accomplissement du projet parental si possible.La prise en charge de la béance vulvaire est essentiellement chirurgicale accompagnée de sexothérapie. La rééducation périnéale n’a pas été étudiée dans cette indication.Postpartum perineal pain decreases spontaneously up to 18 months after delivery.Severe perineal tears (3rd and 4th degree), episiotomy, primiparity and breastfeeding are risk factors for postpartum dyspareunia.The mode of delivery is not a risk factor for dyspareunia.No technique has proven its effectiveness in the management of postpartum dyspareunia. Transcutaneous electrical nerve stimulation and light therapy seem to improve postpartum dyspareunia.On third of women have a pelvic prolapse during third trimester of pregnancy, persisting after delivery in most cases but most commonly asymptomatic.The main risk factors for postpartum prolapse are vaginal and instrumental deliveries (forceps).First line management must combine hygiene and dietary rules, the use of pessary and perineal rehabilitation. Surgical treatment should be postponed until there is no desire for further pregnancy.The management of the vaginal laxity is mainly surgical associated with sex therapy. Perineal rehabilitation has not proven to be effective in this setting.

Lapostolle, Frédéric; De Stefano, Carla; Petrovic, Tomislav; Adnet, Frédéric; Alhéritière, Armelle Author Information

Acute coronary syndromes (ACS) are a diagnostic challenge for Emergency Medicine (EM) clinicians. To help clinicians assess patients with non-ST-elevation ACS (NSTEACS), clinical decision aids have been developed, combining clinical history, cardiac troponin and the electrocardiograph (ECG). These models ask the clinician to subjectively assess the ECG variable, introducing reliability issues. We set out to derive an ECG model that would provide an objective measure for ischaemia using non-ST-elevation myocardial infarction (NSTEMI) as the primary outcome.We derived an ECG model in a retrospective Emergency Department cohort using logistic regression with a primary outcome of NSTEMI. All patients presented with signs or symptoms suggestive of an ACS. The model was validated in a multi-centre prospective Emergency Department cohort.Derivation included 1246 patients, 156 (12.5%) had the primary outcome; validation included 1139 patients, 170 (14.9%) had the primary outcome. Derivation demonstrated Sn 25.6% (95% CI 19.0–33.2), Sp 96.3% (95% CI 95.0–97.4), PPV 50.0% (95% CI 40.0–60.0) and NPV 90.1% (95% CI 89.2–90.9). Validation demonstrated Sn 23.5% (95% CI 17.4% to 30.6%), Sp 95.2% (95% CI 93.6% to 96.4%), PPV 46.0% (95% CI 36.6% to 55.7%) and NPV 87.6% (95% CI 86.7% to 88.5%).We have derived and validated an ECG model that is highly specific for NSTEMI and may be suitable for integration into existing clinical decision aids.

Objectives: The objectives of this study were to evaluate first attempt intubation failure rate, its associated factors, and its related complications in out-of-hospital emergency setting, when emergency physicians perform standardized airway management using rapid sequence intubation in adult patients. Material and methods: The present study was a substudy of the Succinylcholine versus Rocuronium for out-of-hospital Emergency Intubation (CURASMUR) Trial, which compared Succinylcholine and Rocuronium used for Rapid sequence intubation. First attempt Intubation failure rate and early intubation related complications were recorded. We used multivariable logistic regression analysis to determine first intubation failure associated factors. Results: A total of 1230 patients were included with mean age of 55.9 +/- 19 years. First attempt intubation failure was recorded in 285 (23.2%) patients. The occurrence of a first attempt intubation failure was independently associated with history of ear, nose, and throat neoplasia (OR 2.20, CI 95% 1.06-4.60). Early intubation related complications were more frequent in case of first attempt intubation failure: 80 of 285 (28.4%) in patients with first attempt intubation failure and 185 of 945 (19.6%) in patients with successful first attempt intubation [OR 1.44; CI 95%, 1.11-1.87]. Conclusion: Based on a large multicenter study on out-of-hospital tracheal intubation of adult patients, we found that first attempt intubation failure rate was high and that history of ear, nose, and throat (ENT) neoplasia was an independent associated factor. Failure in first intubation attempt was associated with significantly more intubation related complications.

Background: In 2016, three European scientific societies called for standardization to the "2222" as a European unique phone number in case of in-hospital emergencies. This study describes the management of in-hospital emergency calls in all French military training hospitals and aims to detail their original transition, for the first time in France, to the "2222". Methods: An electronic standardized questionnaire was emailed to heads of rapid response teams in the eight French military training hospitals. Results: All participants answered the questionnaire (100%). The eight French military training hospitals had a specific procedure for management of in-hospital emergencies. Six hospitals already used a unique phone number for in-hospital emergencies, but none of them were using the 2222 in March 2019. Two hospitals still used several phone numbers for in-hospital emergencies, mainly due to historical and local arrangements. Rapid response teams included at least a physician and a nurse. There was a discussion to switch to "2222" as the unique phone number for inhospital emergencies in two hospitals. In both, the discussions involved hospital executive officers, medical teams, rapid response teams and technical teams leading to a step-by-step transition. Finally, in October 2019, these two hospitals launched the "2222" procedure for in-hospital emergencies. Conclusion: This study found a large disparity in the eight French military training hospitals, concerning in-hospital emergency protocols. Two French military training hospitals launched the "2222" procedure for the first time in France. Further efforts are still needed to continue to promote the use of the 2222 as a European unique phone number for in-hospital emergencies.

The Incidence of peri-intubation cardiac arrest (PICA) has been rarely assessed in the out-of-hospital setting. The objectives of this study were to assess the incidence and factors associated with PICA (cardiac arrest occurring within 15 min of intubation) in an out-of-hospital emergency setting, wherein emergency physicians perform standardized airway management using a rapid sequence intubation technique in adult patients. This was a secondary analysis of the “Succinylcholine versus Rocuronium for out-of-hospital emergency intubation” (CURASMUR) trial, which compared the first attempt intubation success rate between succinylcholine and rocuronium in adult patients requiring emergency tracheal intubation for any vital distress except cardiac arrest. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. All operators were emergency physicians. The PICA incidence was recorded and multivariable logistic regression analysis was used to identify the factors associated with its occurrence. A total of 1226 patients were included with a mean age of 55.9 ± 19 years. PICA was recorded in 35 (2.8%) patients. Multivariable analysis indicated that the occurrence of PICA was independently associated with a body mass index (BMI) > 30 kg m 2 [adjusted odds ratio (aOR) 4.85; 95% confidence interval (CI) 1.82–12.90, p = 0.02], oxygen saturation (SpO 2 ) before intubation < 90% (aOR 3.4; 95% CI 1.50–7.60, p = 0.003), difficult intubation (defined by an Intubation Difficulty Score [IDS] > 5, [aOR 3.59; 95% CI 1.82–8.08, p = 0.02], the use of rocuronium instead of succinylcholine (aOR 2.47; 95% CI 1.08–5.64, p = 0.03), post intubation hypoxaemia (aOR 2.70; 95% CI 1.05–6.95, p = 0.04), post-intubation hypotension (aOR 4.07; 95% CI 1.62–10.22, p = 0.003), and pulmonary aspiration(aOR 4.78; 95% CI 1.48–15.36, p = 0.009). Early PICA occurred in approximately 3% of cases in the out-of-hospital setting. We identified several independent risk factors for PICA, including obesity, hypoxaemia before intubation and difficult intubation.

Objective: To determine the effectiveness of formalised telephone medical advice (fTMA), provided by a physician for fever or gastroenteritis in out-of-hours. Methods: We performed a cluster pragmatic randomised controlled trial and economic evaluation over 12 months. Patients were randomly assigned to either fTMA given by a general practitioner (GP) or usual care. Six French Emergency Medical Communication Centres serving 5.8 million patients participated. We enrolled patients contacting the out-of-hours service for assistance with fever or gastroenteritis. In the experimental arm, fTMA offered reassurance, explanations and advice on therapeutic management, which may include a telephone prescription. The primary endpoint was the percentage of patients with an out-of-hours face-to-face consultation with a GP, or who were admitted to hospital, during the two weeks following their call. Secondary endpoints were the healthcare pathway, clinical outcome and economic analysis. Results: 2,498 callers (1,234 in the intervention group) were included. Patients in the fTMA group were significantly less likely to be admitted to hospital or receive an out-of-hours face-to-face GP consultation at day 15; relative risk -0.36 (95% CI -0.55 to -0.16). There was no significant difference between the two groups regarding ambulance intervention, intensive care admission, mortality or morbidity, improvement of symptoms. During the two-week survey, the average total cost was €91 ± 457 in the fTMA group vs. €150 ± 644 in the usual care group (p<0.01). Conclusions: Introduction of fTMA was associated with a decrease in out-of-hours face-to-face consultations with a GP, or admission to hospital. This procedure is safe, effective and is associated with lower cost compared to usual practice.

Introduction New-Caledonia, an island located in the South-Pacific, was the first (overseas) French country hit by the coronavirus disease-2019 (COVID-19) pandemic to come out of lockdown. The epidemic was rapidly controlled. Analyzing the impact of an epidemic only makes sense if it is compared with a zone with a similar health care system. Objective To compare epidemic evolution in New-Caledonia and Paris suburb. Methods Health care organization is similar in New-Caledonia and Seine-Saint-Denis, based on an Emergency Medical System call center. We recorded the numbers of patients managed by SAMU (Service d’Aide Médicale Urgente)-Emergency Medical System, transferred to the emergency department and managed in prehospital setting by mobile intensive care unit. We compared these parameters during the reference (February 1-23, 2020) and the COVID-19 (February 24, 2020, to April 19, 2020) periods. Primary end-point: number of days over the 95th percentile of the reference period. Results Number of patients managed was over the 95th percentile during 27 and 47 days in New-Caledonia and Seine-Saint-Denis, respectively. Number of emergency department transfers was more than the 95th percentile during 4 and 31 days, respectively. Number of mobile intensive care unit sent was over the 95th percentile during 3 and 14 days, respectively. Peaks were similar. Conclusion The duration of the critical period rather than its spread affected the health care system.

Background: Significant improvements in survival from out-of-hospital cardiac arrest (OHCA) have been reported; however, these are based only on data from OHCA in whom resuscitation is initiated by emergency medical services (EMS). We aimed to assess the characteristics and temporal trends of OHCA without resuscitation attempt by EMS. Methods: Prospective population-based study between 2011 and 2016 in the Greater Paris area (6.7 million inhabitants). All cases of OHCA were included in collaboration with EMS units, 48 different hospitals, and forensic units. Results: Among 15 207 OHCA (mean age 70.7±16.9 years, 61.6% male), 5486 (36.1%) had no resuscitation attempt by EMS. Factors that were independently associated with increase in likelihood of no resuscitation attempt included: age of patients (odds ratio, 1.06 per year [95% CI, 1.05–1.06], P <0.001), female sex (odds ratio, 1.21 [95% CI, 1.10–1.32], P =0.002), OHCA at home location (odds ratio, 3.38 [95%CI, 2.86–4.01], P <0.001), and absence of bystander (odds ratio, 1.94 [95% CI, 1.74–2.16], P <0.001). Overall, the annual number of OHCA increased by 9.1% (from 2923 to 3189, P =0.028). This increase was related to an increase of the annual number of OHCA without resuscitation attempt by EMS by 26.3% (from 993 to 1253, P =0.012), while the annual number of OHCA with resuscitation attempt by EMS did not significantly change (from 1930 to 1936, P =0.416). Considering only cases with resuscitation attempt, survival rate at hospital discharge increased (from 7.3% to 9.5%, P =0.02). However, when considering all OHCA, survival improvement did not reach statistical significance (from 4.8% to 5.7%, P =0.17). Conclusions: We demonstrated an increase of the total number of OHCA related to an increase of the number of OHCA without resuscitation attempt by EMS. This increasing proportion of OHCA without resuscitation attempt attenuates improvement in survival rates achieved in EMS-treated patients.

OBJECTIVES:To determine the efficacy of emergency medical center physicians' use of a protocol to guide their management of telephone consultations for fever and gastroenteritis.MATERIAL AND METHODS:Cluster randomized controlled trial. Participating centers were randomized to use the telephone protocol or provide usual telephone assistance. Six emergency centers in France included calls from patients needing advice on fever or gastroenteritis. Centers assigned to the protocol followed specific guidelines on managing the call and giving advice on treatment. Primary endpoints were the number of in-person visits and hospital admissions required within 15 days of the call. Secondary endpoints were patient satisfaction and costs.RESULTS:A total of 2498 calls were included. Use of the assigned protocol while attending 1234 calls was associated with a relative risk for hospitalization or an unscheduled in-person visit for care of 0.70 (95% CI, 0.58-0.85) versus usual practice. Ambulance use, admission to an intensive care unit, mortality, morbidity, and symptom improvement did not differ significantly between centers using the protocol and those following usual practice. Ninety percent of the patients were satisfied. The cost of care was €91 in centers applying the protocol and €150 in the other centers (P .01).CONCLUSION:Use of the protocol was associated with fewer unscheduled in-person visits for care and fewer hospital admissions. The protocol is safe and less costly than the centers' usual approaches to giving telephone advice.

Introduction Chest compressions are the cornerstone of cardiopulmonary resuscitation. The recent International Liaison Committee on Resuscitation guidelines recommend increasing the rate and the depth of chest compressions, to 100-120/min and 5-6 cm, based on theoretical arguments and observational studies. We hypothesized that an increased chest compressions rate could decrease chest compressions depth. Methods Operators were asked to perform continuous chest compressions on a mannequin. Chest compressions rate and depth were collected. The ratio of chest compressions compliance to the guidelines, that is rate 100-120/min and depth 5-6 cm, was calculated. Results In total 951 sequences of chest compressions were studied. Median chest compressions rate: 114 (104-130)/min. Median chest compressions depth: 4.5 (3.4-5.3) cm. Correlation between rate and depth: low (R-2 = 0.12). Chest compressions in compliance with the recommended rate: 434 (46%). Rate >120/min in 285 (30%) cases and <100/min in 223 (23%) cases. Chest compressions in compliance with the recommended depth: 286 (30%). Depth >6 cm in 50 (5%) cases and <5 cm in 621 (65%) cases. Finally, chest compressions were in compliance with the guidelines for both rate and depth in 141 (15%) cases. The ratio of chest compressions in compliance with the recommended depth significantly decreased with the increase of the rate: 40% for a rate <100/min, 32% for a rate in the target (100-120/min) and 18% for a rate >100/min (P < 0.0001). Discussion The ratio of chest compressions in compliance with the recommended rate and depth was as low as 15%. The rate of chest compressions in compliance with the recommended depth significantly decreased when the chest compressions rate increased. To reach both recommended rate and depth seems illusive.