L'activité des Smur est essentiellement évaluée à partir du nombre d'interventions et de leur durée. Ces deux paramàtres ne paraissent pas refléter l'activité médicale et la charge de soins. Le but de cette étude était l'évaluation prospective d'un score d'activité Smur (CAS) et sa comparaison à un score de référence, le score TISS.Étude prospective comparative.L'étude a porté sur 4 650 patients, d'âge médian 39 ans [0–100], pris en charge lors de 4 189 sorties du Smur (83 % de sorties primaires et 17 % de sorties secondaires).Le CAS, élaboré à partir du score Oméga, comporte 51 items cotés 1, 3, 6 ou 10, prenant en compte les gestes effectués par le Smur. Les calculs du CAS et du TISS ont été intégrés dans tous les dossiers médicaux de transport pendant un an et demi. Les paramàtres de transport et le diagnostic principal ont été notés. Des tests statistiques non paramétriques ont été utilisés.La durée médiane d'intervention (39 minutes [0–475]) et le CAS (7 [0–72]) étaient comparables (R'= 0,38, P< 0,001 ). Le TISS médian était de 3 [0–30]. Le CAS était bien corrélé au TISS (R'= 0,92, P < 0,001). II était significativement plus élevé chez les hommes que les femmes (7 [0–72] vs 7 [0–45], P < 0,001 ). Les sujets avec une atteinte cardiologique (CAS = 11 [0–72]), respiratoire (CAS = 9 [0–31]) et neurologique (CAS = 9 [0–43]) avaient des CAS plus élevés que ceux avec une autre atteinte (P< 0,001).Le CAS est un indicateur intéressant de l'activité d'une équipe Smur. La prise en compte de facteurs spécifiques à la pratique préhospitaliàre rend le CAS plus facilement utilisable en routine que le score TISS.The activity of prehospital emergency medicine (PEM) teams is mainly assessed by the amount of medical interventions and their duration. However, these two parameters do not reflect workload correctly. The aim of this study was to compare a new activity scoring system for PEM teams (CAS) with the standard TISS score.Prospective comparative study.This study included 4,650 patients, with a median age of 39 years [0-100], attended by PEM teams during 4,189 ambulance transports (83% primary transports and 17% interhospital transfers).The CAS score derived from Omega scoring system is the sum of 51 items specifically suited for PEM, each one being rated 1, 3, 6 or 10. CAS and TISS, were prospectively determined for all medical ambulance transports over 1.5 year. Transport data and main diagnosis were collected. Results were analysed with non parametric statistical tests.Median duration of interventions (39 min [0–475]) and median CAS score (7 [0–72]) were comparable (R'= 0.38, P < 0.001). Median TISS was 3 [0–30]. CAS score was correlated with TISS (R'= 0.92, P < 0.001 ). CAS score was higher in men than in women (7 [0–72] vs 7 [0–45], P < 0.001). CAS scores in patients with cardiologie (11 [0–72]), respiratory (9 [0–31]) or neurological insults (9 [0–43]) were significantly higher than those of patients with other insults (P< 0.001).The CAS scoring sytem is a valuable indicator of medical team prehospital workload, probably more suited for prehospital emergency medicine than TISS.

The primary goal of sedation in emergency prehospital care is to guarantee the security of the mechanically ventilated patients by optimising their adaptation to the respirator. If the French prehospital guidelines are well codified, their applicability in routine clinical practice seem to be rather empirical. The aim of this national survey was to evaluate the use of the clinical sedation scales by the pre-hospital physicians. This prospective and clinical practice survey wits begun in January 2005. An anonymous questionnaire wits sent to the physicians working in the 377 Mobile Intensive Care Unit of the 105 French Emergency Medical Service System.The total response rate from physicians was 28% (n = 497). Only 29% of the physicians (n = 145) declared to use a sedation scale for a mechanically ventilated patient. The Ramsay score was used in 97% of the cases (n = 141). The principal reasons given by the physicians for not n using the sedation scales were their ignorance in 57% of the cases (n = 200) and the systematic choice of a deep sedation in 42% of the cases (n = 147). For 18% of them (it = 62), the use of sedation scores was considered too complicated. The final results show that the utilisation ratio of the sedation scores is very low in emergency prehospital medicine and suggest that an effort toward improving the use of sedation in prehospital emergency medicine is necessary. (C) 2009 Elsevier Masson SAS. All rights reserved.

La substitution propose de remplacer une substance dont le patient est dépendant par un analogue pharmacologique moins nocif afin de faciliter l'arrêt ou la réduction des prises, et réduire les dommages induits du produit initialement consommé. Devenue classique pour les opioïdes ou le tabac, il n'existe à ce jour aucun traitement de substitution validé pour l'addiction à l'alcool. Les consommations d'alcool ou de benzodiazépines, deux agonistes des récepteurs GABAA, sont parmi les plus élevées en France, souvent associées. Alors que l'éthanol est un toxique majeur pour l'organisme, les benzodiazépines ont un meilleur profil de sécurité, malgré divers risques ou effets secondaires. Certains arguments suggèrent que les benzodiazépines pourraient être une substitution à l'alcool. Pour explorer cette hypothèse, une revue narrative de la littérature a été conduite, ne retrouvant que de rares publications, envisageant la possibilité de substitution partielle ou approchée de l'alcool par des benzodiazépines. Afin de conforter cela, des études complémentaires sont nécessaires, de validation pharmacologique ainsi que d'élaboration des abords psychosociaux d'accompagnement de cette médiation.Substitution therapy proposes to replace a substance on which the patient is dependent by another less harmful. Substitution substances are pharmacological analogues to addictive substances, used to facilitate the cessation or reduction of their use, and to reduce their deleterious consequences. Conventionally used for opioids or tobacco, there is to date no validated substitution treatment for alcohol addiction. The use rates of both alcohol and benzodiazepines are among the highest in France, and are frequently associated. France is a country in which alcohol is the second most frequent toxic used, and the most damaging determinant of health for mortality and morbidity after smoking. Meanwhile, alcohol and benzodiazepines are the two most common GABAA receptor agonists, with multiple similarities, despite some distinct chemical properties and actions. However, ethanol has a major toxicity for the body whereas benzodiazepines have a better safety profile, despite various risks and possible side effects. Benzodiazepines are the recommended treatment for alcohol withdrawal, but the guidelines are limited in time on the first two weeks, while only few studies have addressed the pros and cons of maintaining benzodiazepines beyond the detox period.Some arguments suggest that benzodiazepines could be a substitute for alcohol. Both are GABAA receptor agonists. In practice, it is frequent to observe crossed dependences, and, in particular, situations in which subjects with alcohol dependence change for benzodiazepine dependence. However, the medical practice of durably switching alcohol for benzodiazepines has been poorly explored.To review the pharmacological and clinical arguments for and against considering benzodiazepines as a potential substitution treatment for alcohol dependence.A narrative review of international literature has been conducted using the following keyword algorithm: ("substitution" OR "replacement" OR "maintenance") AND "alcohol" AND "benzodiazepine*", without any limitation in time.Among a few hundred articles found on PubMed, only 3 were finally retained, with only 1 controlled study, no review of literature, supplemented by references found during the readings. The possibility of alcohol substitution by benzodiazepines is addressed, with a partial or approximate terminology reserve for qualifying this substitution. Diazepam appears as the molecule of choice. Such a substitution method, out of its usual field and in a design partly innovative in care, could decrease alcohol damages and perhaps consumption levels.Given the impossibility of conducting the synthesis of a non-existent literature, only an exploratory approach is possible, no recommendation or indication of the use of benzodiazepine as an alcoholic substitution can be formulated, without development validation studies of a such hypothesis (including researches about safety, choice of molecule, ways of psychosocial support…). In order to rethink the place of benzodiazepines in alcohol treatment strategies, owing to their frequent consumption with alcohol, the possibility of an approached alcoholic substitution using these drugs should be considered further. The prolonged used of benzodiazepines after alcohol withdrawal could consist of a harm reduction approach which could help support a psychosocial recovery. Long half-life molecules could be safer and easier to use, and should warrant future clinical trials.

Évaluer la prise en charge des patients présentant un syndrome coronarien aigu avec sus-décalage du segment ST en Vendée.Étude prospective observationnelle menée sur toute l'année 2008. Les patients inclus présentaient un infarctus du myocarde depuis moins de 24 heures étaient vivants à l'arrivée des secours, et étaient pris en charge par le SMUR, les urgences ou la cardiologie de l'hôpital de La Roche-sur-Yon.Deux cent dix-sept patients ont été inclus, 163 hommes et 54 femmes, d'âge moyen 65 ans. Cinquante-six pour cent des patients ont appelé initialement le Samu, dont la moitié dans l'heure après le début des signes. Ils ont bénéficié de l'envoi d'un SMUR pour 72 % des cas. Vingt-six pour cent ont consulté initialement un médecin libéral et un tiers d'entre eux ont été redirigés vers le Samu. Trente pour cent des patients ont suivi la filière idéale : succession douleur thoracique, appel Samu, prise en charge SMUR, angioplastie ou fibrinolyse. Le délai moyen séparant l'électrocardiogramme du traitement fibrinolytique est de 36 minutes, ou de l'arrivée en salle de coronarographie de 105 minutes. Le ballonnet est gonflé 42 minutes après. Quatre-vingt-six pour cent des patients pris en charge à la phase aiguë ont bénéficié d'une stratégie de reperfusion : angioplastie primaire (63 %) ou fibrinolyse (21 %). Quatre-vingt-dix pour cent des revascularisations ont été des succès.Dans le cas des douleurs thoraciques, le Samu est sous-utilisé. Le nombre de patients revascularisés est satisfaisant, mais les délais de prise en charge sont trop longs, surtout quand le traitement est l'angioplastie.Estimating the quality of care of the patients presenting an ST-elevation myocardial infarction in Vendee.Prospective observational study carried out over the year 2008. Included patients presenting a myocardial infarction for less than 24 hours, they were alive when emergency team arrived, and were taken care of by the SMUR, the emergencies or the cardiology of the hospital of La Roche-sur-Yon.Two hundred and seventeen patients were included, 163 men and 54 women, average age: 65 years. Fifty-six percent of the patients called initially the emergency medical service, half of those within an hour after pain began. Seventy-two percent of them were looked after by a SMUR. Twenty-six percent consulted initially a general practitionner, and one third of those were redirected towards the emergency medical service. Thirty percent of all patients followed the ideal procedure defined by succession of chest pain, emergency medical service call, SMUR, angioplasty or fibrinolysis. The average time between the ECG and the fibrinolysis is 36 minutes, or of the arrival in coronarography room is 105 minutes. The balloon is inflated 42 minutes later. Eighty-six percent of the patients taken care of in the acute phase benefited from a strategy of reperfusion, primary angioplasty (63%) or fibrinolysis (21%). Ninety percent of revascularisations were successful.In the case of the chest pain, the emergency medical service is under-used. The number of revascularised patients is satisfactory, but the whole procedure takes too much time, especially when the treatment is the angioplasty.

The authors report the case of 2-old-caucasian women in the pre- and interhospital setting, who presented chest pain with ST segment elevation. Coronary angiography did not show any significant coronary lesion, ventriculography revealed typical aspect of tako-tsubo. It resolved in a short time, with normalisation of the left ventricule function. The tako-tsubo syndrome, or transient left ventricular apical ballooning syndrome, first described by Japanese physicians, is more and more frequently observed in caucasian patients. This cardiomyopathy associates an apical transient dysfunction without any significant coronary lesion. This syndrome is usually observed in elderly women, occurs frequently after acute emotional or physical stress. The clinical presentation looks like an acute coronary syndrome, with chest pain, electrocardiographic changes and moderate cardiac enzymes release. Coronary angiography shows no significant coronary disease and ventriculography a systolic dysfunction with akinesia of middle and apical segments, leading apical ballooning, and basale hyperkinesia. These abnormalities are transient, with quick favorable outcome. The aetiopathegenia is still uncertain. The differential diagnosis with an acute coronary syndrome with thrombosis is not yet possible. Clinical or biological criteria allowing early diagnosis would lead to optimize the therapeutic management.

This study, conducted over two time periods, aimed to evaluate the effectiveness of the diffusion of data, implementation of correctives measures and updated protocols in reducing time to reperfusion in acute myocardial infarction (AMI) management in the out-of-hospital setting. Mean (SD) time to hospital admission and to arterial puncture improved (58 (13) vs 67 (18) min, p = 0.03; and 82 (16) vs 95 (29) min, p = 0.02). The study, performed according to quality control programme methodology, showed that the chronology of AMI management could be improved by appropriate interventions and monitoring of intervention times.

The authors report the case of 2-old-caucasian women in the pre- and interhospital setting, who presented chest pain with ST segment elevation. Coronary angiograpby did not show any significant coronary lesion, ventriculograpby revealed typical aspect of tako-tsubo. It resolved in a short time, with normalisation of the left ventricule function. The tako-tsubo syndrome, or transient left ventricular apical ballooning syndrome, first described by Japanese physicians, is more and more frequently observed in caucasian patients. This cardiomyopathy associates an apical transient dysfunction without any significant coronary lesion. This syndrome is usually observed in elderly women, occurs frequently after acute emotional or physical stress. The clinical presentation looks like an acute coronary syndrome, with chest pain, electrocardiographic changes and moderate cardiac enzymes release. Coronary angiography shows no significant coronary disease and ventriculography a systolic dysfunction with akinesia of middle and apical segments, leading apical ballooning, and basale hyperkinesia. These abnormalities are transient, with quick favorable outcome. The aetiopathegenia is still uncertain. The differential diagnosis with an acute coronary syndrome with thrombosis is not yet possible. Clinical or biological criteria allowing early diagnosis would lead to optimize the therapeutic management. (c) 2007 Elsevier Masson SAS. Tous droits reserves.

INTRODUCTION:This study was carried out to estimate the relationship between arterial PCO2 (PaCO2) and end-tidal carbon dioxide (PETCO2) during prehospital controlled ventilation and also to evaluate variation of the gradient between PCO2 and PETCO2 during prehospital transport. METHODS:Measurements of PETCO2 from capnography values and PaCO2 from arterial blood gases were registered at the beginning (T(0)) and at the end (T(end)) of out-of-hospital management. For all patients requiring invasive ventilation, the gradient between PCO2 and PETCO2 was calculated for T(0) and T(end), the PaCO2-PETCO2 variation between T(end) and T(0) was also calculated. RESULTS:One hundred patients were included in this study (mean age, 58.4 +/- 16.4 years; 57 were male). There was no variation of the mean gradient (DeltaPaCO2-PETCO2 ) during transport (8.64 +/- 13.5 mm Hg at T(0) and 7.26 +/- 12.94 mm Hg at T(end)). Thirty-six percent of patients (n = 36) had a gradient above +10 mm Hg, and for 6% of patients (n = 4) the gradient was lower than -10 mm Hg. The PaCO2-PETCO2 gradient was not significantly different according to the pathology, but was significantly higher in hypercapnic patients compared with hypocapnic or normocapnic patients. In patients with severe head injury, the capnia was normalized in 80% of patients at the end of the transport according to the last blood gas result. In this subgroup the DeltaPaCO2-PETCO2 (T(end) - T(0)) gradient was stable between T(0) and T(end) except in 20% of the patients for whom the DeltaPaCO2-PETCO2 was lower than -10 mm Hg. Fifty-four percent of critical care physicians had modified the respiratory setting after the first arterial blood gas results. CONCLUSIONS:The PaCO2 cannot be estimated by the PETCO2 in the prehospital setting. There is wide variation in the gradient between PCO2 and PETCO2 depending on patient condition, and over time, the relationship does not remain constant and thus cannot be useful in prehospital ventilation management.

Les évènements indésirables graves peuvent conduire à un véritable traumatisme chez le soignant, qu’il soit le fait d’une erreur médicale ou non. Le soignant peut ainsi être considéré comme la deuxième victime de l’accident après le patient. Le traumatisme émotionnel peut avoir des conséquences lourdes sur le professionnel impliqué (addiction, troubles mentaux, burnout, état de stress port traumatique, voire suicide) et, de ce fait, sur la qualité des soins prodigués aux patients. Des prises en charge ont été décrites dans la littérature pour limiter les conséquences du traumatisme chez les professionnels de santé : prise en charge immédiate, puis à court terme et long terme, dans lesquelles participent le soutien des pairs, de la hiérarchie et une aide psychologique spécialisée. La communication doit être large sur ce phénomène peu connu des professionnels eux-mêmes afin de mettre en place des stratégies de prises en charge en amont et impliquant toute l’équipe et l’institution.Health care practitioners involved in a serious adverse event (SAE), whether it being a medical error or not, may experience genuine psychological trauma. Practitioners in such situation should be assessed as genuine second injured person. Psychological trauma in practitioners may lead to various disorders such as drug addiction, alcohol abuse, mental disorders, posttraumatic stress disorders or suicide attempt. These situations carry a high risk for patient's further safety and quality of care. Recommendations in preventing psychological trauma in health care practitioners following SAE have been issued including immediate, short-term and long-term help from co-workers, supervisors and individual psychological support. A wider publicity on SAE-related psychological trauma amongst health care practitioners is warranted in order to raise awareness on this matter.