Out-of-Hospital refractory Cardiac Arrest (OHrCA) has a mortality rate between 90 and 95%. Since 2009, French medical academic societies have recommended the use of extracorporeal life support (ECLS) for OHrCA. According to these guidelines, patients were eligible for ECLS support if vital signs were still present during cardiopulmonary resuscitation (CPR), or if cardiac arrest was secondary to intoxication or hypothermia (≤32°C). Otherwise, patients would receive ECLS if (i) no-flow duration was less than 5 min; (ii) time delays from CPR to ECLS start (low flow) were less than 100 min; and (iii) expiratory end tidal CO2 (ETCO2 ) was more than 10 mm Hg 20 min after initiating CPR. We have reported here our experience with ECLS in OHrCA according to the previous guidelines. We retrospectively analyzed mortality rates of patients supported with ECLS in case of OHrCA. From December 2009 to December 2013, 183 patients were assisted with ECLS, among which 32 cases were of OHrCA. Mean age for the OHrCA patients was 43.6 years. Over two-thirds were male (71.9%). Causes of OHrCA included intoxication, isolated hypothermia <32°C, acute coronary syndrome, pulmonary edema, and other cardiac pathology. Despite adherence to protocols, only two patients (6.2%) with hypothermia and acute myocardium ischemia, respectively, could be discharged from hospital after cardiac recovery. Causes of death were brain death and multiple organ failure. Despite ECLS support setting in accordance with French guidelines in case of refractory OHrCA, mortality rates remained high. French ECLS support recommendations for OHrCA due to presumed cardiac cause should be re-examined through new studies. Low flow duration should be improved by a shorter time of CPR before hospital transfer.

OBJECTIVE: Although patients presenting seizures are commonly admitted in the emergency department (ED), the specific use of resources for known epileptic patients (KEP) is rarely studied. DESIGN/METHODS: All consecutive KEP admitted for seizures at our academic ED were included prospectively from November 2011 to November 2012.We collected pre and intra hospital data including clinical features, informations about management and use of resources. Hospitalized patients or outpatients for whom a brain imaging or/and an electroencephalogram were performed in ED were considered as users of resources. RESULTS: Among the 60 578 admissions in ED, 580 files (1%) concerned 451 KEP (344 males; median age 43 years, interquartile range (IQR)15-91years). Four hundred thirty nine (76%) patients utilized emergency medical system (EMS) call centre and 65 (11%) received therapeutics before the admission. One hundred fifty nine (27%) patients were assessed by brain imaging and 91(16%) by EEG. The median ED length of stay in ED was 5h32 (IQR 4:05-8:12 ). At the end of ED management, 50% of patients were hospitalized with a median length of stay of 5 days (interquartile range 2-9 days). Two hundred fifty-five (43%) patients were admitted for usual seizure without additional investigations excepting a blood test. Patients no users of resources were younger, more frequently men, followed by a specialist of epilepsy and admitted for usual seizure (p<0.005). The use of EMS did not differ between patients associated with a consumption of resources and the others. CONCLUSIONS: The admission of KEP was associated to a high amount of resources. Our results suggest that some ED visits could be avoid in a large number of patients. Further studies should be performed in order to optimize the seizure care pathway for KEP. Study Supported by:

OBJECTIVE: To estimate the frequency of emergency department (ED) visits and the modalities of admission for known epileptic patients (KEP) as well as their profiles. DESIGN/METHODS: Between November 2011 and November 2012, we prospectively recruited adults with a seizure diagnostic in ED and intensive care unit (ICU) in a tertiary hospital of a large-sized French city. Patients with established epilepsy were identified. We collected clinical features, characteristics of epilepsy, and modalities of admission. In one year, the number of patients affected by an active epilepsy was estimated at 3765 in our district (584400 inhabitants), based on age-adjusted prevalence value provided by the literature (5.4/1000 inhabitants; Picot et al, 2008). RESULTS: Among the 60 578 admissions in ED, 989 (95% confidence interval [CI]: 1.6% [1.5%-1.7%]) were linked to seizure motive and 580 files (0.96% [0.88%-1.03%]) concerned 451 KEP (344 males; median age 43 years SD 20.3Y). Among these 451 patients, 339 depended on our district. The frequency of ED visit for KEP from our district was 9.0% per year [8.1%-9.9%]. Among the 580 files, 437 (75.3% [71.8%-78.9%]) involved patients with symptomatic partial epilepsy and 247 (42.6% [38.6%-46.6%]) involved patients treated at least with 2 anti-epileptic drugs. One hundred seventy-five patients were followed by a specialist of epilepsy (30.2% [26.4%-33.9%]). Concerning the pre-hospital management, 439 (75.7% [72.2%-79.2%]) patients utilized emergency medical system call centre and 413 (71.2% [67.5%-74.9%]) came from their place of residence, 50 (8.6% [6.3%-10.9%]) patients were admitted directly in ICU. Seventy-seven (13.3% [10.5%-16.0%]) admissions were associated with traumatism or head injury, 299 (51.6% [47.5%-55.6%]) patients were admitted for usual seizures and 44 (7.6% [5.4%-9.7%]) had a final diagnosis of status epilepticus. CONCLUSIONS: The frequency of ED visit for KEP is high and concerned in at least one out of two cases patients with usual seizure. Further studies should be performed in order to optimize the seizure care pathway for KEP. Study Supported by: Disclosure: Dr. Girot has nothing to disclose. Dr. Derambure has nothing to disclose. Dr. Chochoi has nothing to disclose. Dr. Leblanc has nothing to disclose. Dr. Goldstein has nothing to disclose. Dr. Szurhaj has nothing to disclose. Dr. Williate has nothing to disclose. Dr. Lenne has nothing to disclose. Dr. Wiel has nothing to disclose. Dr. Hubert has nothing to disclose. Dr. Richard has nothing to disclose. Dr. Tyvaert has nothing to disclose.

The emergency diagnostic strategy for acute ischemic stroke consists of:--identification of stroke, based on clinical examination (sudden onset of a focal neurological deficit);--identification of the ischemic or hemorrhagic nature by MRI or CT;--determination of the early time-course (clinical examination) and the cause. In all strokes (ischemic or hemorrhagic), treatment consists of:--the same general management (treatment of a life-threatening emergency, ensuring normal biological parameters except for blood pressure, and prevention of complications);--decompressive surgery in the rare cases of intracranial hypertension. For proven ischemic stroke, other therapies consist of: rt-PA for patients admitted with 4.5 hours of stroke onset who have no contraindications, and aspirin (160 to 300 mg) for patients who are not eligible for rt-PA. These treatments should be administered within a few hours. A centralized emergency call system (phone number 15 in France) is the most effective way of achieving this objective.

The emergency diagnostic strategy for acute ischemic stroke consists of: - identification of stroke, based on clinical examination (sudden onset of a focal neurological deficit); - identification of the ischemic or hemorrhagic nature by MRI or CT; - determination of the early time-course (clinical examination) and the cause. In all strokes (ischemic or hemorrhagic), treatment consists of: - the same general management (treatment of a life-threatening emergency, ensuring normal biological parameters except for blood pressure, and prevention of complications); - decompressive surgery in the rare cases of intracranial hypertension. For proven ischemic stroke, other therapies consist of: rt-PA for patients admitted with 4.5 hours of stroke onset who have no contraindications, and aspirin (160 to 300 mg) for patients who are not eligible for rt-PA. These treatments should be administered within a few hours. A centralized emergency call system (phone number 15 in France) is the most effective way of achieving this objective.

Pre-hospital notification enhances thrombolysis rate and improves intra-hospital delays, but the impact of the notification to the neurologist by the emergency medical system (EMS) call centre remains unknown. Our objective was to compare pre-hospital and in-hospital delays in stroke patients treated by intravenous recombinant tissue plasminogen activator (rt-PA), with and without pre-hospital notification. We compared baseline characteristics and in-hospital delays in stroke patients treated by rt-PA with a high-level notification (call to EMS and EMS–neurologist discussion), a low-level notification (call to EMS without EMS–neurologist discussion ) and no pre-hospital notification. Of 302 consecutive patients [165 women, 54.6 %; median age 74 years, interquartile range (IQR) 59–83], patients with high-level, low-level and no notification differed for the severity at admission (median National Institutes of Health Stroke Scale scores, respectively, of: 12, IQR 7–17; 9, IQR 6–15, and 8, IQR 6–14, p = 0.029). Patients with high-level notification had shorter (1) admission-to-completion of imaging times (27 min, IQR 14–35) than patients with low-level notification (35 min, IQR 17–54) or no notification (36 min, IQR 30–58) ( p < 0.01); (2) door-to-needle times (49 min, IQR 39–62 vs. 57 min, IQR 39–81 vs. 63 min, IQR 51–97; p = 0.003); and (3) onset-to-needle times (140 min, IQR 110–175 vs. 155 min, IQR 106–230 vs. 182 min, IQR 131–234; p < 0.001). They did not differ for onset-to-admission time and imaging-to-needle time. Pre-hospital notification by the EMS reduces intra-hospital delays in patients eligible for rt-PA, but the benefit is higher in the case of discussion between the EMS and the neurologist before admission.