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Tracheostomy is considered the airway management of choice for patients who require prolonged mechanical ventilation. The development of percutaneous techniques offers many advantages including the ability to perform the procedure in the intensive care unit. The aim of this study was to compare the controlled rotating dilation method (PercuTwist) and the Griggs' forceps dilational tracheostomy. Patients over 18 years of age undergoing tracheostomy in the intensive care unit were included in the study. They were divided in two random samples--either PercuTwist or forceps dilational tracheostomy. Data collected prospectively included demographic characteristics, procedure duration, blood gas analysis, intracranial pressure, arterial blood pressure and heart rate before and after the procedure. Any complications during or after the procedure due to the tracheostomy were also recorded. Contrary to the main hypothesis, PercuTwist technique took significantly longer to perform than forceps dilational tracheostomy technique (five minutes [2 to 25] vs three minutes [1 to 17][P=0.006]). A significant increase in P(a)CO2 and decrease in arterial pH were observed in both groups between the pre-tracheostomy and post-tracheostomy blood gas analysis. Haemodynamic tolerance was good. Our results show that intracranial pressure is affected by the procedure whatever the technique used. However we did not observe a decrease in cerebral perfusion pressure. The incidence of complications was 23% (20/87). These complications were minor in 18/20 and were not significantly different between the two groups. In conclusion, we consider that the PercuTwist technique is safe despite the longer duration of the procedure. Nevertheless the forceps dilational technique remains our routine procedure. [ABSTRACT FROM AUTHOR]

Introduction: The use of norepinephrine (NE) during uncontrolled haemorrhagic shock (HS) has mostly been investigated in experimental studies. Clinical data including norepinephrine dose and its impact on fluid resuscitation and organ function are scarce. We hypothesized that there is great variability in NE use and that high doses of NE could lead to increased organ dysfunction as measured by the sequential organ failure assessment (SOFA).Method: We included patients with HS (systolic blood pressure < 90 mmHg in severely injured patients) who required haemostasis surgery and a transfusion of more than 4 packed red blood cells (PRBC) in the first 6 h of admission and the used of norepinephrine infusion to maintain the blood pressure goal, between admission and the end of haemostasis surgery in a prospective trauma database. A ROC curve determined that, using Youden's criterion, a dose of NE ≥ 0.6 µg/kg/min was the optimal threshold associated with intrahospital mortality. Patients were compared according to this threshold in a propensity score (PS) model. In a generalized linear mixed model, we searched for independent factors associated with a SOFA ≥ 9 at 24 h RESULTS: A total of 89 patients were analysed. Fluid infusion rate ranged from 1.43 to 57.9 mL/kg/h and norepinephrine infusion rate from 0.1 to 2.8 µg/kg/min. The HDNE group received significantly less fluid than the LDNE group. This dose is associated with a higher SOFA score at 24h: 9 (7-10) vs. 7 (6-9) (p = 0.003). Factors independently associated with a SOFA score ≥ 9 at 24 h were maximal norepinephrine rate ≥ 0.6 µg/kg/min (OR 6.69, 95% CI 1.82 - 25.54; p = 0.004), non-blood resuscitation volume < 9 mL/kg/h (OR 3.98, 95% CI 1.14 - 13.95; p = 0.031) and lactate at admission ≥ 5 mmol/L (OR 5.27, 95% CI 1.48 - 18.77; p = 0.010) CONCLUSION: High dose of norepinephrine infusion is associated with deleterious effects as attested by a higher SOFA score at 24 h and likely hypovolemia as measured by reduced non-blood resuscitation volume. We did not find any significant difference in mortality over the long term. [ABSTRACT FROM AUTHOR]

Competing Interests: The authors have no conflict of interests to disclose.

Background: Burnout among emergency health care professionals is well-described, especially during the COVID-19 pandemic. Prevention interventions, such as mindfulness, focus on the management of stress., Objective: To evaluate the effects of the FIRECARE program (a mindfulness intervention, supplemented by heart coherence training and positive psychology workshops) on burnout, secondary stress, compassion fatigue, and mindfulness among advanced life support ambulance staff of the Paris Fire Brigade., Materials and Methods: We used a non-randomized, two-group quasi-experimental study design with a waitlist control and before-and-after measurements in each group. The intervention consisted of six, once-weekly, 2.5-h sessions that included individual daily meditation and cardiac coherence practice. The study compared intervention and waitlist control groups, and investigated baseline, post-program, and 3-month follow-up change on burnout (measuring using the ProQOL-5 scale) and mindfulness (measuring using the FMI scores). Baseline burnout (measured using the ProQOL-5) was evaluated and used in the analysis., Results: Seventy-four 74 participants volunteered to participate; 66 were included in the final analysis. Of these, 60% were classified as suffering from moderate burnout, the 'burnout cluster'. A comparison of intervention and waitlist control groups found a decrease in the burnout score in the burnout cluster ( p  = 0.0003; partial eta squared = 0.18). However, while secondary stress fell among the burnout cluster, it was only for participants in the intervention group; scores increased for those in the waitlist group ( p  = 0.003; partial eta squared = 0.12). The pre-post-intervention analysis of both groups also showed that burnout fell in the burnout cluster ( p  = 0.006; partial eta squared = 0.11). At 3-month follow-up, the burnout score was significantly reduced in the intervention group ( p  = 0.02; partial eta squared = 0.07), and both the acceptance ( p  = 0.007) and mindfulness scores ( p  = 0.05; partial eta squared = 0.05) were increased in the baseline burnout cluster., Conclusion: FIRECARE may be a useful approach to preventing and reducing burnout among prehospital caregivers.

Background and Purpose: Pulmonary hypertension (PH) is a cardiovascular disease characterised by an increase in pulmonary arterial (PA) resistance leading to right ventricular (RV) failure. Reactive oxygen species (ROS) play a major role in PH. OP2113 is a drug with beneficial effects on cardiac injuries that targets mitochondrial ROS. The aim of the study was to address the in vivo therapeutic effect of OP2113 in PH., Experimental Approach: PH was induced by 3 weeks of chronic hypoxia (CH-PH) in rats treated with OP2113 or its vehicle via subcutaneous osmotic mini-pumps. Haemodynamic parameters and both PA and heart remodelling were assessed. Reactivity was quantified in PA rings and in RV or left ventricular (LV) cardiomyocytes. Oxidative stress was detected by electron paramagnetic resonance and western blotting. Mitochondrial mass and respiration were measured by western blotting and oxygraphy, respectively., Key Results: In CH-PH rats, OP2113 reduced the mean PA pressure, PA remodelling, PA hyperreactivity in response to 5-HT, the contraction slowdown in RV and LV and increased the mitochondrial mass in RV. Interestingly, OP2113 had no effect on haemodynamic parameters, both PA and RV wall thickness and PA reactivity, in control rats. Whereas oxidative stress was evidenced by an increase in protein carbonylation in CH-PH, this was not affected by OP2113., Conclusion and Implications: Our study provides evidence for a selective protective effect of OP2113 in vivo on alterations in both PA and RV from CH-PH rats without side effects in control rats., (© 2023 The Authors. British Journal of Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Purpose: The study of preventable trauma deaths is one mechanism used to examine the quality of care and outcomes of a trauma system. The present study aims to define the rate of preventable (PD) and potentially preventable death (PPD) in our mature trauma center, determine its leading causes, and evaluate the evolution of this rate over the years., Methods: We performed a retrospective observational study in the Sainte Anne Military Teaching Hospital, Toulon (Var), France. From January 2013 to December 2020, all patients with severe trauma admitted to our trauma center and who died were analyzed. An independent group of 4 experts in the management of severe trauma performed the classification of deaths using a DELPHI method., Results: During the study period, 180 deaths occurred among 2642 consecutive severe trauma patients (overall mortality 6.8%). 169 deaths were analyzed, Eleven (6.5%) were considered PD, and thirty-eight (22.1%) were PPD. 69 errors were identified. The most frequent errors were in pre-hospital (excessive pre-hospital times 33.3% and inadequate management 29%). Time before surgery was considered excessive in 15.9% of cases. Over the study period, the rates of PD and PPD deaths remained stable., Conclusion: PD and PPD rates are still high and do not decrease over the years in our mature trauma center. It confirms the need for progress in the management of severe trauma patients. Reducing the time to provide care seems to be the main area for improvement. Further studies will be necessary to better target the points to be improved., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: Out-of-hospital cardiac arrest (OHCA) has a poor prognosis, with an overall survival rate of about 5% at discharge. Shockable rhythm cardiac arrests (ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have a better prognosis. In case of shockable rhythm, treatment is based on defibrillation, and thereafter, in case of failure of 3 external electric shocks (EES), on direct intravenous administration of 300 mg amiodarone, or lidocaine when amiodarone is unavailable or inefficient. During surgical procedures under extracorporeal circulation, a high potassium cardioplegia solution is administered to interrupt cardiac activity and facilitate surgical procedure. By extension, direct intravenous administration of potassium chloride (KCl) has been shown to convert VF, resulting in return to a hemodynamically efficient organized heart rate within a few minutes. The aim of this study is to provide clinical evidence that direct intravenous injection of KCl, into a patient presenting with OHCA due to refractory VF although 3 EES, should interrupt this VF and then allow rapid restauration of an organized heart rhythm, and thus return of spontaneous circulation (ROSC)., Methods: A multicenter, prospective, single group, phase 2 study will be conducted on 81 patients presenting with refractory VF. After failure of 3 EES, each patient will receive direct intravenous injection of 20 mmol KCl instead of amiodarone. The primary outcome will be survival rate at hospital admission. Major secondary outcomes will include ROSC and time to ROSC in the prehospital setting, number of VF recidivism after KCl injection, survival rate at hospital discharge with a good neurologic prognostic, and survival rate 3 months after hospital discharge with a good neurologic prognostic., Results: No patient is currently included in the study., Discussion: Conventional guideline strategy based on antiarrhythmic drug administration, i.e. amiodarone or lidocaine, for OHCA due to shockable rhythm, has not yet demonstrated an increase in survival at hospital admission or at hospital discharge. This may be related to the major cardiodepressant effect of those drugs., Trial Registration: ClinicalTrials.gov Identifier: NCT04316611. Registered on March 2020. AP-HP180577 / N° EUDRACT: 2019-002544-24. Funded by the French Health Ministry. https://clinicaltrials.gov/ct2/show/NCT04316611., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Jouffroy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In France, in 2015, prehospital emergency doctors were faced with civilian casualties in hemorrhagic shock resulting from terrorist attacks with automatic rifle fire and explosive weapons. The present study aimed to evaluate the impact of these attacks on the advanced life support (ALS) team's practices and equipment and on physician training in the prehospital management of traumatic hemorrhagic shock., Methods: This before-and-after multicenter study evaluated professional practices based on a questionnaire sent to emergency department heads and medical practitioners in 370 ALS teams in metropolitan France., Results: We analyzed 672 responses from 209 (56.5 percent) ALS teams in 91 of 95 emergency medical services (EMS) headquarters. Of these 91, 73 (80.2 percent) had a protocol in use for managing traumatic hemorrhagic shock after the attacks, compared with 45 (49.5 percent) who had protocols in use before the attacks (p < 0.001). Ultrasound equipment was available in 49 (53.8 percent) of the EMS headquarters after the attacks, compared to 39 (42.9 percent) before (p < 0.001). Limb tourniquets were available in 90 (98.9 percent) EMS headquarters after the attacks, versus 27 (29.7 percent) before (p < 0.001). Tranexamic acid was available in 88 (96.7 percent) EMS headquarters after the attacks, versus 71 (78 percent) before (p < 0.001). During the post-attack period, training in war medicine did not affect individual practices, neither for using the shock index or the Focused Assessment with Sonography for Trauma (FAST) nor the tourniquet. However, this training was associated with more frequent use of hemostatic dressings (p = 0.002)., Conclusion: Following the attacks in Paris and Nice, ALS teams received additional equipment and training to prepare for future mass causality events.

Importance: Blood transfusion is a mainstay of therapy for trauma-induced coagulopathy, but the optimal modalities for plasma transfusion in the prehospital setting remain to be defined., Objective: To determine whether lyophilized plasma transfusion can reduce the incidence of trauma-induced coagulopathy compared with standard care consisting of normal saline infusion., Design, Setting, and Participants: This randomized clinical trial was performed at multiple centers in France involving prehospital medical teams. Participants included 150 adults with trauma who were at risk for hemorrhagic shock and associated coagulopathy between April 1, 2016, and September 30, 2019, with a 28-day follow-up. Data were analyzed from November 1, 2019, to July 1, 2020., Intervention: Patients were randomized in a 1:1 ratio to receive either plasma or standard care with normal saline infusion (control)., Main Outcomes and Measures: The primary outcome was the international normalized ratio (INR) on arrival at the hospital. Secondary outcomes included the need for massive transfusion and 30-day survival. As a safety outcome, prespecified adverse events included thrombosis, transfusion-related acute lung injury, and transfusion-associated circulatory overload., Results: Among 150 randomized patients, 134 were included in the analysis (median age, 34 [IQR, 26-49] years; 110 men [82.1%]), with 68 in the plasma group and 66 in the control group. Median INR values were 1.21 (IQR, 1.12-1.49) in the plasma group and 1.20 (IQR, 1.10-1.39) in the control group (median difference, -0.01 [IQR, -0.09 to 0.08]; P = .88). The groups did not differ significantly in the need for massive transfusion (7 [10.3%] vs 4 [6.1%]; relative risk, 1.78 [95% CI, 0.42-8.68]; P = .37) or 30-day survival (hazard ratio for death, 1.07 [95% CI, 0.44-2.61]; P = .89). In the full intention-to-treat population (n = 150), the groups did not differ in the rates of any of the prespecified adverse events., Conclusions and Relevance: In this randomized clinical trial including severely injured patients at risk for hemorrhagic shock and associated coagulopathy, prehospital transfusion of lyophilized plasma was not associated with significant differences in INR values vs standard care with normal saline infusion. Nevertheless, these findings show that lyophilized plasma transfusion is a feasible and safe procedure for this patient population., Trial Registration: ClinicalTrials.gov Identifier: NCT02736812.

Background: There exists a need for prognostic tools for the early identification of COVID-19 patients requiring intensive care unit (ICU) admission and mortality. Here we investigated the association between a clinical (initial prehospital shock index (SI)) and biological (initial prehospital lactatemia) tool and the ICU admission and 30-day mortality among COVID-19 patients cared for in the prehospital setting., Methods: We retrospectively analysed COVID-19 patients initially cared for by a Paris Fire Brigade advanced (ALS) or basic life support (BLS) team in the prehospital setting between 2020, March 08th and 2020, May 30th. We assessed the association between prehospital SI and prehospital lactatemia and ICU admission and mortality using logistic regression model analysis after propensity score matching with Inverse Probability Treatment Weighting (IPTW) method. Covariates included in the IPTW propensity analysis were: age, sex, body mass index (BMI), initial respiratory rate (iRR), initial pulse oximetry without (SpO2i) and with oxygen supplementation (SpO2i.O2), initial Glasgow coma scale (GCSi) value, initial prehospital SI and initial prehospital lactatemia., Results: We analysed 410 consecutive COVID-19 patients [254 males (62%); mean age, 64 ± 18 years]. Fifty-seven patients (14%) deceased on the scene, of whom 41 (72%) were male and were significantly older (71 ± 12 years vs. 64 ± 19 years; P 〈10 -3 ). Fifty-three patients (15%) were admitted in ICU and 39 patients (11%) were deceased on day-30. The mean prehospital SI value was 1.5 ± 0.4 and the mean prehospital lactatemia was 2.0 ± 1.7 mmol.l -1 . Multivariate logistic regression analysis on matched population after IPTW propensity analysis reported a significant association between ICU admission and age (adjusted Odd-Ratio (aOR), 0.90; 95% confidence interval (95%CI): 0.93-0.98;p = 10 -3 ), SpO2i.O2 (aOR, 1.10; 95%CI: 1.02-1.20;p = 0.002) and BMI (aOR, 1.09; 95% CI: 1.03-1.16;p = 0.02). 30-day mortality was significantly associated with SpO2i.O2 (aOR, 0.92; 95% CI: 0.87-0.98;p = 0.01 P < 10 -3 ) and GCSi (aOR, 0.90; 95% CI: 0.82-0.99;p = 0.04). Neither prehospital SI nor prehospital lactatemia were associated with ICU admission and 30-day mortality., Conclusion: Neither prehospital initial SI nor lactatemia were associated with ICU admission and 30-day mortality among COVID-19 patients initially cared for by a Paris Fire Brigade BLS or ALS team. Further prospective studies are needed to confirm these preliminary results., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022. Published by Elsevier Inc.)

Background: Emergency physicians can use a manual or an automated defibrillator to provide defibrillation of patients who had out-of-hospital cardiac arrest (OHCA). Performance of emergency physicians in identifying shockable rhythm with a manual defibrillator has been poorly explored whereas that of automated defibrillators is well known (sensitivity 0.91-1.00, specificity 0.96-0.99). We conducted this study to estimate the sensitivity/specificity and speed of shock/no-shock decision-making by prehospital emergency physicians for shockable or non-shockable rhythm, and their preference for manual versus automated defibrillation., Methods: We developed a web application that simulates a manual defibrillator (https://simul-shock.firebaseapp.com/). In 2019, all (262) emergency physicians of six French emergency medical services were invited to participate in a study in which 60 ECG rhythms from real OHCA recordings were successively presented to the physicians for determination of whether they would or would not administer a shock. Time to decision was recorded. Answers were compared with a gold standard (concordant answers of three experts). We report sensitivity for shockable rhythms (decision to shock) and specificity for non-shockable rhythms (decision not to shock). Physicians were also asked whether they preferred manual or automated defibrillation., Results: Among 215 respondents, we were able to analyse results for 190 physicians. 57% of emergency physicians preferred manual defibrillation. Median (IQR) sensitivity for a shock delivery for shockable rhythm was 0.91 (0.81-1.00); median specificity for no-shock delivery for non-shockable rhythms was 0.91 (0.80-0.96). More precisely, sensitivities for shock delivery for ventricular tachycardia (VT) and coarse ventricular fibrillation (VF) were both 1.0 (1.0-1.0); sensitivity for fine VF was 0.6 (0.2-1). Specificity for not shocking a pulseless electrical activity (PEA) was 0.83 (0.72-0.86), and for asystole, specificity was 0.93 (0.86-1). Median speed of decision-making (in seconds) were: VT 2.0 (1.6-2.7), coarse VF 2.1 (1.7-2.9), asystole 2.4 (1.8-3.5), PEA 2.8 (2.0-4.2) and fine VF 2.8 (2.1-4.3)., Conclusions: Global sensitivity and specificity were comparable with published automated external defibrillator studies. Shockable rhythms with the best clinical prognoses (VT and coarse VF) were very rapidly recognised with very good sensitivity. The decision-making for fine VF or asystole and PEA was less accurate., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

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 in-hospital 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., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 Published by Elsevier B.V.)

The aim of this study was to assess the level of exposure to and contamination by smoke within a population of firefighter instructors. We performed a prospective observational study from September 17 to September 26, 2018, using environmental samples and urinary biomarker analysis. Occupational exposure limits (OELs) were never exceeded, except for carbon monoxide for the fire attack training chamber and formaldehyde and carbon monoxide for the fire box. As regards to urinary biomarkers, we observed that 1OHP and 1-naphtol did accumulate. The pre-post analysis showed an acute exposure exceeding the BRVs of benzene, 1-hydroxypyrene and naphtol, except for 3-benzo[a]pyrene which was undetectable in half of the cases. Even if values were reassuring, an effort could be made to improve the working conditions and reduce contamination by rethinking the respiratory protection and improving PPE quality.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique that uses internal clamping of the aorta to control abdominal, pelvic, or junctional bleeding. We created a course to train military physicians in both civilian prehospital use and battlefield use. To determine the effectiveness of this training, we conducted REBOA training for French military emergency physicians., Methods: We trained 15 military physicians, organizing the training as follows: a half-day of theoretical training, a half-day of training on mannequins, a half-day on human corpses, and a half-day on a living pig. The primary endpoint was the success rate after training. We defined success as the balloon being inflated in zone 1 of a PryTime mannequin. The secondary endpoints were the progression of each trainee during the training, the difference between the median completion duration before and after training, the median post-training duration, and the median duration for the placement of the sheath introducer before and after training., Results: Fourteen of the physicians (93%) correctly placed the balloon in the mannequin at the end of the training period. During the training, the success rate increased from 73% to 93% (p = .33). The median time for REBOA after training was only 222 seconds (interquartile range [IQR] 194-278), significantly faster than before training (330 seconds, IQR 260-360.5; p = .0033). We also found significantly faster sheath introducer placement (148 seconds, IQR 126-203 versus 145 seconds, IQR 115.5 - 192.5; p = .426)., Conclusion: The training can be performed successfully and paves the way for the use of REBOA by emergency physicians in austere conditions., (2021.)

Goal: To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre., Design: A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded., Methods: The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology., Results: The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations., Conclusions: There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients., (Copyright © 2021 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Background Although commonly used inside hospitals, no previous case report has been published on high-flow nasal oxygen (HFNO) therapy in an adult in the prehospital setting. Case Report A 46-year-old nonsmoking man presented with a cough and fever. He deteriorated suddenly 5 days later. When the basic life support team arrived, his peripheral oxygen saturation (SpO 2 ) in ambient air was 56% and respiratory rate was 46 breaths/min. The man was weak with thoracoabdominal asynchrony. An emergency medical team with a physician was dispatched. As France was still under lockdown for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic, COVID-19 (coronavirus disease 2019) was suspected. In spite of 15 L/min of oxygen delivered with a nonrebreathing mask, the patient's SpO 2 tended to drop below 90% at the slightest effort and during transport from home to the ambulance. It was therefore decided to start HFNO therapy. The patient was transferred to an intensive care unit, where HFNO was continued. Why Should an Emergency Physician Be Aware of This? As the trend in emergency medical services may move toward prehospital HFNO, this case report is an opportunity to question the feasibility of HFNO therapy in the prehospital setting., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: In December 2019, coronavirus disease (COVID-19) emerged in China and became a world-wide pandemic in March 2020. Emergency services and intensive care units (ICUs) were faced with a novel disease with unknown clinical characteristics and presentations. Acute respiratory distress (ARD) was often the chief complaint for an EMS call. This retrospective study evaluated prehospital ARD management and identified factors associated with the need of prehospital mechanical ventilation (PMV) for suspected COVID-19 patients., Methods: We included 256 consecutive patients with suspected COVID-19-related ARD that received prehospital care from a Paris Fire Brigade BLS or ALS team, from March 08 to April 18, 2020. We performed multivariate regression to identify factors predisposing to PMV., Results: Of 256 patients (mean age 60 ± 18 years; 82 (32%) males), 77 (30%) had previous hypertension, 31 (12%) were obese, and 49 (19%) had diabetes mellitus. Nineteen patients (7%) required PMV. Logistic regression observed that a low initial pulse oximetry was associated with prehospital PMV (ORa = 0.86, 95%CI: 0.73-0.92; p = 0.004)., Conclusions: This study showed that pulse oximetry might be a valuable marker for rapidly determining suspected COVID-19-patients requiring prehospital mechanical ventilation. Nevertheless, the impact of prehospital mechanical ventilation on COVID-19 patients outcome require further investigations., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Aim: To reduce the delay in defibrillation of out-of-hospital cardiac arrest (OHCA) patients, recent publications have shown that drones equipped with an automatic external defibrillator (AED) appear to be effective in sparsely populated areas. To study the effectiveness of AED-drones in high-density urban areas, we developed an algorithm based on emergency dispatch parameters for the rate and detection speed of cardiac arrests and technical and meteorological parameters., Methods: We ran a numerical simulation to compare the actual time required by the Basic Life Support team (BLSt) for OHCA patients in Greater Paris in 2017 to the time required by an AED-drone. Endpoints were the proportion of patients with "AED-drone first" and the defibrillation time gained. We built an open-source website (https://airborne-aed.org/) to allow modelling by modifying one or more parameters and to help other teams model their own OHCA data., Results: Of 3014 OHCA patients, 72.2 ± 0.7% were in the "no drone flight" group, 25.8 ± 0.2% in the "AED-drone first" group, and 2.1 ± 0.2% in the "BLSt-drone first" group. When a drone flight was authorized, it arrived an average 190 s before BLSt in 93% of cases. The possibility of flying the drone during the aeronautical night improved the results of the "AED-drone first" group the most (+60%)., Conclusions: In our very high-density urban model, at most 26% of OHCA patients received an AED from an AED-drone before BLSt. The flexible parameters of our website model allows evaluation of the impact of each choice and concrete implementation of the AED-drone., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: On 15th April 2019, the fire at Notre Dame Cathedral, Paris, resulted in the melting of 410 tons of lead. Four hundred fourteen Paris firefighters were involved. For the purpose of preventive medicine, the level of lead contamination among the firefighters was assessed. This study objectives' were to describe the blood lead levels (BLLs) in the firefighters, to study the influence of some parameters such as the function of firefighters and the decrease in BLLs during the follow-up investigations., Methods: The emission of 138 kg of melted lead from the roof and spire of the Notre Dame Cathedral during the fire was estimated by the National Institute for Industrial Environment and Risks. Three categories were defined according to the estimated levels of external lead exposure and fire proximity: high (category 1, n = 170), medium (category 2, n = 151), and low (category 3, n = 93). Two to three weeks after the fire, blood samples to assess the BLLs were taken from firefighters in category 1 (N = 164) and from every female firefighter in category 1 and 2 (N = 4). When the BLL was above 50 μg/L (95th percentile of reference range concentrations for a sample of the French population), it was checked again at one month later (N = 31) and then, if still above 50 μg/L, at six months later (N = 10)., Results: The geometric mean of initial blood lead level was 31.5 μg/L (CI 95% [27.7-35.9]; Min-Max: 7.0-307.6 μg/L). Twenty-five percent (n = 42) of initial BLLs were above 50 μg/L, versus 10% (n = 16) at 1 month, and 2% (n = 3) at 6 months. The French binding biological BLL limit value (400 μg/L for men and 300 μg/L for women was never exceeded and all BLLs decreased over time. BLLs varied according to the function occupied during the extinguishing of the fire: operators', officers' and those of unknown function. BLLs were significantly higher compared to drivers reflecting their lower distance to fire and fume., Conclusions: The fire at Notre Dame Cathedral, Paris, resulted in moderate lead contamination among firefighters. Individual and collective protection measures probably helped to limit the contamination. Nevertheless, an effort could be made to improve the working conditions by rethinking the respiratory protection., (Copyright © 2021 Elsevier GmbH. All rights reserved.)