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Background Out-of-hospital cardiac arrest (OHCA) is a major public health concern in France, given that there are 61.5 cases per 100,000 inhabitants a year. The impact of bystander action, performed before the arrival of emergency medical services (EMS), on survival has never been studied in France. Purpose Determine whether bystander cardiopulmonary resuscitation (CPR), performed before the arrival of EMS, was correlated with an increased 30-day survival rate after an OHCA. Methods 24,885 out-of-hospital cardiac arrests witnessed in France from 1 January 2012 to 1 May 2018 were analysed to determine whether CPR, performed before the arrival of EMS, was correlated with survival. Data from the Electronic Registry of Cardiac Arrests was used. The association between the effect of CPR performed before the arrival of EMS and 30-day survival rate was studied, using propensity analysis (which included variables such as age and sex of the patient, location, cause, and year of cardiac arrest, initial cardiac rhythm, EMS response time and no-flow time). Results CPR was performed before the arrival of EMS in 14,904 cases (59.9%) and was not performed in 9,981 cases (40.1%). The 30-day survival rate was 10.2% when CRP was performed by bystanders versus 3.9% when CRP was not performed before the EMS arrival (p The effect of bystander CPR on survival Conclusion Bystander CPR performed before the arrival of EMS was associated with an increased 30-day survival rate after an out-of-hospital cardiac arrest in France.

Detection of microorganisms by blood cultures (BCs) is essential in managing patients with bacteraemia. Rather than the number of punctures, the volume of blood drawn is considered paramount in efficient and reliable detection of microorganisms. We performed a 1-year prospective multicentre study in adult emergency departments of three French university hospitals comparing two methods for BCs: a unique blood culture (UBC) collecting a large volume of blood (40 mL) and the standard method of multiple blood cultures (MBC). The performances of both methods for bacterial contamination and efficient microbial detection were compared, each patient serving as his own control. Amongst the 2314 patients included, three hundred were positive for pathogens (n = 245) or contaminants (n = 55). Out of the 245 patients, 11 were positive for pathogens by UBC but negative by MBC and seven negative by UBC but positive by MBC (p 0.480). In the subgroup of 137 patients with only two BCs, UBC was superior to MBC (p 0.044). Seven and 17 patients had contaminated BCs by UBC and MBC only, respectively (p 0.062). Considering the sums of pathogens missed and contaminants, UBC significantly outperformed MBC (p 0.045). Considering the complete picture of cost savings, efficient detection of microorganisms and decrease in contaminations, UBC offers an interesting alternative to MBC.

Objectifs Cette etude a ete realisee afin d’evaluer l’effet antalgique de la neurocryostimulation (NCS) sur les douleurs post-traumatiques en medecine d’urgence. Methodes: Cette etude prospective s’est deroulee durant 12 jours dans un service d’urgence. Tous les patients âges de plus de 12 ans se presentant aux urgences avec une douleur post-traumatique evoluant depuis moins de 24 heures etaient inclus. Apres une appreciation de l’intensite de leur douleur lors de l’admission (t0) par une echelle visuelle analogique (EVA, score de 0 a 100), ces derniers ont beneficie directement d’une seance de NCS. L’intensite de la douleur a ete reevaluee a l’issue de cette cryotherapie (t1) puis a la sortie des urgences (t2).

RésuméLa prise en charge en urgence de patients présentant un syndrome coronaire aigu (SCA) repose sur un diagnostic clinique et électrocardiographique précis. La stratification initiale du risque est l’étape clé. L’orientation, ultime étape, dépend du degré de l’urgence et de la stratégie de reperfusion envisagée dès la phase pré-hospitalière. La prise en charge d’un patient présentant un SCA nécessite donc une collaboration étroite entre les médecins de l’urgence et les cardiologues selon des protocoles pour un accès facilité au cathétérisme si nécessaire.Les défis de la prise en charge des SCA en pré-hospitalier reposent sur plusieurs facteurs:a)la « maîtrise » par l’urgentiste de nouvelles molécules anti-agrégantes et anticoagulantes pour adapter leurs prescriptions au profil du patient;b)le développement de filières en fonction des spécificités régionales (considérations géographiques et répartition des centres interventionnels) de mutualisations entre les établissements, afin de réduire le temps d’accès aux salles de cathétérisme des patients à haut risque;c)l’organisation en réseau où le SAMU joue un rôle essentiel pour la coordination entre les différents acteurs médicaux;d)l’analyse en routine de l’évolution des pratiques professionnelles en corrélation avec les recommandations de la Haute Autorité de santé;e)et l’intégration de la médecine pré-hospitalière aux programmes de prévention en santé pour mieux décrypter les représentations de la maladie coronaire et encourager les patients et leurs proches à utiliser le « 15 ».SummaryRisk stratification in the prehospital setting is key in the emergency management of patients with acute coronary syndromes (ACS), based on clinical diagnosis and specific electrocardiographic criteria. The orientation is the ultimate stage of this decision support and depends on the degree of urgency and the strategy chosen. The management of ACS patients requires close collaboration between emergency physicians and cardiologists, using simplified protocols to facilitate access to catheterization if judged necessary. Multiple other challenges exist in the prehospital management of ACS:a)‘control’ by emergency physicians of new antiplatelet and anticoagulant molecules, adjusting their prescription to patient profiles;b)the development of clusters based on regional specifics (e.g. geographic considerations and distribution of percutaneous coronary intervention centers) to reduce delay to catheterization in high-risk patients;c)the network organization, where the SAMU is essential for coordination between different medical teams;d)the routine evaluation of evolving practices in terms of quality of care;e)and the integration of prehospital medicine into healthcare programs to better understand the manifestations of coronary artery disease and to encourage patients and their families to use the emergency medical system. The task faced by emergency physicians is to adopt strategies that more closely align to patients’ needs.

La mortalidad de la sepsis grave (definida como una disfuncion o hipoperfusion organica inducida por una infeccion) y del shock septico (hipotension arterial refractaria a la reposicion liquida, asociada a la disfuncion o hipoperfusion organica) tratada en una unidad de reanimacion sigue siendo elevada (del orden del 45%), mientras que se espera un aumento de su incidencia en los proximos 25 anos (por el incremento de su deteccion). No obstante, se ha podido registrar recientemente una disminucion significativa de su mortalidad en varios ensayos terapeuticos aislados, basados en una monitorizacion dirigida hacia el tratamiento global de la oxigenacion tisular o que empleaba nuevas vias de tratamiento, que son sobre todo la utilizacion de corticoides en dosis moderadas, la modulacion de la activacion de la hemostasia por la proteina C activada y la aplicacion sistematica de referenciales de cuidados en la reanimacion. Al igual que en el infarto de miocardio, la combinacion de estas nuevas medidas terapeuticas debe realizarse en un ambito global de optimizacion precoz y rapida (6-24 horas). Este nuevo esquema de tratamiento deberia garantizar en el futuro una reduccion considerable de la mortalidad y de la morbilidad de la sepsis (reduccion esperada del 25% durante los proximos 5-10 anos).

Objectives: To point out prognosis factors of local recurrence after endoscopic cordectomies for Tis, T1a, T1b, and T2 glottic squamous cell carcinomas. Study Design: A cohort of 110 patients treated from January 1990 to December 2000 at a single institution was retrospectively analyzed: 21 had Tis, 76 T1a, 7 T1b, and 6 T2 (mean follow-up 42 mo; range 1–160 mo). Methods: The depth and extension of the excision were graded according to the European Laryngological Society Classification. Univariate analysis was used to review the impact on disease-free survival of factors related to the host, the tumor, and the treatment. Results: According to the Kaplan-Meier method, the 5 year overall survival and the disease-free survival were 87% and 75%, respectively. The rates of cause-specific survival, ultimate local control with laser alone, and laryngeal preservation were 97%, 84%, and 90%, respectively. Univariate analysis by the log rank test revealed that vocal muscle infiltration (P = .001) and subglottic involvement (P = .02) have a significant impact on disease-free survival. Of the 22 patients with local recurrence (17 T1a, 1 T1b, and 4 T2), 9 were managed with total laryngectomy, 5 with partial laryngectomy, 4 with further laser cordectomy, 2 with radiotherapy, and 2 had no curative treatment. Conclusion: Transoral laser surgery for early glottic carcinoma is a valid alternative to radiotherapy and partial laryngectomy in terms of oncologic results. It offers low morbidity and excellent retreatment options in case of local failure. Careful patient selection for laser surgery is essential to secure good results.

Intoxication, by cyanurate and its chlorated derivatives in children, is increasingly reported in the literature due to accidental ingestion compared to accidental inhalation. We report a case in a 5-year-old child who presented with acute lung injury due to accidental inhalation of gas formed after a reaction of sodium dichloroisocyanurate tablets with water. Prevention remains the best way to reduce the risk of children being intoxicated by inhalation of the gas formed after contact of tablets with water.

Resume Nous rapportons l’observation d’un homme de 64 ans hospitalise pour prise en charge d’une epistaxis droite recidivante. Le bilan standard d’hemostase (TP, TCA, numeration plaquettaire) retrouvait un allongement isole du TCA a 105 s pour un temoin a 33 s. Le patient ne presentait pas d’histoire hemorragique anterieure. Le bilan d’hemostase complet avec etude des facteurs de coagulation montrait un facteur VIII effondre a 5 %, ainsi que la presence d’un auto-anticorps dirige contre le facteur VIII dose a 4,5 unites Bethesda·mL –1 . Le bilan etiologique retrouvait une infection pulmonaire a Chlamydia pneumoniae . Le traitement comportait deux volets : a) le controle de l’hemorragie par mechages anterieurs (quatre au total) et par perfusion de facteur VIIa recombinant (NovoSeven ® ) ; b) l’eradication de l’auto-anticorps anti-FVIII par la mise en route d’une corticotherapie et d’une bi-antibiotherapie efficace sur Chlamydia pneumoniae . L’evolution a ete favorable avec d’une part tarissement de l’epistaxis et d’autre part normalisation du bilan d’hemostase, disparition de l’auto-anticorps et guerison de l’infection pulmonaire (disparition du syndrome inflammatoire biologique et de l’image pulmonaire en quelques semaines).

Septic shock is reported as the most common cause of death in intensive care units. Worldwide data indicate a 30 to 60% mortality rate. This death rate has not really changed since the early 1970s despite improved antibiotic therapy, cardiovascular support, and various advances in the management and treatment of sepsis. Septic shock pathophysiology may be related to several altered blood vessel functions associated or not with obvious anatomical injury. Normally, endothelial cells act as a signaling sensor for blood messages to vascular smooth muscle cells. They play a pivotal role in the regulation of local vascular tone. Endothelial injury due to systemic inflammation and induction of the coagulation cascade has been well recognized in the pathophysiology of septic shock. A better understanding of endothelial cell abnormalities occurring during septic shock might prove to be a good way to optimize septic shock therapy.

Resume Les auteurs rapportent l'observation d'un enfant de 22 mois, hospitalise pour un volumineux hematome du scalp survenu 72 heures apres une chute. Deux drainages ont ete pratiques a 48 heures d'intervalle en raison d'une recidive. Le patient, ne de parents consanguins, avait des antecedents d'hemorragies recidivantes depuis la naissance. Un bilan standard de l'hemostase comprenant taux de prothrombine, temps de cephaline active, temps de saignement, fibrinogene et plaquettes etait normal. Dans ce contexte, le dosage des facteurs de la coagulation a permis de mettre en evidence un deficit constitutionnel severe isole en facteur XIII (activite inferieure a 2 %). Un nouveau drainage a ete pratique sous couvert d'une injection de concentre de facteur XIII. Les suites operatoires ont ete simples. Un traitement prophylactique a ete propose, a raison d'une injection de 50 UI·kg −1 de concentre de facteur XIII toutes les 5 semaines.

Resume Un jeune homme de 21 ans, victime d'un accident du travail, a ete hospitalise pour fracture complexe non deplacee du tiers superieur du tibia droit, sans traumatisme crânien associe. Son etat hemodynamique etait stable. Une contention par plâtre cruropedieux a ete effectuee. Deux heures apres son admission, l'examen clinique mettait en evidence une obnubilation (score de Glasgow a 10) d'apparition brutale, sans signe de focalisation. Quatre heures apres l'admission, une aggravation des troubles de conscience (score de Glasgow a 7), accompagnee d'une crise convulsive hemicorporelle gauche, etait notee. La tomodensitometrie cerebrale initiale et la ponction lombaire etaient normales. La radiographie pulmonaire etait normale. Des petechies sur le tronc et l'abdomen etaient progressivement apparues. Une thrombopenie et un allongement du temps de prothrombine etaient notes. L'imagerie par resonance magnetique realisee a la 27 e heure montrait des hypersignaux en T2 au niveau du tronc cerebral et des noyaux gris centraux, evoquant une embolie graisseuse. Au fond d'œil, une hemorragie papillaire en flammeches a ete observee. Le diagnostic d'embolie graisseuse cerebrale a ete conforte par le lavage broncho-alveolaire mettant en evidence des inclusions lipidiques macrophagiques. L'interet de cette observation est de rappeler la possibilite de forme neurologique predominante d'embolie graisseuse et l'interet diagnostique de l'imagerie par resonance magnetique realisee precocement apres le traumatisme.

Le syndrome coronarien ou coronaire aigu (SCA) est constitue des manifestations cliniques, electrocardiographiques et biologiques liees a la rupture d’une plaque « vulnerable » d’atherome ayant induit la formation d’un thrombus limitant le flux sanguin dans le reseau arteriel coronaire [1,2] Merci de replacer ces appels de reference dans le texte. Les SCA sont classes en SCA avec elevation (ou sus-decalage) du segment ST (SCA ST+) et en SCA sans elevation du segment ST (SCA non ST+). Dans les SCA ST +, le thrombus est constitue principalement de fibrine entrainant une occlusion coronaire aigue totale responsable d’une necrose complete du tissu myocardique dans les six heures, tandis que dans les SCA non ST+, il est plutot de type plaquettaire n’obstruant pas completement la lumiere arterielle [3] Merci de replacer cet appel de reference dans le texte. La douleur thoracique est le signe d’appel le plus courant. Le facteur temps est l’element cle dans la prise en charge des SCA. Le role des Samu-Smur-Centre 15 est essentiel, permettant une prise en charge rapide. Quel que soit le type de SCA, le traitement comporte la prise d’aspirine, de clopidogrel ou de prasugrel, d’anticoagulant, une anxiolyse (si besoin) et un traitement antalgique. Dans les SCA non ST +, l’evaluation des marqueurs biologiques de souffrance myocardique (troponine) peut permettre une orientation diagnostique et therapeutique des la phase prehospitaliere. L’apport recent de nouvelles et puissantes molecules antiagregantes plaquettaires et anticoagulantes a modifie les strategies decisionnelles et de prise en charge des SCA en prehospitalier afin de garantir une reperfusion optimale et dans les meilleurs delais.

Chondronecrosis of the cricoid cartilage is a rare complication of intubation. The records of two children were reviewed. An 8-month-old girl with myelomonocytic leukaemia developed chondronecrosis 10 days after a 2-day period of ventilation. A 4-year-old girl comatose after poisoning by the histamine antagonist, alimemazine, developed chondronecrosis after a 2-day period of intubation. The complication was suspected when extubation led to dyspnoea owing to laryngeal stridor and was confirmed by direct laryngoscopy. We review the development of the condition, the causative factors, treatment and prevention.

Resume L'avulsion partielle du cornet moyen est une complication inhabituelle de l'intubation nasotracheale, alors que le traumatisme de la muqueuse nasale est plus frequent. Nous rapportons le cas d'une patiente de 25 ans, sans antecedent particulier, qui apres une intubation nasotracheale pour extractions dentaires, a presente une obstruction nasale unilaterale en rapport avec un arrachement du cornet moyen sur toute sa longueur, avec bascule en arriere bloquant la choane.

Remifentanil and alfentanil are opioids often used during direct laryngoscopy (DL). This prospective, randomized study compared these agents with respect to haemodynamic and Bispectral Index (BIS) responses, glottic visualization, and rapidity of recovery (spontaneous ventilation, eye opening) in DL without intubation.A total of 60 patients undergoing DL were randomized into two groups: remifentanil (R) and alfentanil (A). Anaesthesia was induced with propofol 2.5 mg kg(-1) and the opioid was administered 1 min later (R=2 microg kg(-1) or A=30 microg kg(-1) over 30 s). DL was commenced 1 min after (corresponding to 3 min after the beginning of induction). Glottic visualization, opioid and/or propofol re-injection, spontaneous ventilation recovery, and eye opening were recorded.During DL, mean arterial pressure (MAP) increased by 6% in the R group vs 20% in the A group (P0.05) when compared with post-induction values without affecting heart rate or BIS. No significant difference was observed between groups with respect to glottic exposure, opioid and/or propofol re-injection, and spontaneous ventilation recovery (mean (SEM) 3.8 (0.6) min, R group vs 3.2 (0.7) min, A group, NS) or eye opening (7.1 (1.1) min, R group vs 7.4 (0.9) min, A group, NS). Thirty minutes after postanaesthesia care unit (PACU) admission, MAP returned to its pre-induction value in the R group (104 (3) vs 109 (3) at baseline, NS), whereas in the A group MAP remained significantly lower at this time point (96 (4) vs 106 (3) at baseline, P0.05).This study showed that only remifentanil prevented MAP increase without adverse effects such as bradycardia during DL, and prevented MAP decrease 30 min after PACU admission.

In the United Kingdom, a recent analysis of an intensive care unit (ICU) database reported that surgical patients represented 45% of total ICU admissions with an important mortality rate since 20.1% of them died [1]. A surgical patient is considered at high risk if their preoperative status is altered or if the surgical procedure is prolonged and/or associated with heavy blood loss. Many attempts have been made to identify such patients early and to evaluate the impact of perioperative therapeutic optimization on outcome. In 1979, Shoemaker et al. [2] defined criteria for high surgical risk. These included: patient history: age more than 70 years with evidence of limited major physiologic function, previous severe cardiopulmonary or vascular illness, severe nutritional disorders critical factors: severe multiple trauma, massive acute blood loss, shock, septicemia or septic shock, respiratory failure, acute abdominal catastrophe, acute intestinal or renal failure surgical procedure factors: extensive surgery for cancer or prolonged surgery more than 8 hours.

The vascular endothelium is a highly specialized tissue involved in modulating immune responses and vascular cell growth, and in regulating the level of hemostatic, inflammatory, and vasoactive agents in the blood (Table 1). Endothelial cells line vessels in every organ system and regulate the flow of nutrient substances, diverse biologically active molecules, and the blood cells themselves. This ‘gate-keeping’ role of the endothelium is effected through the presence of membrane-bound receptors for numerous molecules including proteins, lipid transporting particles, metabolites and hormones, as well as through specific junction proteins and receptors that govern cell-to-cell and cell-tomatrix interactions [1]. This feature explains why endothelium dysfunction and/or injury with subendothelium exposure facilitates leukocyte and platelet aggregation and aggravation of coagulopathy. Therefore, endothelial dysfunction and/or injury should favor impaired perfusion, tissue hypoxia and subsequent organ dysfunction.

Aim and Background The stroke network is organised around the Stroke Unit (SU) which is known to be effective to reduce mortality and handicap in all types of strokes. However, most of patients do not receive imaging in a timely manner, only 40% of patients admitted in a hospital with SU are hospitalised in this unit and less than 1% of patients are thrombolysed. The aim of our study was to evaluate the efficacy of the stroke network before the stroke unit for improving. Programme We conducted a prospective study during 2 months to evaluate the intra-hospital management of patients admitted for suspected stroke in emergency department (ED) before the SUof our University Hospital in terms of delay, imaging and orientation. We compared the length of stay in ED for patients admitted for suspected stroke and for patients hospitalised for other neurological reasons. Results 258 patients were admitted for suspected stroke. This diagnosis was confirmed in 225 patients, including 44 transient ischaemic attack, 155 ischaemic stroke, 26 hemorrhagic stroke; 13 patients received intravenous thrombolysis. 27% were admitted within 3 h after symptom onset, 8% between 3 and 4 h 30 and 20% awaked with stroke. The delay of admission was significantly shorter in patients with hemorrhagic stroke and in patients for whom the emergency telephone system have been used. Median delay for imaging was1 h 59 min in the all population and was 53 min for patients admitted within 3 h. Only 12% of patients received CT scan within 25 min of hospital admission. Two third of the patients were admitted in stroke unit. The mean length of stay at the ED was 25 min for thrombolysis patients, 5 h 20 for the others admitted in stroke unit and 5 h 57 for all the population hospitalised for stroke, which did not differ from the length of stay for the other neurological hospitalisations. Discussion The impact of the stroke network is proved by the high percentage of patients admitted in stroke unit and the shorter delay of management for patients who are thrombolysed. However, the benefit is not observed for all patients with stroke. Conclusion These data suggest areas for improvement in hospital-level stroke system of care which could increase patient access to stroke unit and therefore potentially reduce stroke related morbidity and mortality. It should be recommended for all patients admitted for stroke and not only for patients who can be thrombolysed. Objectif(s), Contexte Les autorites sanitaires francaises ont favorise la mise en place d9une filiere d9organisation des soins, structuree autour de l9unite neurovasculaire (UNV) dont le benefice est attendu quel que soit l9âge du patient, le type et la severite de l9AVC. Malgre cette organisation, l9acces rapide a l9imagerie est reserve a une minorite de patients, 40% des patients admis dans un etablissement avec UNV y sont admis et moins de 1% des patients victimes d9AVC sont actuellement thrombolyses. L9objectif de notre travail est d9analyser le fonctionnement de la filiere neurovasculaire (fNV) en amont de l9UNV afin de l9optimiser. Programme Nous avons mene une etude prospective sur une periode de 2 mois en analysant les modalites de prise en charge intra-hospistaliere (delais d9admission, acces a l9imagerie, duree de sejour, orientation) des patients admis pour AVC dans le SAU du CHU de Lille en amont de l9UNV. Nous avons compare, dans un deuxieme temps, le delai de sejour des patients admis pour AVC a celui des patients hospitalises pour un autre motif neurologique. Resultats 250 patients suspects d9AVC ont ete admis, ce diagnostic a ete retenu chez 225 d9entre eux. Il s9agissait de 44 accidents transitoires et 181 accidents constitues dont 155 d9origine ischemique ; parmi eux 13 ont ete thrombolyses. 27% des patients etaient admis dans les 3h ; 8% entre 3-4h30 et 20% avaient un AVC du reveil. Les delais d9admission sont plus courts chez les patients ayant beneficie d9une regulation et chez ceux dont l9accident est de nature hemorragique. Tous les patients ont eu un scanner cerebral dont le delai median de realisation etait de 1h59. Pour les patients admis dans les 3 heures le delai median etait de 53 minutes. Au total, seuls 12% des patients ont eu leur imagerie dans les 25 minutes apres leur admission conformement aux recommandations. Au terme de la prise en charge, 2 patients sur 3 ont ete admis en UNV. Le duree de sejour au SAU pour les patients admis en UNV etait de 5h20 apres exclusion des patients thrombolyses (pour qui le delai etait de 25 minutes), ce delai etait de 5h57 pour l9ensemble des admissions pour AVC, il ne differait pas significativement des autres motifs d9admission en neurologie. Discussion Il existe un effet filiere avec plus de 60% des patients admis en UNV et des delais plus courts pour les patients eligibles pour une thrombolyse. Cependant, ce benefice en termes de delai ne se repercute pas sur l9AVC « standard » dont les delais de prise en charge et de duree de sejour restent prolonges au SAU alors que les premieres heures de l9AVC sont decisives tant sur le plan physiopathologique que therapeutique. Conclusion Le developpement d9une prise en charge structuree des AVC doit maintenant s9etendre a tous les AVC et non pas aux seuls patients susceptibles de beneficier d9une thrombolyse.

Backgrounds STEMI management is a public healthcare priority. Prompt reperfusion leads to a decrease in mortality and morbidities induced by myocardial necrosis. Every year, pre-hospital medical teams at Lille University Hospital handle almost one hundred and fifty STEMI. These patients need a reperfusion strategy either with a pre-hospital intra venous thrombolysis or a Percutaneous Coronary Intervention (PCI) in catheterism laboratory (cath-lab). Program This study is a cross-disciplinary professional practices evaluation between SAMU 59 and Lille University Hospital9s Cardiology Intensive-Care Unit. A retrospective analyse of medical data was done. We have made a review of medical data from ESTIM registry involving SAMU 59 since 2001. During the first 6 months of 2006, twenty medical records were random drawn. These data were compared with HAS guidelines in Acute Coronary Syndromes. Emergency Medical Physicians and Cardiologists daily implicated in STEMI support did analyse these data. Reperfusion rate, strategy of reperfusion and delays regarding the strategy were analysed. Results 90% of patients received Aspirin (ASA). Reperfusion rate is about 75%: 12 pre-hospital intravenous thrombolysis, 3PCI, five patients with no reperfusion. In case of thrombolysis, thrombolytic was administrated within 30 min after ECG diagnosis in 100% of cases. In case of PCI, patients did not directly reach the cath-lab: the 90 min average delay recommended in guidelines was therefore never respected. Clinical guidance for STEMI patients has thus been revised. Patients needing PCI should be directly admitted to the cath-lab. Public and private hospital partnership has been strengthened so that cath-lab availability was increased. A second look was performed with the same data, reviewing 18 medical records. ASA has been administrated in 100% of cases. Reperfusion rate is about 100%. Twelve patients received pre-hospital intravenous thrombolysis and 12 patients were admitted to cath-lab to undergo PCI. For those PCI occurred patients, in 50% of cases, delay between ECG diagnosis and balloon inflation was under 90 min. The other 6 PCI performed on patients after 90 min resulted in rhythmic and hemodynamic complications during transportation to hospital, needing Intensive-Care Unit first. Conclusion Rating scales have been validated by the HAS in 2008, and provided for every physician willing to assess professional practices. It enabled us to focus on consensual indicators. STEMI reperfusion is a challenge against time. All the actors are involved: the call-center emergency physician who sets off and coordinates resources, the cardiologist who will perform PCI, the pre-hospital emergency physician who diagnoses STEMI. Evaluation of professional practices allowed to detect weakness of STEMI management system in which choice of a reperfusion strategy and delay linked to this strategy directly impact early mortality. The choice of a reperfusion strategy suited to each patient and its environment is a guarantee of quality in management of STEMI. Objectif(s), contexte La prise en charge des SCA ST+ est un enjeu majeur de sante publique. La precocite de la reperfusion permet de diminuer la mortalite et les morbidites associees a la necrose myocardique. Chaque annee, environ 150 patients presentant un SCA ST+ sont pris en charge par le SMUR de Lille. Ils doivent beneficier d9une strategie de reperfusion en urgence que ce soit une thrombolyse IV des la phase pre-hospitaliere ou une angioplastie primaire en salle de catheterisme. Programme Ce travail a permis de realiser une « Evaluation de Pratiques Professionnelles » transversale entre le SAMU 59 et le service des soins intensifs cardiologiques du CHRU de Lille. Un audit cible de dossiers a ete realise. Les dossiers du registre ESTIM, auquel le SAMU59 participe depuis 2001 ont ete utilises. Un tirage au sort de 20 dossiers sur les 6 premiers mois de l9annee 2006 a ete realise. Ces dossiers ont ete compares au referentiel RPC/HAS: « Syndromes coronariens Aigus » Des medecins urgentistes et des cardiologues directement impliques dans la prise en charge des patients ont participe a cette evaluation. Le taux de reperfusion, la technique choisie, les delais selon la technique de reperfusion ont ete etudies. Resultats L9ASA est administre dans 90% des cas. Le taux de reperfusion est de 75%: 12 thrombolyses, 3 angioplasties primaires (ATLP), 5 patients non reperfuses. En cas de thrombolyse, elle est realisee dans les 30 min apres l9ECG qualifiant dans 100% des cas; par contre en cas d9angioplastie primaire, les patients ne sont pas directement deposes sur la table de coronarographie et le delai global de 90 min recommandes n9est pas respecte. De ce fait, le chemin clinique a ete modifie, en cas de decision d9angioplastie primaire les patients arrivent directement en salle de catheterisme. Le partenariat public-prive a ete renforce afin d9ameliorer la disponibilite des tables de coronarographie. Une seconde evaluation a ete realisee en etudiant les memes indicateurs de reperfusion. 18 dossiers de SCA ST+ ont ete analyses. L9ASA est alors administre dans 100% des cas. Le taux de reperfusion est de 100%. 12 patients ont beneficie d9une thrombolyse pre hospitaliere et 12 d9une angioplastie primaire. 50% des patients en ATLP ont un delai (ECG qualifiant-ballon) inferieur a 90 min. Les 6 autres patients ont presentes des complications lors de la prise en charge necessitant une prise en charge plus lourde. Conclusion Les grilles d9evaluation, validees par la HAS en 2008 et mises a disposition des praticiens, permettent de diriger l9EPP sur des indicateurs consensuels. La reperfusion en urgence d9un SCA ST + est un defi contre le temps. Elle implique tous les acteurs de la prise en charge depuis le medecin regulateur du SAMU, qui declenche et coordonne l9envoi des moyens, jusqu9au cardiologue realisant l9angioplastie en passant par le medecin urgentiste du SMUR. L9EPP permet de deceler « les failles » d9un systeme de prise en charge ou le choix d9une strategie et le delai de mise en œuvre de celle-ci sont des elements qui conditionnent directement la mortalite en phase aigue. Le choix d9une strategie de reperfusion adaptee a chaque patient et a son environnement est un gage de qualite en terme de prise en charge des SCA ST+.

Acquired laryngotracheal stenosis is a serious long term complication of tracheal intubation with an incidence of 0.7 to 8% in intubated children. We report five cases of subglottic stenosis over a 4.5-year period and review the pathology and pathogenesis of the condition. A diagnosis of subglottic stenosis was suspected when extubation failed due to the onset of dyspnoea or laryngeal stridor. An incidence of 0.9% of all intubated children was observed. We conclude that the main components contributing to stenosis are pathologies with decreased mucosal capillary perfusion pressure and intubation conditions.