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Introduction: Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.Methods: Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected.Results: A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.Conclusion: These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Background Children with rare bone diseases (RBDs), whether medically complex or not, raise multiple issues in emergency situations. The healthcare burden of children with RBD in emergency structures remains unknown. The objective of this study was to describe the place of the pediatric emergency department (PED) in the healthcare of children with RBD. Methods We performed a retrospective single-center cohort study at a French university hospital. We included all children under the age of 18 years with RBD who visited the PED in 2017. By cross-checking data from the hospital clinical data warehouse, we were able to trace the healthcare trajectories of the patients. The main outcome of interest was the incidence (IR) of a second healthcare visit (HCV) within 30 days of the index visit to the PED. The secondary outcomes were the IR of planned and unplanned second HCVs and the proportion of patients classified as having chronic medically complex (CMC) disease at the PED visit. Results The 141 visits to the PED were followed by 84 s HCVs, giving an IR of 0.60 [95% CI: 0.48–0.74]. These second HCVs were planned in 60 cases (IR = 0.43 [95% CI: 0.33–0.55]) and unplanned in 24 (IR = 0.17 [95% CI: 0.11–0.25]). Patients with CMC diseases accounted for 59 index visits (42%) and 43 s HCVs (51%). Multivariate analysis including CMC status as an independent variable, with adjustment for age, yielded an incidence rate ratio (IRR) of second HCVs of 1.51 [95% CI: 0.98–2.32]. The IRR of planned second HCVs was 1.20 [95% CI: 0.76–1.90] and that of unplanned second HCVs was 2.81 [95% CI: 1.20–6.58]. Conclusion An index PED visit is often associated with further HCVs in patients with RBD. The IRR of unplanned second HCVs was high, highlighting the major burden of HCVs for patients with chronic and severe disease.

The emergency department (ED) is often confronted with end-of-life care. We searched if the missing information identifying patients as needing palliative care was detrimental for the emergency care. We conducted an analytical retrospective study at the ED of European Georges Pompidou Hospital (Paris), including 99 patients for whom a means’ limitation decision had been taken. We created a composite criterion of detrimental care. The palliative care information was present in the chart for one fourth of patients. Care was more often detrimental in the non-identified as palliative group (62 patients (85%) vs. 9 (35%) (p

Introduction: The general practitioner is the cornerstone of victims’ care in case of CBRN event. He organizes the first survival aids, hampered by a large outfit. What is the suit’s impact on time required to carry out these actions? Materials and Methods: We performed a clinical controlled study. Doctors and nurses, with and without CBRN suits, were timed on two actions. On one hand, they were performed on airway control (by laryngeal mask, Fastrach or orotracheal intubation). On the other hand, they had to prepare an antidotic solution, and find an endovascular access (intravenous and intra osseous effective perfusion). Statistical comparison was performed by paired Student T test. Results CBRN suit significantly slowed down the realization of survival aids, notably intubation with laryngeal mask (12.0 +- 2.9 vs 14.3 +- 3.9 s, p = 0.0005) and with Fastrach (30.1 +- 15 4 vs 40.6 +- 26.2 s, p = 0.035). It did not significantly modify the orotracheal intubation (50.8 +- 25.9 vs 59.6 +- 39.1s, p = 0.27). Drug preparation, venous perfusion and intraosseous infusion were also slowed down in our experience (respectively 131.4 +- 44.2 vs 157.1 +- 66.4s, p = 0.033; 136.2 +- 27.5 vs 169.2 +- 41.5s, p = 0.0006; 139.7 +- 35.3 vs 158.5 +- 41.3s, p = 0.018). Discussion: This study illustrates the negative impact of CBRN suits on survival actions. Fastrach seems to be relevant in this situation.; Introduction - Le médecin généraliste est la pierre angulaire de la prise en charge des victimes en cas d’événement NRBC. Il doit réaliser les premiers gestes de survie entravé par une tenue de protection. Quel est l’impact du port de cette tenue sur le temps de réalisation de ces gestes ? Matériels et Méthodes - Une étude clinique d’intervention contrôlée a été réalisée. Des médecins et infirmiers, avec et sans tenue NRBC, étaient chronométrés, d’une part sur le contrôle des voies aériennes (pose de masque laryngé, de Fastrach et d’intubation orotrachéale), d’autre part sur une préparation antidotique, enfin, sur l’abord vasculaire (pose de voie veineuse et de perfusion intra-osseuse efficaces). La comparaison statistique était effectuée par test t apparié. Résultats - La tenue NRBC ralentissait significativement la mise en place du masque laryngé (12,0 +- 2,9 vs 14,3 +- 3,9s; p=0,0005) et la pose de Fastrach (30,1 +- 15,4 vs 40,6 +- 26,2s; p=0,035). Elle ne ralentissait pas de manière significative la réalisation d’une intubation orotrachéale (50,8 +- 25,9 vs 59,6 +- 39,1s; p=0,27). La préparation de drogue, la perfusion veineuse et la perfusion intra-osseuse étaient aussi ralenties (respectivement 131,4 +- 44,2 vs 157,1 +- 66,4s avec p=0,033; 136,2 +- 27,5 vs 169,2 +- 41,5s avec p=0,0006; 139,7 +- 35,3 vs 158,5 +- 41,3s avec p=0,018). Discussion - Cette étude illustre l’impact négatif de la tenue NRBC sur le temps de réalisation des gestes de survie. L’intubation par Fastrach semble pertinente dans cette situation.

Training exercises are now frequently used in health disaster and emergency medicine to train first responders,1 including the use of tabletops’ exercises.2–4 However, these kinds of drill are barely described in occupational and industrial safety and health. They represent an interesting alternative to real life disaster plans, considering the enormous human and technical resources that are required, and the disruptance of company’s daily business. We aimed at developing a special training for professionals of health and safety (occupational physicians, hygienists…) in case of health disaster in industrial settings, using a tabletop exercise. We organized a one day-session about disaster fundamentals for 28 occupational physicians included in a Master degree in emergency medicine training. A tabletop exercise was made based on a scenario of a fire in a plant with risk of chemical explosion - 22 victims and one dead (person). Three groups of 9/10 participants had 1h15 to discuss and « play » rescue operations from the initial accident to the discharge of the last victims from the triage centre. They were supervised by a physician and a nurse who are specialized in disaster training. We used a large tabletop representing the industrial plant and the figurines/vehicles (patients, industrial and emergency responders, firemen and police officers, journalist…). Satisfaction and cost were evaluated such as repeatability. The participants were largely satisfied by the training and believe, such as the teachers, that the exercise well illustrates the roles of occupational physicians, the triage centre, and intricate logistics during a health disaster. The direct cost was $1,285 (975 euros), namely $646 for the figurines and $639 for the supervisors for the first year ($46 per participant). At the opposite of a real life exercise, we didn’t notice any impact on daily activities of the company/plant. One year later, the tabletop was performed again with other 28 participants with similar satisfaction and reduced cost (only $639 for the supervisors, $23 per participants). Tabletop exercises simulating industrial disasters appear to be a cost-effective way to train professionals of health and safety. Similar experiences are reported in other contexts: airport disasters,2 biological threats in a public health preparedness,5;6 training of medical technicians for emergency.3 Tabletop exercises could also be used to train different categories of participants in similar drill. Considering the purpose of training participants to organise the prevention and the management of industrial disasters in their own company, it was seen as easier and as cheaper than real life disaster plans. To conclude, although real life exercise remains essential (especially in order to challenge emergency responders) effectiveness should be studied in depth. We think these kinds of exercises should be developed in the industrial settings.

BACKGROUND: The development of a short training program for emergency care physicians for rapid ultrasound assessment of two points (the groin and popliteal areas) could be useful for later implementation of a safe home care strategy for patients with suspected deep vein thrombosis before the results of a complete duplex-Doppler exploration are available. PURPOSE: Validation of the proposed training program by studying inter-operator agreement (trainee versus vascular physician) in a multicentric assessment of 60 emergency care physicians. Establish the learning curve. METHODOLOGY: Theoretical training: two-page document with schematic drawings and consultation of image bank on the Web. Practical training: 25 patients in all, the last 15 as an independent operator, writing a standardized report. Interoperator agreement: (a) centralized data collection and independent analysis of the report written by the trainee and a vascular physician for the same patients (n(o) 11 to 25); (b) determination of the coefficient of variance, kappa, and construction of the learning curve (900 agreement points for 60 trainees). INCLUSION CRITERIA: (a) Treated distal or proximal thrombosis recruited by the vascular physician (blinded to the result of the flash US); patient's oral consent. EXPECTED RESULTS: Learning curve leveling off at about the 20th patient with a kappa>0.61 or even 0.80. ORIGINAL CONTRIBUTION OF THE PROJECT: (a) Prospective, multicentric, blinded study: (i) confirming the feasibility of a two-point venous ultrasound performed by emergency care physicians; (ii) validation of the contents and duration of a short simplified training program; (b) Validation of a decision criterion for home care; If validated, this type of training program might be applied in other disciplines (intensive care, geriatrics).

Overuse of the d-dimer to screen for possible pulmonary embolism (PE) can have negative consequences. This study derives and tests clinical criteria to justify not ordering a d-dimer. The test threshold was estimated at 1.8% using the method of Pauker and Kassirer. The PE rule-out criteria were derived from logistic regression analysis with stepwise backward elimination of 21 variables collected on 3148 emergency department patients evaluated for PE at 10 US hospitals. Eight variables were included in a block rule: Age50 years, pulse100 bpm, SaO(2)94%, no unilateral leg swelling, no hemoptysis, no recent trauma or surgery, no prior PE or DVT, no hormone use. The rule was then prospectively tested in a low-risk group (1427 patients from two hospitals initially tested for PE with a d-dimer) and a very low-risk group (convenience sample of 382 patients with chief complaint of dyspnea, PE not suspected). The prevalence of PE was 8% (95% confidence interval: 7-9%) in the low-risk group and 2% (1-4%) in the very low-risk group on longitudinal follow-up. Application of the rule in the low-risk and very low-risk populations yielded sensitivities of 96% and 100% and specificities of 27% and 15%, respectively. The prevalence of PE in those who met the rule criteria was 1.4% (0.5-3.0%) and 0% (0-6.2%), respectively. The derived eight-factor block rule reduced the pretest probability below the test threshold for d-dimer in two validation populations, but the rule's utility was limited by low specificity.

International audience; no abstract