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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.

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.

Résumé L’état d’urgence sanitaire est levé en France le 10 juillet 2020. A cette date, la Brigade de sapeurs-pompiers de Paris (BSPP) a déjà réalisé 11 737 interventions en lien direct avec l’épidémie. Au paroxysme de cette crise sanitaire, la Brigade a répondu à plus de 2 600 appels quotidiens et réalisé presque 600 interventions COVID-19 par jour, sans ne jamais avoir à dégrader la qualité de sa réponse contre les incendies. Cet article rapporte l’expérience de la BSPP et les enseignements issus de la crise COVID-19. Il décrit la cinétique de sa montée en puissance progressive ainsi que les actions diverses menées au profit de la population défendue ainsi que de ses propres personnels.

Resume Cet article rapporte l’experience et les enseignements issus de la tres grave explosion due au gaz survenue a Paris (rue de Trevise) le 12 janvier 2019 alors qu’une equipe de la Brigade de sapeurs-pompiers de Paris intervenait pour une odeur de gaz. Le plan d’afflux massif de victimes est declenche et d’importants renforts prennent en charge les nombreux blesses presentant essentiellement des lesions dues au blast. Le bilan a 24 heures est de quatre decedes dont deux sapeurs-pompiers, neuf victimes en urgence absolue et 45 urgences relatives.

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.To determine whether lyophilized plasma transfusion can reduce the incidence of trauma-induced coagulopathy compared with standard care consisting of normal saline infusion.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.Patients were randomized in a 1:1 ratio to receive either plasma or standard care with normal saline infusion (control).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.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.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.ClinicalTrials.gov Identifier: NCT02736812.

International audience; Introduction: In out-of-hospital cardiac arrest (OHCA), external electric shock (EES) is recommended for treating ventricular fibrillation (VF). Refibrillation commonly occurs within one minute post-shock. We aimed to investigate refibrillation times and identifyclinical and electrical factors associated with them.Materials and methods: This retrospective observational study, based on the Paris Fire Brigade database, included non-traumatic OHCA over 18 years of age who received at least one shock with an AED from Basic Life Support (BLS) rescuers and from which we randomly selected a sample to measure the refibrillation-times. Without prior reference to it in the literature, we classified the refibrillation-time into two modalities according to whether it was above or below the median-time. We performed multiple regression analysis to assess associations between refibrillation-time and potential explanatory factors.Results: Among 13,181 patients who experienced OHCA from January 2010 to January 2014, we analysed AED data from 215 patients (590 shocks), 82.1% males, median age 61[IQR: 52-75] years. Most of them occurred at home (57%), were witnessed (87%), and were shockable (88.8%). A median of 5[4-7] EES/patients were delivered. The median-time from shock to refibrillation was 25[13-44] s. Multivariate analysis showed that a shorter post-shock hands-off time favoured earlier refibrillation (p = 0.034), as well as older age (p = 0.002) (Fig. 2, Supplementary table).Conclusion: In non-traumatic OHCA, most refibrillations occurred within 45-s post-shock. Age and post-shock hands-off time were the two contributing factors to time to refibrillation.

On November 13, 2015, in 40 minutes, Paris suffered four suicide bombers attacks; shootings at three different restaurant terraces; and an attack on the Bataclan concert hall, resulting in 130 dead and 495 wounded. How did the Parisian rescue system respond and how did it evolve since? We proved we could deploy quickly wide prehospital and hospital resources and teams' equipment and preparedness is being further developed. To secure a swifter initial response, we need a better integration of the operators of the rescue chain with a simpler and more robust organization as well as improved communications channels. We must continue to anticipate and prepare for possible future attacks.

BACKGROUND Out-of-hospital cardiac arrest (OHCA) remains associated with very high mortality. Accelerating the initiation of efficient cardiopulmonary resuscitation (CPR) is widely perceived as key to improving outcomes. The main goal was to determine whether identification and activation of nearby first responders through a smartphone application named Staying Alive (SA) can improve survival following OHCA in a large urban area (Paris). METHODS We conducted a nonrandomized cohort study of all adults with OHCA managed by the Greater Paris Fire Brigade during 2018, irrespective of mobile application usage. We compared survival data in cases where SA did or did not lead to the activation of nearby first responders. During dispatch, calls for OHCA were managed with or without SA. The intervention group included all cases where nearby first responders were successfully identified by SA and actively contributed to CPR. The control group included all other cases. We compared survival at hospital discharge between the intervention and control groups. We analyzed patient data, CPR metrics, and first responders' characteristics. RESULTS Approximately 4,107 OHCA cases were recorded in 2018. Among those, 320 patients were in the control group, whereas 46 patients, in the intervention group, received first responder-initiated CPR. After adjustment for confounders, survival at hospital discharge was significantly improved for patients in the intervention group (35% vs. 16%, adjusted odds ratio = 5.9, 95% confidence interval = 2.1 to 16.5, p

Objectives The aim of this landmark exploratory analysis, ATLANTIC-H 24 , was to evaluate the effects of pre-hospital ticagrelor during the first 24 h after primary percutaneous coronary intervention (PCI) in the ATLANTIC (Administration of Ticagrelor in the cath Lab or in the Ambulance for New ST elevation myocardial infarction to open the Coronary artery) study. Background The ATLANTIC trial in patients with ongoing ST-segment elevation myocardial infarction showed that pre-hospital ticagrelor was safe but did not improve pre-PCI coronary reperfusion compared with in-hospital ticagrelor. We hypothesized that the effect of pre-hospital ticagrelor may not have manifested until after PCI due to the rapid transfer time (31 min). Methods The ATLANTIC-H 24 analysis included 1,629 patients who underwent PCI, evaluating platelet reactivity, Thrombolysis In Myocardial Infarction flow grade 3, ≥70% ST-segment elevation resolution, and clinical endpoints over the first 24 h. Results Following PCI, largest between-group differences in platelet reactivity occurred at 1 to 6 h; coronary reperfusion rates numerically favored pre-hospital ticagrelor, and the degree of ST-segment elevation resolution was significantly greater in the pre-hospital group (median, 75.0% vs. 71.4%; p = 0.049). At 24 h, the composite ischemic endpoint was lower with pre-hospital ticagrelor (10.4% vs. 13.7%; p = 0.039), as were individual endpoints of definite stent thrombosis (p = 0.0078) and myocardial infarction (p = 0.031). All endpoints except death (1.1% vs. 0.2%; p = 0.048) favored pre-hospital ticagrelor, with no differences in bleeding events. Conclusions The effects of pre-hospital ticagrelor became apparent after PCI, with numerical differences in platelet reactivity and immediate post-PCI reperfusion, associated with reductions in ischemic endpoints, over the first 24 h, whereas there was a small excess of mortality. (Administration of Ticagrelor in the cath Lab or in the Ambulance for New ST elevation myocardial infarction to open the Coronary artery [ATLANTIC, NCT01347580 ])

Summary Background Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction has traditionally been supported by unfractionated heparin, which has never been directly compared with a new anticoagulant using consistent anticoagulation and similar antiplatelet strategies in both groups. We compared traditional heparin treatment with intravenous enoxaparin in primary PCI. Methods In a randomised open-label trial, patients presenting with ST-elevation myocardial infarction were randomly assigned (1:1) to receive an intravenous bolus of 0·5 mg/kg of enoxaparin or unfractionated heparin before primary PCI. Wherever possible, medical teams travelling in mobile intensive care units (ambulances) selected, randomly assigned (using an interactive voice response system at the central randomisation centre), and treated patients. Patients who had received any anticoagulant before randomisation were excluded. Patients and caregivers were not masked to treatment allocation. The primary endpoint was 30-day incidence of death, complication of myocardial infarction, procedure failure, or major bleeding. The main secondary endpoint was the composite of death, recurrent acute coronary syndrome, or urgent revascularisation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00718471. Findings 910 patients were assigned to treatment with enoxaparin (n=450) or unfractionated heparin (n=460). The primary endpoint occurred in 126 (28%) patients after anticoagulation with enoxaparin versus 155 (34%) patients on unfractionated heparin (relative risk [RR] 0·83, 95% CI 0·68–1·01, p=0·06). The incidence of death (enoxaparin, 17 [4%] vs heparin, 29 [6%] patients; p=0·08), complication of myocardial infarction (20 [4%] vs 29 [6%]; p=0·21), procedure failure (100 [26%] vs 109 [28%]; p=0·61), and major bleeding (20 [5%] vs 22 [5%]; p=0·79) did not differ between groups. Enoxaparin resulted in a significantly reduced rate of the main secondary endpoint (30 [7%] vs 52 [11%] patients; RR 0·59, 95% CI 0·38–0·91, p=0·015). Death, complication of myocardial infarction, or major bleeding (46 [10%] vs 69 [15%] patients; p=0·03), death or complication of myocardial infarction (35 [8%] vs 57 [12%]; p=0·02), and death, recurrent myocardial infarction, or urgent revascularisation (23 [5%] vs 39 [8%]; p=0·04) were all reduced with enoxaparin. Interpretation Intravenous enoxaparin compared with unfractionated heparin significantly reduced clinical ischaemic outcomes without differences in bleeding and procedural success. Therefore, enoxaparin provided an improvement in net clinical benefit in patients undergoing primary PCI. Funding Direction de la Recherche Clinique, Assistance Publique-Hopitaux de Paris; Sanofi-Aventis.

BACKGROUND: The direct-acting platelet P2Y12 receptor antagonist ticagrelor can reduce the incidence of major adverse cardiovascular events when administered at hospital admission to patients with ST-segment elevation myocardial infarction (STEMI). Whether prehospital administration of ticagrelor can improve coronary reperfusion and the clinical outcome is unknown.METHODS: We conducted an international, multicenter, randomized, double-blind study involving 1862 patients with ongoing STEMI of less than 6 hours' duration, comparing prehospital (in the ambulance) versus in-hospital (in the catheterization laboratory) treatment with ticagrelor. The coprimary end points were the proportion of patients who did not have a 70% or greater resolution of ST-segment elevation before percutaneous coronary intervention (PCI) and the proportion of patients who did not have Thrombolysis in Myocardial Infarction flow grade 3 in the infarct-related artery at initial angiography. Secondary end points included the rates of major adverse cardiovascular events and definite stent thrombosis at 30 days.RESULTS: The median time from randomization to angiography was 48 minutes, and the median time difference between the two treatment strategies was 31 minutes. The two coprimary end points did not differ significantly between the prehospital and in-hospital groups. The absence of ST-segment elevation resolution of 70% or greater after PCI (a secondary end point) was reported for 42.5% and 47.5% of the patients, respectively. The rates of major adverse cardiovascular events did not differ significantly between the two study groups. The rates of definite stent thrombosis were lower in the prehospital group than in the in-hospital group (0% vs. 0.8% in the first 24 hours; 0.2% vs. 1.2% at 30 days). Rates of major bleeding events were low and virtually identical in the two groups, regardless of the bleeding definition used.CONCLUSIONS: Prehospital administration of ticagrelor in patients with acute STEMI appeared to be safe but did not improve pre-PCI coronary reperfusion. (Funded by AstraZeneca; ATLANTIC ClinicalTrials.gov number, NCT01347580.).

Resume Nous rapportons le cas d’une intoxication fatale par ingestion volontaire de formol en milieu hospitalier, a l’origine d’un arret cardiorespiratoire brutal associe a une coagulation intravasculaire disseminee, une acidose metabolique, une fibrinolyse et un etat de choc refractaire. Il s’agit d’une intoxication gravissime avec une toxicite systemique et caustique. La prise en charge symptomatique doit etre precoce et pluridisciplinaire. En raison du risque toxique, il convient de maintenir a l’hopital les bouteilles de formol dans des locaux ou armoires uniquement accessibles aux professionnels avertis.