Les situations qui mettent en jeu dans l’immédiat, à court terme, la vie des patients sont régies en France par l’organisation du “ Secours à personne “ et celle de l’aide médicale urgente. Succès indéniable, cette prise en charge pré-hospitalière de l’urgence vitale repose sur un trépied spécifique : point de recueil unique des appels, régulation médicale et médicalisation précoce sur place. Sont décrits les multiples acteurs qui interviennent et le parcours de la personne en détresse. En matière d’urgence vitale, le patient doit être amené directement, le plus rapidement possible dans la structure hospitalière de référence dévolue à la pathologie qu’il présente. Cette “ filière du suraigu “ concerne l’urgence traumato- logique (polytraumatologie et/ou l’hémorragie non contrôlée, les traumatismes de la moelle épinière), les hémorragies de la délivrance, les urgences médicales vitales telles les cardiopathies ischémiques, l’arrêt cardiaque — la “ mort subite “, l’isché- mie cérébrale aiguë et sa conséquence l’infarctus cérébral, certaines situations de détresse respiratoire aiguë (accident anaphylactique sévère, inhalation de corps étrangers, électrocution, asphyxie par noyade, overdose chez les toxicomanes, certaines intoxications) et les pathologies relevant en première intention de l’oxygéno- thérapie hyperbare (accident de plongée sous-marine, intoxications aigues au monoxyde de carbone ou par fumée d’incendie). L’identification des dysfonctionnements à l’origine de retard, voire de manquement dans la prise en charge des situations d’urgence concerne un retard dans la prise en charge initiale, une médicalisation inadaptée, une mauvaise orientation hospitalière. Ils renvoient à la question de l’égalité des chances pour tous, compte tenu de la diversité du territoire national au plan de la géographie et de la répartition de la population. Les objectifs à atteindre pour améliorer l’efficacité du système sont définis tels : l’amélioration des coordinations fonctionnelles, la mise en place d’un maillage territorial des structures d’urgence, la réduction des inégalités d’accès aux soins d’urgence, le développement des actions de formation aux premiers secours pour le plus grand nombre. Dix propositions ont été retenues par l’Académie nationale de médecine, en termes d’organisation et de moyens.

In France, acute life-threatening situations are handled by the French Secours à Personne (assistance to persons) and emergency medical facilities. An unequivocal success, this early management of life-threatening emergency situations relies upon centralized call reception, medical dispatching, and immediate on-site emergency medical care. We describe the different emergency care providers and steps involved in the response to emergency situations. Each call centre (Samu, phone number 15 ; Sapeurs-Pompiers, 18) provides a response tailored to the nature of incoming calls for assistance. A check-list of grounds for an “ automatic response “ by the SDIS (Service Départemental d’Incendie et de Secours — the French fire brigade) is in use, ensuring that firefighters are often the first on the spot, while the knowledge and skills of the dispatching physician are essential to ascertain the patient’s needs, to preserve life and vital functions, and to ensure the patient is sent to the appropriate emergency healthcare facility. In life-threatening emergency situations, patients must be brought straight to the appropriate reference emergency healthcare facility, as quickly as possible, without prior admittance to an emergency department. This is the procedure for extremely acute emergency situations in the following areas: trauma (multiple trauma and/or uncontrolled bleeding, spinal cord trauma), delivery bleeding, other life-threatening situations such as ischemic heart disease, cardiac arrest (sudden death), cerebrovascular stroke and ensuing brain damage, some acute respiratory situations such as anaphylactic shock, foreign- body inhalation, electrocution, drowning, drug overdose, certain forms of poisoning, and conditions requiring initial hyperbaric oxygen (diving accidents, acute carbon monoxide and smoke poisoning). The reasons for suboptimal emergency care in life-threatening situations are currently a major issue, with medical facilities being reduced in some areas, fewer voluntary firemen, hospital reorganization, tight funding, difficulties of medical dispatching, and the varying skills of “ first-on-the- scene “ emergency workers. Grievances include late emergency responses, inap- propriate medical care, and dispatching to the wrong facility. This raises the question of equal opportunity for all in a country with widely varying geographic features and population density. Improvement in the system’s efficiency will require a series of objectives to be met in varied and complementary — Enhanced functional coordi- nation, by speeding up the deployment of the ANTARES digital radio-frequency transmission network (Adaptation Nationale des Transmissions Aux Risques Et aux Secours). — Implementation of a network of emergency services with varying degrees of emergency healthcare management related to the technical nature of the facilities. Three levels of emergency healthcare must be made available: level 1 is provided by local hospitals, level 2 includes support facilities available in general hospitals (not necessarily the nearest hospital), and level 3 provides specialized healthcare in large and/or training hospitals with specialized departments. Life- threatening emergency situations are to be handled by level 2 or 3 facilities. Specific facilities must be selected as reference centers. In France, the ARS (Agences Régionales de Santé) is in charge of this procedure, as it provide funding for healthcare continuity. — Reducing inequalities in access to emergency care. This will involve improving the network of SDIS brigades, making local medical facilities more responsive, delegating more medical procedures, on-site telemedicine, provi- ding more helicopters equipped with healthcare facilities, more automated external defibrillators, and more dedicated neuro-vascular units. — First aid training must be made widely available. The French National Academy of Medicine has approved ten recommendations regarding organization and facilities.