Bibliographie du mois de mars 2019 en Médecine d'urgence

Contrôle strict de la glycémie chez les patients gravement malades |

Intensive Glucose Control for Critically Ill Patients.
Conway J, Friedman B. | Acad Emerg Med. 2019 May 10
DOI: https://doi.org/10.1111/acem.13777
Keywords: Aucun

The Brass Tacks: Concise Reviews of Published Evidence

Editorial : In the past decade, emergency department (ED) to intensive care unit (ICU) admissions increased by 79% to 2.2 million admissions annually, reflecting the increasing role of emergency medicine physicians in providing care for critically ill patients. Optimal glucose control in critical care patients has been a topic of contention for decades. In 2001 a single-center trial of mechanically ventilated surgical patients found intensive glucose control (maintaining glucose at 80–110 mg/dL) reduced mortality compared to conventional control (180–200 mg/dL only if glucose exceeded 215). Subsequent studies provided conflicting data, and in 2009, the multicenter NICE-SUGAR trial, the largest trial yet, demonstrated increased mortality with intensive glucose control. Current American Diabetes Association (ADA) guidelines, reflecting concern about harms associated with intensive glucose control, recommend conventional glucose control with a target glucose range of 140 to 180 mg/dL for critically ill patients who experience persistent hyperglycemia.

Conclusion : In summary, there was no benefit found with intensive glucose control in critical care patients but there was increased incidence of severe hypoglycemia. With no benefits and increased harms, the most appropriate color rating for intensive glucose control is black (harms > benefits). Current ADA guidelines, citing the findings of prior meta-analyses, recommend conventional glucose control with targeted blood glucose of 140 to 180 mg/dL in critically ill patients who experience persistent hyperglycemia.

Conclusion (proposition de traduction) : En résumé, aucun avantage n'a été constaté avec le contrôle glycémique strict chez les patients en soins intensifs, mais l'incidence des hypoglycémies graves a augmenté. En l'absence d'avantages et en raison de l'augmentation des méfaits, la couleur la plus appropriée pour un contrôle glycémique intensif est le noir (avantages > méfaits).
Les lignes directrices actuelles de l'ADA, citant les résultats de méta-analyses antérieures, recommandent un contrôle glycémique conventionnel avec une glycémie ciblée de 140 à 180 mg/dL chez les patients gravement malades qui présentent une hyperglycémie persistante.

Association d'un antiviral avec un corticostéroïde pour le traitement de la paralysie aigüe de Bell (paralysie faciale a frigore ou paralysie faciale périphérique) |

Antivirals With Corticosteroids for the Treatment of Acute Bell's Palsy.
Portela RC, Miller AC. | Acad Emerg Med. 2019 Mar;26(3):342-344
DOI: https://doi.org/10.1111/acem.13563
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : The Cochrane meta-analysis cited here assesses the effectiveness of antiviral treatment alone or in combination with corticosteroids to decrease the risk of incomplete recovery from Bell’s palsy. It includes 10 clinical trials (RCTs; 2280 participants). The analysis (8 trials, 1365 participants) suggests that antivirals plus corticosteroids reduces the incidence of incomplete recovery when compared either to corticosteroids alone (RR 0.61, 95% CI, 0.39 to 0.97, Absolute Risk Difference [ARD]: 6.5%, NNT: 15; quality of evidence: Low), or to placebo or no treatment (RR 0.56, 95% CI, 0.41 to 0.76, ARD: 12%, NNT: 8; quality of evidence: Low). Antivirals alone did not improve the risk of incomplete recovery rates when compared to placebo/no treatment (RR 1.10, 95% CI, 0.87 to 1.40; quality of evidence: Low), and increased rates of incomplete recovery when compared to corticosteroids alone (RR 1.52, 95% CI, 1.08 to 2.12, quality of evidence: Low). The risk of long term after-effects including motor synkinesis (abnormal involuntary facial movement) or crocodile tears syndrome (unilateral tearing when eating) was decreased when antivirals plus corticosteroids were compared to corticosteroids alone (RR 0.56, 95% CI, 0.36 to 0.87, ARD: 8.5%, NNT: 12; quality of evidence: Moderate), whereas corticosteroids alone decreased long-term after-effects greater than antivirals alone (RR 1.52, 95% CI 1.08 to 2.12; quality of evidence: Moderate). No published data was available comparing either antivirals plus corticosteroids or antivirals alone with placebo or no treatment for this specific outcome.
The referenced meta-analysis contained an overall lack of details regarding adverse reactions. That being said, aggregate adverse events was significantly less with antivirals alone when compared to corticosteroids alone (RR 0.85, 95% CI, 0.57 to 1.28, ARD: 2.04%, NNT: 49; quality of evidence: Low), or placebo or no treatment (RR 0.83, 95% CI, 0.56 to 1.24, ARD: 2.8%, NNT: 36; n=651; quality of evidence: Low). Adverse events were not significantly different when comparing antivirals plus corticosteroids to either corticosteroids alone (RR 1.18, 95% CI 0.83 to 1.69) or placebo or no treatment (RR 1.14, 95% CI 0.79 to 1.65).

Conclusion : When taken with corticosteroids for Bell’s Palsy, antivirals decrease incomplete recovery (NNT=8) and long-term after-effects including motor synkinesis and crocodile tears syndrome (NNT=12) when compared to placebo or no treatment. Antivirals in combination with corticosteroids should be considered in the management of patients with Bell’s Palsy in the emergency department.

Conclusion (proposition de traduction) : Lorsqu'ils sont pris avec des corticoïdes pour la paralysie de Bell, les antiviraux diminuent la récupération incomplète (NNT = 8) et les séquelles à long terme, notamment la synkinésie motrice et le syndrome des larmes de crocodile (NNT = 12) par rapport au placebo ou à l'absence de traitement. La prise d’antiviraux en association avec des corticostéroïdes doit être prise en compte dans la prise en charge des patients atteints de paralysie de Bell au service des urgences.

La kétamine à dose subdissociative est efficace pour traiter les exacerbations aiguës de la douleur chronique |

Subdissociative-dose Ketamine Is Effective for Treating Acute Exacerbations of Chronic Pain.
Lumanauw DD, Youn S, Horeczko T, Yadav K, Tanen DA. | Acad Emerg Med. 2019 Mar 22
DOI: https://doi.org/10.1111/acem.13755
Keywords: Aucun

Original Contribution

Introduction : Subdissociative-dose ketamine (SDDK) is used to treat acute pain. We sought to determine if SDDK is effective in relieving acute exacerbations of chronic pain.

Méthode : This study was a randomized double-blind placebo-controlled trial conducted May 2017 to June 2018 at a public teaching hospital (ClinicalTrials.gov #NCT02920528). The primary endpoint was a 20-mm decrease on a 100-mm visual analog scale (VAS) at 60 minutes. Power analysis using three groups (0.5 mg/kg ketamine, 0.25 mg/kg ketamine, or placebo infused over 20 minutes) estimated that 96 subjects were needed for 90% power. Inclusion criteria included age > 18 years, chronic pain > 3 months, and acute exacerbation (VAS ≥ 70 mm). Pain, agitation, and sedation were assessed by VAS at baseline and 20, 40, and 60 minutes after initiation of study drug. Telephone follow-up at 24 to 48 hours used a 10-point numeric rating scale for pain.

Résultats : A total of 106 subjects were recruited, with three excluded for baseline pain < 70 mm. After randomization, 35 received 0.5 mg/kg ketamine, 36 received 0.25 mg/kg ketamine, and 35 received placebo. Three subjects receiving 0.5 mg/kg withdrew during the infusion due to adverse effects, and one subject in each group had incomplete data, leaving 97 for analysis. Initial pain scores (91.9 ± 8.9 mm), age (46.5 ± 12.6 years), sex distribution, and types of pain reported were similar. Primary endpoint analysis found that 25 of 30 (83%) improved with 0.5 mg/kg ketamine, 28 of 35 (80%) with 0.25 mg/kg ketamine, and 13 of 32 (41%) with placebo (p = 0.001). More adverse effects occurred in the ketamine groups with one subject in the 0.25 mg/kg group requiring a restraint code for agitation. A total of 89% of subjects were contacted at 24 to 48 hours, and no difference in pain level was detected between groups.

Conclusion : Ketamine infusions at both 0.5 and 0.25 mg/kg over 20 minutes were effective in treating acute exacerbations of chronic pain but resulted in more adverse effects compared to placebo. Ketamine did not demonstrate longer-term pain control over the next 24 to 48 hours.

Conclusion (proposition de traduction) : Les perfusions de kétamine à 0,5 et 0,25 mg/kg pendant 20 minutes ont été efficaces dans le traitement des exacerbations aiguës de la douleur chronique, mais ont entraîné plus d'effets indésirables que le placebo. La kétamine n'a pas démontré de maîtrise de la douleur à long terme au cours des prochaines 24 à 48 heures.

Ordre d'administration des médicaments dans l'intubation en séquence rapide |

Drug Order in Rapid Sequence Intubation.
Driver BE, Klein LR, Prekker ME, Cole JB, Satpathy R, Kartha G, Robinson A, Miner JR, Reardon RF. | Acad Emerg Med. 2019 Mar 4
DOI: https://doi.org/10.1111/acem.13723
Keywords: Aucun

Original Contribution

Introduction : The optimal order of drug administration (sedative first vs. neuromuscular blocking agent first) in rapid sequence intubation (RSI) is debated.
Objectifs : We sought to determine if RSI drug order was associated with the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt.

Méthode : We conducted a planned secondary analysis of a randomized trial of adult ED patients undergoing emergency orotracheal intubation that demonstrated higher first-attempt success with bougie use compared to a tracheal tube + stylet. Drug choice, dose, and the order of sedative and neuromuscular blocking agent were not stipulated. We analyzed trial patients who received both a sedative and a neuromuscular blocking agent within 30 seconds of each other who were intubated successfully on the first attempt. The primary outcome was the time elapsed from complete administration of the first RSI drug to the end of the first intubation attempt, a surrogate outcome for apnea time. We performed a multivariable analysis using a mixed-effects generalized linear model.

Résultats : Of 757 original trial patients, 562 patients (74%) met criteria for analysis; 153 received the sedative agent first, and 409 received the neuromuscular blocking agent first. Administration of the neuromuscular blocking agent before the sedative agent was associated with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds (95% confidence interval = 0 to 11 sec).

Conclusion : Administration of either the neuromuscular blocking or the sedative agent first are both acceptable. Administering the neuromuscular blocking agent first may result in modestly faster time to intubation. For now, it is reasonable for physicians to continue performing RSI in the way they are most comfortable with. If future research determines that the order of medication administration is not associated with awareness of neuromuscular blockade, administration of the neuromuscular blocking agent first may be a logical default administration method to attempt to minimize apnea time during intubation.

Conclusion (proposition de traduction) : L'administration que se soit du curare ou de l'hypnotique en premier est acceptable. L'administration du curare en premier peut permettre une durée d'intubation légèrement plus rapide. Pour l'instant, il est raisonnable pour les médecins de continuer à pratiquer l'ISR de la façon qui leur convient le mieux. Si des recherches futures déterminent que l'ordre d'administration du médicament n'est pas associé à une prise de conscience pendant la curarisation, l'administration du curare en premier peut être une méthode d'administration par défaut logique pour tenter de minimiser le durée de l'apnée pendant l'intubation.

Commentaire : Pour mémoire :
• Le chlorure de suxaméthonium agit environ 30 à 60 secondes après administration par voie intraveineuse et produit un effet pendant quelques minutes (6 à 13).
• L'étomidate est un hypnotique intraveineux à brève durée d'action, dénué de propriétés analgésiques. L'effet hypnotique dépend de la dose administrée : chez un adulte moyen, 0,2 à 0,3 mg/kg d'étomidate procure un sommeil de 4 à 6 min.
ANSM. Base de données publique des médicaments [en ligne]. Mis à jour le : 21/09/2018 [consulté le 12 août 2019]. Disponible sur : base-donnees-publique.medicaments.gouv.fr .

• L'étomidate. Il s’agit d’un hypnotique intraveineux d’action rapide et brève. Dosé à 0,3 mg/kg, le sommeil débute au bout de 30 secondes et dure entre trois et six minutes.
F. Adnet, J.-E. De La Coussaye, P. Jabre. Mise au point. Intubation en séquence rapide : quels médicaments utiliser en préhospitalier ? Reanim. Novembre 2010;19(7):622-626 .

Comparaison des événements cliniques indésirables graves survenus dans les 30 jours chez des patients âgés se présentant aux urgences avec une lipothymie versus syncope | Accès libre

Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope.
Bastani A, Su E, Adler DH, Baugh C, Caterino JM, Clark CL, Diercks DB, Hollander JE, Malveau SE, Nicks BA, Nishijima DK, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Yagapen AN, Weiss RE, Sun BC. | Ann Emerg Med. 2019 Mar;73(3):274-280
DOI: https://doi.org/10.1016/j.annemergmed.2018.10.032 | Télécharger l'article au format
Keywords: Aucun

Geriatrics

Introduction : Controversy remains in regard to the risk of adverse events for patients presenting with syncope compared with near-syncope. The purpose of our study is to describe the difference in outcomes between these groups in a large multicenter cohort of older emergency department (ED) patients.

Méthode : From April 28, 2013, to September 21, 2016, we conducted a prospective, observational study across 11 EDs in adults (≥60 years) with syncope or near-syncope. A standardized data extraction tool was used to collect information during their index visit and at 30-day follow-up. Our primary outcome was the incidence of 30-day death or serious clinical events. Data were analyzed with descriptive statistics and multivariate logistic regression analysis adjusting for relevant demographic or historical variables.

Résultats : A total of 3,581 patients (mean age 72.8 years; 51.6% men) were enrolled in the study. There were 1,380 patients (39%) presenting with near-syncope and 2,201 (61%) presenting with syncope. Baseline characteristics revealed a greater incidence of congestive heart failure, coronary artery disease, previous arrhythmia, nonwhite race, and presenting dyspnea in the near-syncope compared with syncope cohort. There were no differences in the primary outcome between the groups (near-syncope 18.7% versus syncope 18.2%). A multivariate logistic regression analysis identified no difference in 30-day serious outcomes for patients with near-syncope (odds ratio 0.94; 95% confidence interval 0.78 to 1.14) compared with syncope.

Conclusion : Near-syncope confers risk to patients similar to that of syncope for the composite outcome of 30-day death or serious clinical event.

Conclusion (proposition de traduction) : Une lipothymie entraîne un risque similaire à celui de la syncope en ce qui concerne le résultat composite d'un décès ou d'un événement clinique grave à 30 jours.

Gérer les patients âgés au service des urgences |

Managing the Elderly Emergency Department Patient.
Shenvi CL, Platts-Mills TF. | Ann Emerg Med. 2019 Mar;73(3):302-307
DOI: https://doi.org/10.1016/j.annemergmed.2018.08.426
Keywords: Aucun

Geriatrics

Editorial : Older US adults make more than 20 million emergency department (ED) visits annually, accounting for more than 15% of all visits. In contrast to younger ED patients, older ones typically have more medical problems, are taking more medications, are more likely to have baseline impairments in function and cognition, and are less likely to fully recover from illness or injury. Older adults are also more likely to experience social isolation, malnutrition, and abuse or neglect, which may contribute to their ED presentation and influence outcomes. Like younger adults, however, most older adults want to receive prompt emergency care and would rather not be admitted to the hospital. These characteristics create two of the central challenges of emergency care for older adults: to provide efficient care without missing a serious medical condition, and to honor, when possible, the patient’s desire for discharge despite the risk of adverse outcomes. They also suggest a third challenge that pushes the scope of emergency care beyond traditional boundaries: to recognize and address nonmedical problems that may influence health outcomes. In recognition of these and other challenges, guidelines to improve ED care for older adults have been established, and the American College of Emergency Physicians (ACEP) has created a Geriatric ED Accreditation Program (https://www.acep.org/geda ). Here, we discuss our approach to the care of the elderly ED patient according to our expertise and available evidence, with implications for physician practice and ED processes of care.

Conclusion : During the next 2 decades, the percentage of older adults in the United States will grow to exceed 20%, and ED visits by older adults will almost certainly increase to an even greater proportion. Caring for these patients is often difficult and requires attention to the possibility of subtle acute severe illness and injury, patient preferences about care, and nonmedical problems that may influence outcomes. Additional ED resources and coordination of care with inpatient teams and community services will be essential to optimize outcomes.

Conclusion (proposition de traduction) : Aux États-Unis, le pourcentage d'adultes âgés dépassera les 20% au cours des deux prochaines décennies, et le nombre de visites aux urgences des adultes plus âgés augmentera presque certainement encore davantage. S'occuper de ces patients est souvent difficile et requiert une attention particulière à la possibilité d'une maladie et d'une blessure aiguës et subtiles, aux préférences des patients en matière de soins et à des problèmes non médicaux pouvant influer sur les résultats. Des ressources supplémentaires au service des urgences et la coordination des soins avec les équipes de patients hospitalisés et les services communautaires seront essentielles pour optimiser les résultats.

Examen cytobactériologique (ECBU) des urines et cystite non compliquée : une vision plus large ? |

Urine Culture and Uncomplicated Cystitis: A Bigger Picture?.
Liang SY, Camins BC. | Ann Emerg Med.. 2019 Mar;73(3):308-309
DOI: https://doi.org/10.1016/j.annemergmed.2018.06.012
Keywords: Aucun

Clinical Controversies

Editorial : Diagnosis of uncomplicated cystitis in a nonpregnant, premenopausal woman hinges on the presence of dysuria, frequency, urgency, hematuria, or suprapubic discomfort. When these signs and symptoms are present, urine testing in the emergency department (ED) helps confirm the diagnosis of urinary tract infection and support the decision to start empiric antibiotic therapy. Considered the diagnostic reference standard for urinary tract infection, quantitative urine culture and susceptibility testing ensure that appropriate antibiotics have been prescribed, inform future empiric antibiotic therapy, and promote ED antibiotic stewardship.
Optimal antibiotic therapy for any infection entails use of “the right drug for the right bug.” Most antibiotic therapy initiated in the ED is by necessity empiric. Guidelines from the Infectious Diseases Society of America aid with antibiotic selection and help identify patients at risk for antibiotic-resistant infection. Despite the inherent lag in results, a properly collected, noncontaminated urine culture provides objective microbiologic data, allowing emergency physicians to identify bacterium-drug mismatches and adjust therapy accordingly. Studies of ED pharmacist-driven urine culture review for symptomatic urinary tract infection and pyelonephritis report interventions to address inappropriate empiric therapy in up to a quarter of discharged patients, most often because of bacterium-drug mismatch. Although these studies do not focus solely on uncomplicated cystitis, they demonstrate how urine culture maximizes targeted therapy when a robust ED culture follow-up mechanism exists. As antibiotic-resistant infections caused by organisms including extended- spectrum b-lactamase–producing Enterobacteriaceae (including Escherichia coli) have become more common in ED patient populations, some in the absence of traditional risk factors (eg, previous antibiotic exposure, health care, travel), urine culture has added importance in uncovering bacterium-drug mismatches. In cases of therapeutic failure despite appropriate antibiotic selection, urine culture also helps determine whether a more extensive evaluation is necessary (eg, evaluation for an anatomic defect predisposing to urinary retention).

Conclusion : In an era of mounting antibiotic resistance, urine culture remains our primary means of determining whether a prescribed antibiotic for uncomplicated cystitis will be effective against the infecting pathogen. It is also the backbone on which local antibiotic resistance rates are determined and reported to prescribers through antibiograms. Although a single urine culture may not change the management of uncomplicated cystitis in the emergency department, a population-focused approach to culture and susceptibility testing paints a bigger picture of the evolving epidemiology of urinary tract infection and antibiotic resistance, better and more accurately guiding clinical practice. Future research characterizing emergency department treatment failure rates for uncomplicated cystitis, the effect of emergency department-specific antibiograms on treatment success, and the true value of using empiric antibiotics that are narrow spectrum or that concentrate primarily in the urine in curbing antibiotic resistance in emergency department populations will help optimize our use of urine culture in the management of uncomplicated cystitis.

Conclusion (proposition de traduction) : À l'ère de la résistance aux antibiotiques, l'examen cytobactériologique des urines reste notre principal moyen de déterminer si un antibiotique prescrit pour le traitement de la cystite non compliquée sera efficace contre l'agent pathogène infectant. C’est également l’épine dorsale sur laquelle les taux de résistance aux antibiotiques locaux sont déterminés et communiqués aux prescripteurs au moyen d’antibiogrammes. Bien qu'une seule culture d'urine ne puisse pas changer la prise en charge de la cystite non compliquée à l'urgence, une approche axée sur la population en matière de culture et d'antibiogramme brosse un tableau plus complet de l'évolution de l'épidémiologie des infections urinaires et de la résistance aux antibiotiques et permet de mieux orienter et plus précisément la pratique clinique. De futures recherches caractérisant les taux d'échec du traitement de la cystite non compliquée aux urgences, l'effet des antibiogrammes propres aux services d'urgence sur le succès du traitement et la valeur réelle de l'utilisation d'antibiotiques empiriques à spectre étroit qui se concentrent principalement dans l'urine pour réduire la résistance aux antibiotiques dans les services d'urgence aideront à optimiser notre utilisation des examen cytobactériologique des urines dans le traitement de la cystite non compliquée.

Commentaire : La SPILF, en matière de prise en charge des infections urinaires communautaires de l’adulte, recommande concernant l'ECBU :
Un ECBU est indiqué devant toute suspicion clinique d’IU, à l’exception des cystites simples, et pour le diagnostic des colonisations nécessitant un traitement (grossesse ; geste urologique programmé). Un ECBU de contrôle est inutile dans le suivi de toute IU (y compris PNA et IU masculines), sauf évolution clinique défavorable. (page 344)
Caron F and al. Practice guidelines for the management of adult community-acquired urinary tract infections.Med Mal Infect. 2018 Aug;48(5):327-358

Historique d'imagerie par tomodensitométrie des patients se présentant aux urgences pour une colique néphrétique - données provenant d'une base de données multi-hospitalière |

CT imaging history for patients presenting to the ED with renal colic--evidence from a multi-hospital database.
Schmid E, Leeson K, Xu KT, Richman P, Nwosu C, Carrasco L. | BMC Emerg Med. 2019 Mar 1;19(1):24
DOI: https://doi.org/10.1186/s12873-019-0232-7v
Keywords: CT scan; Renal colic; Repeat imaging

Research article

Introduction : Patients with renal colic have a 7% chance of annual recurrence. Previous studies evaluating cumulative Abbreviations: computed tomography (CT) exposure for renal colic patients were typically from single centers.

Méthode : This was an observational cohort study. Inner-city ED patients with a final diagnosis of renal colic were prospectively identified (1/10/16-10/16/16). Authors conducted structured electronic record reviews from a 6-hospital system encompassing over 192,000 annual ED visits. Categorical data analyzed by chi-square; continuous data by t-tests. Primary outcome measure was the proportion of study group patients with prior history CT abdomen/pelvis CT.

Résultats : Two hundred thirteen patients in the study group; 59% male, age 38+/- 10 years, 67% Hispanic, 62% prior stone history, flank pain (78%), dysuria (22%), UA (+) blood (75%). 60% (95% CI = 53-66%) of patients received an EDCV CT; hydronephrosis seen in 55% (95% CI = 46-63%), stone in 90%(95% CI = 83-94%). No significant differences observed in the proportion of EDCV patients who received CT with respect to: female vs. male (62% vs. 56%; p = 0.4), mean age (37+/- 9 years vs. 39+/- 11 years; p = 0.2), and Hispanic vs. non-Hispanic white (63% vs.63%; p = 0.96). Patients with a prior stone history were more likely than those with no history to receive an EDCV CT (88% vs. 16%; p < 0.001). 118 (55%; 95% CI = 49-62%) of patients had at least one prior CT, 46 (22%; 95% CI = 16-28%) had ≥3 prior CTs; 29 (14%; 95% CI = 10-19%), ≥ 10 prior CTs. Patients who did not receive an EDCV CT had a significantly higher mean prior number of CTs than those who had EDCV CT (5.1+/- 7.7 vs 2.2+/- 4.9; p < 0.001). Patients with prior stone were more likely to receive only U/S during EDCV (33% vs. 15%; p = 0.003).

Conclusion : Within our EDCV cohort of renal colic patients, 55% had at least one prior CT. The mean number of prior CTs was lower for patients receiving CT on EDCV, and Ultrasound (US) alone was used more often in patients with prior stone history vs. those with no prior history.

Conclusion (proposition de traduction) : Dans la cohorte de patients présentant des coliques néphrétiques dans notre service d'urgence, 55 % avaient eu au moins un scanner antérieur. Le nombre moyen de TDM antérieurs était plus faible chez les patients recevant une TDM lors de visites aux urgences et une échographie était réalisée plus souvent chez les patients ayant des antécédents de calculs précoces par rapport à ceux sans antécédents.

Association entre l'utilisation d'ondansétron et la persistance des symptômes chez l'enfant présentant une commotion cérébrale : une étude secondaire 5P |

Association between ondansetron use and symptom persistence in children with concussions: A 5P substudy.
Gravel J, Boutis K, Tang K, Beauchamp MH, Freedman SB, Dubrovsky AS, Gagnon I, Momoli F, Zemek R. | CJEM. 2019 Mar;21(2):204-210
DOI: https://doi.org/10.1017/cem.2018.384
Keywords: children; concussion; ondansetron

Original Research

Introduction : On administre de plus en plus souvent de l’ondan- sétron aux enfants qui souffrent de nausées ou de vomisse- ments associés à une commotion cérébrale. L’étude visait à examiner l’association entre l’utilisation de l’ondansétron et les symptômes liés à une commotion cérébrale chez les enfants, une semaine et un mois suivant le trauma.

Méthode : Il s’agit d’une analyse secondaire de données recueillies dans le cadre d’une étude prospective de cohorte (étude 5P), menée dans 9 services des urgences (SU) pédiatri- ques. Les participants étaient des enfants âgés de 5 à 17,99 ans, qui avaient subi une commotion cérébrale au cours des 48 heures précédentes. Seulement les participants de l'étude 5P faisant état de nausées ou de vomissements au SU, étaient admissibles à l’étude en question. Le point d’intérêt était l’administration d’ondansétron; le groupe de comparaison était formé de tous les autres participants. Le principal critère d’évaluation consistait en l’intensification d’au moins 3 symp- tômes selon l’inventaire des symptômes postcommotionnels, une semaine et un mois suivant le trauma.

Résultats : Sur les 3063 enfants ayant participé à l’étude 5P, 1805 (59 %) avaient fait état de nausées ou de vomissements, et avaient fourni des données au bout d’une semaine et d’un mois. Parmi ceux-ci, 132 enfants (7 %) avaient reçu de l’ondansétron. D’après une analyse de régression logistique à plusieurs variables, rajustée pour tenir compte de facteurs parasites, il n’y avait pas d’association entre l’utilisation de l’ondansétron et le risque de persistance de symptômes postcommotionnels au bout d’une semaine (risque relatif approché [RRA] : 1,13 [IC à 95 % : 0,86-1,49]), mais une association a été établie avec une augmentation du risque au bout d’un mois (RRA : 1,33 [IC à 95 % : 1,05-1,97]).

Conclusion : In children presenting to the ED with an acute concussion, ondansetron use was associated with a higher risk of persistent post-concussion symptoms at 1 month. Although this may be related to the limitations of the design, it highlights the importance of evaluating this association using a randomized clinical trial.

Conclusion (proposition de traduction) : D’après les résultats de l’étude, l’utilisation de l’ondansétron chez les enfants traités au SU pour une commotion cérébrale en phase aiguë a été associée à une augmentation du risque de persistance de symptômes postcommotionnels au bout d’un mois. Si les constatations peuvent être liées aux limites du plan d’étude, elles font néanmoins ressortir l’importance d’évaluer la relation dans le cadre d’un essai clinique à répartition aléatoire.

Combinaison de protoxyde d'azote à 70 % et de fentanyl intranasal pour l'analgésie procédurale chez l'enfant : un essai prospectif, randomisé, en double aveugle, contrôlé par placebo |

Combined nitrous oxide 70% with intranasal fentanyl for procedural analgosedation in children: a prospective, randomised, double-blind, placebo-controlled trial.
Seiler M, Staubli G, Landolt MA. | Emerg Med J. 2019 Mar;36(3):142-147
DOI: https://doi.org/10.1136/emermed-2018-207892
Keywords: paediatric injury; paediatrics; paediatrics, paediatric emergency medicine; pain management

Original articles

Introduction : Nitrous oxide 70% (N2O 70%) is an excellent medication for procedural analgosedation (PAS), yet the limit of its analgesic power remains uncertain; therefore, a combination with intranasal fentanyl (INF) was suggested. However, this combination seems to result in a higher rate of vomiting and deeper sedation. This study aimed at assessing the analgesic efficacy, sedation depth and rate of adverse events of PAS with N2O 70% with and without INF.

Méthode : Patients aged 2-16 years who qualified for PAS with N2O 70% were randomly assigned to receive either INF or placebo prior to N2O inhalation in this randomised, double-blind study, which was performed in a tertiary children's hospital ED between September 2015 and October 2017. Behaviour during the procedure was evaluated using the Face, Leg, Activity, Cry and Consolability (FLACC) scale and the Modified Behavioural Pain Scale (MBPS); analgesic efficacy was assessed with a self-reported pain scale. Sedation depth using the validated University of Michigan Sedation Scale and adverse events in the ED and during the following 12 hours were documented.

Résultats : A total of 402 patients were included; 3 did not tolerate N2O and therefore had to be excluded. Overall, 399 patients were analysed, of whom 201 (50.4%) received INF. No significant group differences with regard to FLACC scale score, self-reported pain, MBPS score and sedation depth were found. In addition, the two groups did not differ with regard to all types of adverse events.

Conclusion : Combining N2O 70% with INF resulted in no differences with regard to FLACC scale score, self-reported pain, MBPS score, patient and parental satisfaction rate, sedation depth, and adverse events.

Conclusion (proposition de traduction) : L'association de N₂O à 70 % avec du fentanyl par voie intranasale n'a entraîné aucune différence en ce qui concerne le score d'échelle Visage, jambe, activité, Cry et consolabilité (FLACC), la douleur autoévaluée, le score de l'échelle de la douleur comportementale modifiée, le taux de satisfaction des patients et des parents, la profondeur de sédation et les effets indésirables.

Respect des règles d'hygiène des mains dans les services médicaux d'urgence : étude d'observation internationale |

Compliance with hand hygiene in emergency medical services: an international observational study.
Vikke HS, Vittinghus S, Giebner M, Kolmos HJ, Smith K, Castrén M, Lindström V. | Emerg Med J. 2019 Mar;36(3):171-175
DOI: https://doi.org/10.1136/emermed-2018-207872
Keywords: emergency medical services; hand hygiene; prehospital care

Original articles

Introduction : Healthcare-associated infection caused by insufficient hygiene is associated with mortality, economic burden, and suffering for the patient. Emergency medical service (EMS) providers encounter many patients in different surroundings and are thus at risk of posing a source of microbial transmission. Hand hygiene (HH), a proven infection control intervention, has rarely been studied in the EMS.

Méthode : A multicentre prospective observational study was conducted from December 2016 to May 2017 in ambulance services from Finland, Sweden, Australia and Denmark. Two observers recorded the following parameters: HH compliance according to WHO guidelines (before patient contact, before clean/aseptic procedures, after risk of body fluids, after patient contact and after contact with patient surroundings). Glove use and basic parameters such as nails, hair and use of jewellery were also recorded.

Résultats : Sixty hours of observation occurred in each country, for a total of 87 patient encounters. In total, there were 1344 indications for HH. Use of hand rub or hand wash was observed: before patient contact, 3%; before clean/aseptic procedures, 2%; after the risk of body fluids, 8%; after patient contact, 29%; and after contact with patient-related surroundings, 38%. Gloves were worn in 54% of all HH indications. Adherence to short or up done hair, short, clean nails without polish and no jewellery was 99%, 84% and 62%, respectively. HH compliance was associated with wearing gloves (OR 45; 95% CI 10.8 to 187.8; p=0.000) and provider level (OR 1.7; 95% CI 1.1 to 2.4; p=0.007), but not associated with gender (OR 1.3; 95% CI 0.9 to 1.9; p=0.107).

Conclusion : HH compliance among EMS providers was remarkably low, with higher compliance after patient contacts compared with before patient contacts, and an over-reliance on gloves. We recommend further research on contextual challenges and hygiene perceptions among EMS providers to clarify future improvement strategies.

Conclusion (proposition de traduction) : Le taux de conformité à l'hygiène des mains chez les fournisseurs de services médicaux d'urgence était remarquablement faible, avec un taux de conformité plus élevé après les contacts avec les patients qu'avant les contacts avec les patients et une dépendance excessive à l'égard des gants. Nous recommandons de poursuivre les recherches sur les défis contextuels et les perceptions en matière d'hygiène chez les fournisseurs de services médicaux d'urgence afin de clarifier les stratégies d'amélioration futures.

Comparaison de l'utilisation de l'échographie pulmonaire et de la radiographie thoracique dans le diagnostic des fractures de côte : revue systématique |

Comparison of the use of lung ultrasound and chest radiography in the diagnosis of rib fractures: a systematic review.
Battle C, Hayward S, Eggert S, Evans PA. | Emerg Med J. 2019 Mar;36(3):185-190
DOI: https://doi.org/10.1136/emermed-2017-207416
Keywords: diagnosis; trauma, chest; ultrasound; x-ray

REVIEW

Introduction : It is well-recognised that the detection of rib fractures is unreliable using chest radiograph. The aim of this systematic review was to investigate whether the use of lung ultrasound is superior in accuracy to chest radiography, in the diagnosis of rib fractures following blunt chest wall trauma.

Méthode : The search filter was used for international online electronic databases including MEDLINE, EMBASE, Cochrane and ScienceDirect, with no imposed time or language limitations. Grey literature was searched. Two review authors completed study selection, data extraction and data synthesis/analysis process. Quality assessment using the Quality Assessment of Diagnostic Accuracy Studies Tool (QUADAS-2) was completed.

Résultats : 13 studies were included. Overall, study results demonstrated that the use of lung ultrasound in the diagnosis of rib fractures in blunt chest wall trauma patients appears superior compared with chest radiograph. All studies were small, single centre and considered to be at risk of bias on quality assessment. Meta-analysis was not possible due to high levels of heterogeneity, lack of appropriate reference standard and poor study quality.

Conclusion : The results demonstrate that lung ultrasound may be superior to chest radiography, but the low quality of the studies means that no definitive statement can be made.

Conclusion (proposition de traduction) : Les résultats démontrent que l'échographie pulmonaire peut être supérieure à la radiographie pulmonaire, mais la faible qualité des études signifie qu'aucune déclaration définitive ne peut être faite.

Une formation vidéo pour enseigner efficacement la RCP avec une mémorisation à long terme : le projet ScuolaSalvaVita.it («SchoolSavesLives.it») |

A video-based training to effectively teach CPR with long-term retention: the ScuolaSalvaVita.it ("SchoolSavesLives.it") project.
Paglino M, Contri E, Baggiani M, Tonani M, Costantini G, Bonomo MC, Baldi E. | Intern Emerg Med. 2019 March;4(2):275–279
DOI: https://doi.org/10.1007/s11739-018-1946-3
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Schoolchildren; Schools; Training

EM - ORIGINAL

Editorial : Enhancing CPR knowledge in schools is the key to improving bystander CPR rate and survival after an out-of-hospital car- diac arrest, but the best method to do so in a whole area is unknown. We wanted to assess if a province-based project, which involves the Secondary Schools of a whole Province, is effective in teaching schoolchildren CPR, and how well the skills are retained. We trained 100 teachers from the 21 Secondary Schools of the Province of Pavia with a BLS/AED course and we supplied each school with 10 low-budget manikins and four educational videos. These videos, about 2 min each, consist of a motivational part, an instructive part, a demonstrative part and a practice-while-watching part. We explained to the teachers how to use manikins and videos in a 2-h course. We carried out both a theoretical and a practical test in 21 classes, randomly selected between the classes trained by the teachers, 3 months and 6 months after the training. In the first 5 months of the project, 5146 schoolchildren aged 14–19, in the 21 Secondary Schools of our Province, were trained by their teachers. We tested 304 students 3 months after the course and 318 students 6 months after the course, with good results both in theoretical and practical skills. Our study demonstrates that the ScuolaSalvaVita project is able to effectively teach CPR through teachers using a video-based training in the Secondary Schools of a whole Province obtaining good long-term memory of CPR skills.

Conclusion : We demonstrated that the ScuolaSalvaVita project is able to effectively teach CPR by teachers with video-based training in the Secondary Schools of a whole Province with a good retentiveness of both theoretical and practical skills after three and 6 months.

Conclusion (proposition de traduction) : Nous avons démontré que le projet ScuolaSalvaVita est capable d'enseigner efficacement la RCP par des enseignants formés par vidéo dans les écoles secondaires d'une province entière avec une bonne réactivité des compétences théoriques et pratiques après trois et six mois.

Réseaux neuronaux artificiels et stratification des risques dans les services d'urgence |

Artificial neural networks and risk stratification in emergency departments.
Falavigna G, Costantino G, Furlan R, Quinn JV, Ungar A, Ippoliti R. | Intern Emerg Med. 2019 Mar;14(2):291-299
DOI: https://doi.org/10.1007/s11739-018-1971-2
Keywords: Artificial neural networks (ANNs); Decision processes; Emergency departments (ERs); Risk stratification; Syncope

EM - ORIGINAL

Editorial : Emergency departments are characterized by the need for quick diagnosis under pressure. To select the most appropriate treatment, a series of rules to support decision-making has been offered by scientific societies. The effectiveness of these rules affects the appropriateness of treatment and the hospitalization of patients. Analyzing a sample of 1844 patients and focusing on the decision to hospitalize a patient after a syncope event to prevent severe short-term outcomes, this work proposes a new algorithm based on neural networks. Artificial neural networks are a non-parametric technique with the well-known ability to generalize behaviors, and they can thus predict severe short-term outcomes with pre-selected levels of sensitivity and specificity. This innovative technique can outperform the traditional models, since it does not require a specific functional form, i.e., the data are not supposed to be distributed following a specific design. Based on our results, the innovative model can predict hospitalization with a sensitivity of 100% and a specificity of 79%, significantly increasing the appropriateness of medical treatment and, as a result, hospital efficiency. According to Garson's Indexes, the most significant variables are exertion, the absence of symptoms, and the patient's gender. On the contrary, cardio-vascular history, hypertension, and age have the lowest impact on the determination of the subject's health status. The main application of this new technology is the adoption of smart solutions (e.g., a mobile app) to customize the stratification of patients admitted to emergency departments (ED)s after a syncope event. Indeed, the adoption of these smart solutions gives the opportunity to customize risk stratification according to the specific clinical case (i.e., the patient's health status) and the physician's decision-making process (i.e., the desired levels of sensitivity and specificity). Moreover, a decision-making process based on these smart solutions might ensure a more effective use of available resources, improving the management of syncope patients and reducing the cost of inappropriate treatment and hospitalization.

Conclusion : A decision-making process based on ANNs might represent an improvement for the healthcare sector, ameliorating the management and rate of admission to emergency departments of syncope patients, reducing the cost of inappropriate treatments and hospitalization, and ensuring a more effective use of resources.

Conclusion (proposition de traduction) : Un processus de prise de décision basé sur des réseaux de neurones artificiels pourrait représenter une amélioration pour le secteur de la santé, améliorer la gestion et le taux d'admission aux urgences des patients atteints de syncope, réduire le coût des traitements inappropriés et de l'hospitalisation et assurer une utilisation plus efficace des ressources.

Cinq erreurs courantes à éviter en pratique clinique : la campagne Choisir avec soin, Association italienne des gastroentérologues et endoscopistes hospitaliers (AIGO) |

Five common errors to avoid in clinical practice: the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) Choosing Wisely Campaign.
Stasi E, Michielan A, Morreale GC, Tozzi A, Venezia L, Bortoluzzi F, Triossi O, Soncini M, Leandro G, Milazzo G, Anderloni A. | Intern Emerg Med. 2019 Mar;14(2):301-308
DOI: https://doi.org/10.1007/s11739-018-1992-x
Keywords: Appropriateness; Choosing wisely; Overdiagnosis; Overtreatment; Recommendations

CE - ORIGINAL

Editorial : Modern medicine provides almost infinite diagnostic and therapeutic possibilities if compared to the past. As a result, patients undergo a multiplication of tests and therapies, which in turn may trigger further tests, often based on physicians' attitudes or beliefs, which are not always evidence-based. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) adhered to the Choosing Wisely Campaign to promote an informed, evidence-based approach to gastroenterological problems. The aim of this article is to report the five recommendations of the AIGO Choosing Wisely Campaign, and the process used to develop them. The AIGO members' suggestions regarding inappropriate practices/interventions were collected. One hundred and twenty-one items were identified. Among these, five items were selected and five recommendations were developed. The five recommendations developed were: (1) Do not request a fecal occult blood test outside the colorectal cancer screening programme; (2) Do not repeat surveillance colonoscopy for polyps, after a quality colonoscopy, before the interval suggested by the gastroenterologist on the colonoscopy report, or based on the polyp histology report; (3) Do not repeat esophagogastroduodenoscopy in patients with reflux symptoms, with or without hiatal hernia, in the absence of different symptoms or alarm symptoms; (4) Do not repeat abdominal ultrasound in asymptomatic patients with small hepatic haemangiomas (diameter < 3 cm) once the diagnosis has been established conclusively; (5) Do not routinely prescribe proton pump inhibitors within the context of steroid use or long-term in patients with functional dyspepsia. AIGO adhered to the Choosing Wisely Campaign and developed five recommendations. Further studies are needed to assess the impact of these recommendations in clinical practice with regards to clinical outcome and cost-effectiveness.

Conclusion : In conclusion, AIGO joined the Choosing Wisely Cam- paign and developed five recommendations, with the aim of reducing unnecessary care and promoting an evidence- based, conscious attitude to resource use. Further studies are needed to assess whether these recommendations are embraced in clinical practice, and whether they have an impact on patients’ clinical outcomes and cost-effective- ness of care.

Conclusion (proposition de traduction) : En conclusion, l'Association italienne des gastroentérologues et endoscopistes hospitaliers (AIGO) s'est associée à la campagne Choisir avec soin et a formulé cinq recommandations visant à réduire les soins inutiles et à promouvoir une attitude consciente et fondée sur des preuves à l'égard de l'utilisation des ressources. Des études complémentaires sont nécessaires pour déterminer si ces recommandations sont intégrées dans la pratique clinique et si elles ont un impact sur les résultats cliniques des patients et la rentabilité des soins.

Commentaire : Les cinq recommandations formulées étaient les suivantes :
(1) Ne pas demander de test de sang occulte dans les selles en dehors du programme de dépistage du cancer colorectal ;
(2) Ne pas répéter la coloscopie de surveillance pour les polypes, après une coloscopie de qualité, avant l'intervalle suggéré par le gastro-entérologue dans le rapport de coloscopie, ou sur la base du rapport d'histologie du polype ;
(3) Ne pas répéter l'œsophagogastroduodénoscopie chez les patients présentant des symptômes de reflux, avec ou sans hernie hiatale, en l'absence de symptômes différents ou de symptômes d'alarme ;
(4) Ne pas répéter l'échographie abdominale chez les patients asymptomatiques présentant de petits hémangiomes hépatiques (diamètre <3 cm) une fois le diagnostic établi de manière concluante ;
(5) Ne pas prescrire systématiquement d'inhibiteurs de la pompe à protons dans le contexte d'une utilisation de stéroïdes ou à long terme chez les patients atteints de dyspepsie fonctionnelle.

Effet des critères d'élimination de l'embolie pulmonaire sur les événements thromboemboliques ultérieurs chez les patients des services d'urgence à faible risque : l'essai clinique randomisé PROPER |

Effect of the Pulmonary Embolism Rule-Out Criteria on subsequent thromboembolic events among low-risk emergency department patients: the PROPER randomized clinical trial.
Malavolta D1, Quatela V, Moffat J, Ottolini BB; GrAM (Gruppo di Autoformazione metodologica). | Intern Emerg Med. 2019 Mar;14(2):309-310
DOI: https://doi.org/10.1007/s11739-019-02027-1
Keywords: Aucun

THE CUTTING EDGE: RESEARCH UPDATE

Introduction : The diagnostic strategy for pulmonary embolism (PE) endorsed by the European guidelines recommends an assessment of the clinical probability of PE using a structured score (Geneva score or Wells score) or an unstructured estimation of probability (referred as clinical gestalt) [1]. In patients with low to moderate pre-test likelihood of PE, the D-dimer test should be carried out, and, if positive, followup should be done with a computed tomography pulmonary angiogram (CTPA) [2]. Due to high mortality rate if left untreated, emergency physicians often feel compelled to order a D-dimer test for patients complaining of dyspnea, chest pain or both. However, the D-dimer test has low specificity, resulting in more than 50% of false-positive patients undergoing the CTPA confirmatory test [3], which has significant clinical and biological contraindications, as well as cost implications. Consequently in 2004, Kline et al. developed the PERC score (Pulmonary Embolism Rule-out Criteria) to reduce the use of the D-dimer test [4]. The PROPER trial (PERC Rule to Exclude Pulmonary Embolism in the Emergency Department) [5] is the first randomized clinical trial that has its objective to prospectively validate the safety of PERC in ruling out PE by assessing the percentage of failures of this diagnostic strategy.

Méthode : Of the 1916 patients initially enrolled (ITT population), only 1749 completed the trial: 847 in the PERC group and 902 in the control group with a mean age of 44 years and 51% women. PE was diagnosed at the initial presentation in 14 patients in the PERC group (1.5%) vs 26 patients in the control group (2.7%) [difference 1.3% (95% CI − 0.1% to 2.7%), p = 0.052]. One PE (0.1%) was diagnosed during the follow-up period in the PERC group compared with none in the control group: the difference of proportion between the two groups was 0.1% [95% CI −∞ to 0.8%]. The proportion of patients who underwent CTPA in the PERC was 13% while it was 23% (p < 0.001) in the control group. In the PERC group, there was a significantly lower hospital stay in the ED (average reduction 36 min), and a lower number of admissions (13% vs 16% in the control group). There was no significant difference in the rate of allcause mortality at 3 months: 0.3% (3 patients) in the PERC group and 0.2% (2 patients) in the control group [difference 0.1% (95% CI −0.5 to 0.7%), p > 0.99]. The five deaths were reviewed by an adjudication committee and none was considered likely to be linked to a PE. There was no severe hemorrhage or any severe adverse events following CTPA.

Résultats : This is a non-inferiority, crossover cluster-randomized clinical trial carried out in 14 France emergency departments (ED) during the period August 2015–September 2016. The follow-up period ended in December 2016. Patients with a low clinical probability of PE were included. Each center was randomized for a sequence of two periods of 6 months (the control period and the PERC period with a washout interval in between of 2 months). In the PERC period, the diagnosis of PE was excluded without conducting any other diagnostic test when the eight items of PERC score were all negative. Inclusion criteria were new onset or worsening of dyspnea or chest pain, and a low clinical probability of PE (estimated by the treating physician’s gestalt evaluation as below 15%). Exclusion criteria were an obvious etiology presentation different from PE, an acute severe presentation (SpO2 < 90%, respiratory distress, and hypotension) or a contraindication to CTPA, pregnancy, and the impossibility to follow-up with anticoagulant therapy.
The primary endpoint was the number of thromboembolic events during the 3-month follow-up period that were not initially diagnosed. The noninferiority threshold was set at 1.5%. Secondary endpoints included patients undergoing CTPA, adverse events related to this diagnostic technique, length of stay in the ED, hospital admissions and re-admis- sion, anticoagulant therapies prescribed and related major hemorrhages, and all-cause mortality at 3 months.

Conclusion : The authors conclude that in very low-risk patients with suspected PE, the randomisation of patients to a PERC strategy versus a conventional diagnostic strategy did not result in an inferior rate of missed diagnosis of thromboembolic events over 3 months. Moreover, they conclude that a PERC strategy is associated with various benefits in terms of reduced use of CTPA, shorter ED length of stay, and lower likelihood of initial hospital admission.

Conclusion (proposition de traduction) : Les auteurs concluent que chez des patients à très faible risque soupçonnés d'être atteints d'EP, la randomisation des patients selon une stratégie PERC versus une stratégie diagnostique conventionnelle n'a pas entraîné de taux inférieur de diagnostics manqués d'événements thromboemboliques sur une période de 3 mois. En outre, ils concluent qu’une stratégie PERC est associée à divers avantages en termes de réduction de l’utilisation de la CTPA, de réduction de la durée du séjour aux urgences et de probabilité plus faible d’hospitalisation initiale.

Cinq étapes pour l'utilisation et l'interprétation du D-dimère au service des urgences |

Five steps for the use and interpretation of D-dimer in the Emergency Department.
Gesu E, Maria Rusconi A, Ceriani E. | Intern Emerg Med. 2019 Mar;14(2):311-314
DOI: https://doi.org/10.1007/s11739-019-02044-0
Keywords: Aucun

CE - Clinical Notes

Editorial : D-dimer is one of the major fibrin clot degradation prod- ucts, released from cleavage of crosslinked fibrin by plasmin during fibrinolysis process. Since its introduction in 1990, D-dimer dosage has been proposed and used as a marker for several acute pathologies in which thrombosis or fibrinoly- sis processes are involved. Blood D-dimer’s values rise in several situations such as inflammation, neoplastic disease, autoimmune and rheumatic diseases, trauma, liver disease, pregnancy and age [1]. The purpose of this paper, part of a series of articles on biomarkers in the emergency medicine setting [2], is to provide a few practical steps that we think should be followed by the physician to correctly test and interpret D-dimer levels when evaluating patients.

Conclusion : In conclusion, physicians should ask themselves whether D-dimer results can affect the patient management, and proceed with measurement only when the answer to the question is positive (Table 1). Clinicians should also know which kind of test is available in their setting. It is important to know pathologies in which D-dimer test could really be useful and proceed in ordering it only if one of them is suspected taking into consideration test characteristics and pre-test probability of the disease for that patient.

Conclusion (proposition de traduction) : En conclusion, les médecins doivent se demander si les résultats du D-dimère peuvent affecter la gestion du patient et ne procéder à la mesure que lorsque la réponse à la question est positive (Tableau 1). Les cliniciens doivent également savoir quel type de test est disponible dans leur milieu. Il est important de connaître les pathologies dans lesquelles le test D-dimère pourrait réellement être utile et de ne le commander que si l’un d’eux est suspecté, compte tenu des caractéristiques du test et de la probabilité de la maladie avant le test pour ce patient.

Commentaire : Les cinq étapes
Étape 1: connaissance des tests disponibles.
Étape 2: demandez-vous pourquoi vous demandez les D-dimères (règles de sortie, règles de base) ?
Étape 3: demandez-vous ce que vous ferez en fonction du résultat.
Étape 4: demandez-vous quoi faire si quelqu'un d'autre l'a prescrit ?
Étape 5: situations cliniques et autres considérations : D-dimères dans la thrombose veineuse, D-dimères chez la personne âgée, la femme enceinte et le patient néoplasique, coagulation intravasculaire disséminée, dissection aortique, thrombose veineuse cérébrale.

Ictus amnésique |

Viader F, Quinette P, Cogez J. | JEUR. 2019 Mars;31(1):42-49
DOI: https://doi.org/10.1016/j.praneu.2017.11.001
Keywords: Transient global amnesia, Acute amnesia, Memory, Hippocampus

Republication

Editorial : L’ictus amnésique idiopathique (IA) réalise un syndrome amnésique aigu affectant exclusivement la mémoire épisodique antérograde et rétrograde, durant moins de 24heures et régressant sans séquelles. Il touche les personnes de plus de 50 ans et survient souvent après un stress physique ou émotionnel. Il peut récidiver dans environ 10 % des cas. Le diagnostic repose sur la clinique et peut être confirmé par l’IRM en séquence de diffusion montrant des hypersignaux punctiformes dans le champ CA1 de l’hippocampe, une structure cruciale pour la mémoire épisodique. L’IA doit être distingué de l’épilepsie amnésique transitoire, dont les crises sont plus brèves et récurrentes, ainsi que des accidents vasculaires cérébraux, bien que certains IA apparemment typiques puissent être symptomatiques d’une pathologie vasculaire. L’étiologie de l’IA est inconnue, mais son mécanisme supposé est un stress glutamatergique de l’hippocampe. Le traitement se limite à la surveillance clinique et à la réassurance, à condition d’avoir éliminé certaines causes rares mais parfois graves de syndrome amnésique aigu.

Conclusion (proposition de traduction) : Malgré les inconnues persistantes concernant sa physiopathologie, l'ictus amnésique idiopathique est un syndrome aisé à reconnaître cliniquement et d'évolution constamment favorable.
Face à un sujet présentant un trouble aigu du fonctionnement mental, il faut successivement éliminer ce qui n'est pas une amnésie (aphasie, confusion, état psychotique), ce qui n'est pas une amnésie épisodique (amnésie rétrograde isolée par exemple), les amnésies manifestement symptomatiques (post-critique, post-traumatique, métabolique, toxique, infectieuse ou vasculaire), et vérifier ensuite les critères de diagnostic de l'IA. Aucune recommandation n'impose la réalisation d'examens complémentaires. Pourtant, si l'application des critères cliniques permet d'éliminer la plupart des diagnostics différentiels, il faut rester attentif à la possibilité d'IA « symptomatiques » qui bien que rares peuvent révéler des pathologies graves. L'examen clinique est essentiel, en particulier à la recherche du moindre signe neurologique supplémentaire évoquant un AVC, d'anomalies vasculaires ou de signes généraux évoquant une cardiopathie ou une dissection aortique. Il est nécessaire de le compléter par un examen biologique et un électrocardiogramme. L'IRM en urgence n'est en principe recommandée que pour les sujets de moins de 50 ans et en présence de facteurs de risque vasculaires, mais certains auteurs [25] jugent aujourd'hui que les indications devraient peut-être en être posées plus largement.

Commentaire : Article original : Viader F, Quinette P, Cogez J. Ictus amnésique. Pratique Neurologique. 2018;9(1):13–20 .

L’embolie pulmonaire aux urgences : que disent les recommandations ? |

Meneveau N | JEUR. 2019 Mars;31(1):23-31
DOI: https://doi.org/10.1016/j.lpm.2018.08.003
Keywords: Aucun

Republication

Introduction : La maladie thromboembolique veineuse (MTEV) a une incidence annuelle de 100 à 200 pour 100 000 personnes, ce qui en fait la troisième pathologie cardiovasculaire en termes de fréquence. L'embolie pulmonaire (EP) en est la manifestation clinique la plus sévère, responsable d'une morbi-mortalité très élevée. Les données issues de registres ont permis de mieux appréhender l'évolution clinique de l'EP au cours de ces dernières années. La mortalité rapportée à un mois varie ainsi de 9 à 11 % et celle à 3 mois de 9 à 17 %. C'est précisément sur l'estimation de la mortalité précoce à 1 mois que repose la classification clinique de la sévérité d'une EP aiguë. Cette stratification, qui a d'importantes implications diagnostiques et thérapeutiques, repose sur la présence ou non d'une instabilité hémodynamique (choc ou hypotension artérielle systémique), qui définit les EP à haut risque de mortalité précoce. En l'absence d'instabilité hémodynamique, il convient d'identifier le risque évolutif du patient sur la base de scores cliniques et la présence d'une dysfonction ventriculaire droite (VD) et/ou d'une élévation des biomarqueurs (troponine, BNP, NT-proBNP). Cette stratification du risque doit être établie dès la prise en charge hospitalière ce qui confère aux médecins urgentistes un rôle déterminant dans la mise en place des filières de soins appropriées à chaque type d'EP.

Conclusion (proposition de traduction) : La stratification du risque de mortalité précoce doit guider la stratégie thérapeutique à la phase aiguë de l'embolie pulmonaire (EP), dès la prise en charge des patients aux urgences, et guider la mise en place des filières de soins appropriées à chaque type d'EP. Le traitement anticoagulant est incontournable pour toutes les formes d'EP dès leur arrivée aux urgences et les anticoagulants oraux directs sont dans ce contexte amenés à remplacer les antivitamines K dans la majorité des cas. Le recours à une stratégie de reperfusion doit systématiquement être envisagé chez les patients avec EP à haut risque présentant des signes d'instabilité hémodynamique. L'embolectomie chirurgicale ou percutanée constitue une alternative en cas de contre-indication au traitement thrombolytique chez ces patients. Les EP à risque intermédiaire définies par un score sPESI≥1 justifient d'une hospitalisation et une surveillance en unités de soins continus en cas d'élévation des biomarqueurs associée à la présence d'une dysfonction ventriculaire droite. Les EP à bas risque (sPESI=0) pourraient quant à elles faire l'objet d'une prise en charge en ambulatoire, sous réserve qu'un parcours de soin ait été préalablement défini.

Commentaire : Article original : Meneveau M. L’embolie pulmonaire aux urgences : que disent les recommandations ? Presse Med 2018;47:784–91 .

L’empyème sous-dural : une urgence neurochirurgicale sous-estimée |

Mathon B, Korinek AM. | JEUR. 2019 Mars;31(1):50-53
DOI: https://doi.org/10.1016/j.lpm.2018.02.014
Keywords: Aucun

Republication

Introduction : L'empyème sous-dural (ESD) est une pathologie pouvant compliquer les affections de la sphère oto-rhino-laryngologique ou l'immunodépression. Dans les pays occidentaux, l'ESD est une pathologie rare, touchant environ 5 patients/million d'habitants/an. Du fait de sa faible incidence, l'ESD est une pathologie souvent méconnue des filières d'urgence ou de médecine de ville, et sa gravité peut ainsi être sous-estimée. La littérature scientifique est faiblement pourvue en articles récents traitant de la prise en charge des ESD. C'est pourquoi, à l'aide de trois cas illustratifs, cet article a pour but de montrer comment la prise en charge médico-chirurgicale des ESD peut en modifier leur évolution et leur pronostic, et de réaffirmer les recommandations thérapeutiques les concernant.

Conclusion (proposition de traduction) : L'ESD est une urgence neurochirurgicale absolue. Tout retard de prise en charge diagnostique et/ou thérapeutique expose le patient à un risque accru de décès ou de séquelles neurologiques. L'évacuation chirurgicale de l'ESD, à l'aide d'une craniotomie large, doit être réalisée systématiquement et sans délai. L'antibiothérapie doit être instaurée dès les prélèvements réalisés, et maintenue à doses méningées pendant plusieurs semaines. Une prise en charge en réanimation neurochirurgicale doit être envisagée selon l'état neurologique. La prévention et le traitement des crises épileptiques, fréquemment associées aux ESD, doivent être systématiques.

Commentaire : Article original : Mathon B, Korinek AM. L’empyème sous-dural : une urgence neurochirurgicale sous-estimée. Presse Med. 2018 Apr;47(4 Pt 1):331-334 .

Résistance aux antibiotiques des Enterobacteriaceae provoquant des infections des voies urinaires chez les patients âgés vivant en communauté et dans des foyers de soins : une étude observationnelle rétrospective |

Antibiotic resistance of Enterobacteriaceae causing urinary tract infections in elderly patients living in the community and in the nursing home: a retrospective observational study.
Pulcini C, Clerc-Urmes I, Attinsounon CA, Fougnot S, Thilly N. | J Antimicrob Chemother. 2019 Mar 1;74(3):775-781
DOI: https://doi.org/10.1093/jac/dky488
Keywords: Aucun

Original research

Introduction : Although nursing homes are thought to be significant reservoirs of antibiotic-resistant bacteria, very few large population-based studies comparing antibiotic resistance prevalence in nursing homes and in the community have adjusted for patient characteristics. Our objective was to compare the prevalence of antibiotic resistance of Enterobacteriaceae cultured from urine samples of nursing home residents with that of community-dwelling adults, all aged 65 years or older.

Méthode : This study analysed around 20 000 positive urine samples sent to a large laboratory in north-eastern France from 2014 to 2017, collected from individuals aged 65 years or older. A multivariable logistic regression model adjusted for patient characteristics (gender, age, year of sampling, presence of urinary catheter and number of urine samples/year) compared the resistance of Escherichia coli, Proteus mirabilis and Klebsiella pneumoniae to amoxicillin/clavulanate, nitrofurantoin, trimethoprim/sulfamethoxazole, nalidixic acid, ofloxacin, ciprofloxacin and ceftriaxone, as well as their possible EBSL production, in nursing home residents and community-dwellers.

Résultats : Nursing home residents had a higher adjusted OR (aOR) of Enterobacteriaceae (E. coli, P. mirabilis or K. pneumoniae) resistant to amoxicillin/clavulanate (aOR 1.38, 95% CI 1.27-1.50), ciprofloxacin (aOR 1.33, 95% CI 1.20-1.49) and ceftriaxone (aOR 1.37, 95% CI 1.15-1.63) or producing an ESBL (aOR 1.43, 95% CI 1.18-1.72), but did not differ in resistance to nitrofurantoin or trimethoprim/sulfamethoxazole.

Conclusion : Elderly people in nursing homes had a risk around 40% higher than their community-dwelling peers of having antibiotic-resistant Enterobacteriaceae cultured from their urine samples. Antibiotic stewardship and infection prevention and control programmes should be implemented in nursing homes.

Conclusion (proposition de traduction) : Les personnes âgées vivant dans des maisons de retraite avaient un risque environ 40 % plus élevé que leurs homologues vivant dans la communauté de faire cultiver des Enterobacteriaceae résistantes aux antibiotiques à partir de leurs échantillons d'urine. Des programmes de gestion des antibiotiques et de prévention et de contrôle des infections devraient être mis en place dans les maisons de retraite.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Résistance des entérobactéries isolées des urines des patients en institution pour personnes âgées : étude de la prévalence en France . Rédigé par le Dr ean-Pierre Bru.

Lésion cérébrale traumatique mineure pédiatrique avec hémorragie intracrânienne : identification des patients à faible risque susceptibles de ne pas bénéficier de l'admission aux soins intensifs |

Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage: Identifying Low-Risk Patients Who May Not Benefit From ICU Admission.
Burns EC, Burns B, Newgard CD, Laurie A, Fu R, Graif T, Ward CS, Bauer A, Steinhardt D1, Ibsen LM, Spiro DM. | Pediatr Emerg Care. 2019 Mar;35(3):161-169
DOI: https://doi.org/10.1097/PEC.0000000000000950
Keywords: Aucun

Original Articles

Introduction : Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary.
OBJECTIVES: To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI).

Méthode : We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI.

Résultats : Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6%; 95% confidence interval, 82.2%-99.9%) from the low-risk group, with a negative likelihood ratio of 0.056 (95% confidence interval, -0.053-0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55% of the sample).

Conclusion : A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.

Conclusion (proposition de traduction) : Un sous-ensemble de patients à faible risque peut ne pas nécessiter une admission en USI. La règle de décision proposée identifiait les enfants à faible risque présentant une hémorragie intracrânienne traumatique pouvant être surveillés en dehors d'une USC, bien que cette règle nécessite une validation externe avant la mise en œuvre.

Répéter les examens de laboratoire aux urgences pédiatriques : à quelle fréquence et quel intérêt ? |

Repeat Laboratory Testing in the Pediatric Emergency Department: How Often and How Important?.
Fieldston ES, Fakeye OA1, Friedman DF. | Pediatr Emerg Care. 2019 Mar;35(3):190-193
DOI: https://doi.org/10.1097/PEC.0000000000001599
Keywords: Aucun

Original articles

Introduction : Little is known about repeat testing for patients admitted to children's hospitals from the emergency department (ED).
OBJECTIVE: The objective of this study was to describe the trend of repeat laboratory testing from a children's hospital ED.

Méthode : Laboratory studies were analyzed for July 2002 to June 2010 for complete blood counts (CBCs; 7 years), basic metabolic panels (BMPs; 2.5 years), and coagulation studies (7 years) ordered and reordered in the ED within 8 hours for patients admitted to the hospital. Results for tests were generated and classified into high, low, and normal based on reference ranges. To reflect actual practice, we expanded the normal range from 95% of lower bound to 105% of upper bound.

Résultats : A total of 37,035 CBCs, 11,414 BMPs, and 3903 coagulation studies were ordered. Proportions of these tests repeated were 0.9%, 1.9%, and 1.9%, respectively. Mean time to repeat was 2 hours. For CBCs, 25% of repeats were for a missing component; 35% were for low platelet counts. Sixty-eight percent of initial BMPs were repeated for high potassium. Half of coagulation studies were repeated for high prothrombin time; 36% were repeated for a missing component. On repeat, 75% of BMPs with high potassium levels and 65% of CBCs with low platelet count returned normal values, but 16% of coagulation studies repeated for high prothrombin time returned normal values.

Conclusion : Repeat ED laboratory testing occurs infrequently at a children's hospital, and a large proportion of repeats is attributed to missing results. When repeated, abnormal results on initial studies are often returned as normal.

Conclusion (proposition de traduction) : La répétition des examens de laboratoire est rarement aux urgences d'un hôpital pour enfants, et une grande partie est attribuée aux résultats manquants.
Lorsqu'ils sont répétés, les résultats anormaux précédents sont souvent retournés comme étant normaux.

Utilisation de la tomodensitométrie chez les enfants consultants aux urgences pour des douleurs abdominales |

Computed Tomography Use Plateaus Among Children With Emergency Visits for Abdominal Pain.
Fahimi J, Kornblith AE, Kanzaria H, Herring A, Wang RC. | Pediatr Emerg Care. 2019 Mar;35(3):194-198
DOI: https://doi.org/10.1097/PEC.0000000000001261
Keywords: Aucun

Original articles

Introduction : Abdominal pain is a common pediatric complaint to emergency departments (EDs), and clinicians often rely on imaging for diagnosis. Studies have demonstrated an increase in computed tomography (CT) in this population. Following emphasis on radiation reduction by researchers and organizations, this study evaluates recent national trends in CT use among pediatric patients presenting to EDs with abdominal pain.

Méthode : This is a cross-sectional analysis of ED patients 18 years or younger with chief complaint of abdominal pain in the National Hospital Ambulatory Medical Care Survey from 2008 to 2011. Outcomes include annual proportions of visits with x-ray, ultrasound, or CT, as well as diagnosis of appendicitis and hospital admission.

Résultats : Of 32,304 ED visits, 2120 (6.6%) were for abdominal pain. Proportions of visits using CT, ultrasound, and plain x-ray were 16.0%, 10.5%, and 23.4%, respectively. For all outcome measures, including imaging, hospital admission, and diagnosis of appendicitis, there was no change from 2008 to 2011. Considering previous data, there was a significant rise in ultrasound use from 5.4% (95% confidence interval, 2.4%-8.4%) in 1998 to 12.1% (95% confidence interval, 9.4%-13.7%) in 2011. Multivariate analysis of CT use found the strongest predictor to be increasing age. Females, black children, and those with Medicaid insurance had lower odds of having a CT.

Conclusion : In contrast to the earlier dramatic increase in CT use for pediatric patients with abdominal pain, CT remained constant between 2008 and 2011. There was no associated change in the rate of diagnosis of appendicitis or hospitalization; however, ultrasound is increasing.

Conclusion (proposition de traduction) : Contrairement à l'augmentation spectaculaire du recours à la tomodensitométrie chez les enfants se présentant pour douleurs abdominales, la tomodensitométrie est demeurée constante entre 2008 et 2011. Il n'y a eu aucun changement associé au taux de diagnostic d'appendicite ou d'hospitalisation ; cependant, l'échographie est en hausse.

Comparaison de trois tourniquets jonctionnels à l'aide d'un essai randomisé |

Comparison of Three Junctional Tourniquets Using a Randomized Trial Design.
Gaspary M, Zarow GJ, Barry MJ, Walchak AC, Conley SP, Roszko PJD. | Prehosp Emerg Care. 2019 Mar-Apr;23(2):187-194
DOI: https://doi.org/10.1080/10903127.2018.1484968
Keywords: groin; hemorrhage; inguinal; medical device; resuscitation; tourniquets

Original Contributions

Introduction : Hemorrhage remains a leading cause of death in both civilian and military settings. Of preventable deaths from hemorrhage, a significant portion occurs from junctional wounds that are not amenable to traditional extremity tourniquets. Junctional tourniquets (JTQs) can potentially provide hemorrhage control by compressing the arteries at the junction of the trunk and extremities. The FDA has cleared 3 JTQ products: The Combat Ready Clamp (CRoC®), the Junctional Emergency Treatment Tool (JETT™), and the SAM® Junctional Tourniquet (SJT). However, little is known regarding which of these JTQs is superior in application time, effectiveness in pulse elimination, effectiveness during transport, and user preference.

Méthode : Active duty corpsmen (N = 49) were given standardized instruction and hands-on training with the CRoC®, JETT™, and SJT, then sequentially applied each JTQ unilaterally to a fellow study participant in a randomized order. Pulse elimination was determined by Doppler ultrasound at the dorsalis pedis immediately then reevaluated after a short transport. User preference data were collected following testing. Data were analyzed using repeated measures ANOVA and non-parametric statistics at p < 0.05.

Résultats : The CRoC® was significantly slower in application time than the JETT™ and SJT. Effectiveness was similar for CRoC®, JETT™, and SJT. Effectiveness during transport was significantly higher for SJT than for the JETT™, but no JTQ performed well during transport (24-48% effectiveness). SJT ranked first in perceived ease of use, stability, and reliability, and in user trust and overall preference. Participants provided cogent suggestions for product improvement.

Conclusion : All JTQ devices performed poorly during transport. Combined, present findings highlight the potential of JTQ products for saving lives threatened by junctional wounds, but also highlight the need for specific product improvements towards fostering JTQ performance in patient transport.

Conclusion (proposition de traduction) : Tous les dispositifs de garrot jonctionnel ont mal fonctionné pendant le transport. Les résultats actuels combinés mettent en évidence le potentiel des produits de tourniquets jonctionnels pour sauver des vies menacées par des blessures jonctionnelles, mais soulignent également la nécessité d’améliorer des produits spécifiques en vue d’améliorer les performances des tourniquets jonctionnels dans le transport des patients.

Commentaire : Les dispositifs de compression jonctionnelle sont destinés a interrompre la vascularisation d’un membre par la compression artérielle proximale (axe ilio-fémoral, artère sous-clavière…).
Consulter l'article de Pierret C and al. Les traumatismes jonctionnels en situation de guerre. Médecine & Armées. 2014 Octobre;42(4):291-298

Devenir de la sédation chimique préhospitalière par kétamine par rapport à l'halopéridol et à une benzodiazépine ou par la contention physique seulement |

Outcomes of Prehospital Chemical Sedation With Ketamine Versus Haloperidol and Benzodiazepine or Physical Restraint Only.
O'Connor L, Rebesco M, Robinson C, Gross K, Castellana A, O'Connor MJ, Restuccia M. | Prehosp Emerg Care. 2019 Mar-Apr;23(2):201-209
DOI: https://doi.org/10.1080/10903127.2018.1501445
Keywords: agitated delirium; ketamine; restraint; sedation

Original Contributions

Introduction : The goal of this study is to describe complications and outcomes of prehospital ketamine use for agitation as compared to other methods of physical or chemical restraint such as haloperidol plus benzodiazepine or physical restraint only.

Méthode : We conducted a single-center retrospective review of patient encounters in which restraint was administered in the prehospital setting. At the beginning of our study window, only physical restraint was available to paramedics managing agitated patients but subsequently, haloperidol and benzodiazepines were introduced, followed by ketamine 2 years later. By comparing patients before and after each transition, we divided subjects into 3 cohorts based on restraint type: physical restraint, haloperidol plus benzodiazepine, and ketamine. Demographic data were collected, and outcome measures included intubation rate, need for additional physical or chemical restraint, emergency department (ED) length of stay, need for hospital admission, and employee injury.

Résultats : Of 214 subjects included in the study, 95 patients were administered ketamine, 68 received haloperidol and benzodiazepine, and 51 were physically restrained. Eleven of the patients (11.6%) who received ketamine were intubated. Compared to patients who received haloperidol plus benzodiazepine, patients who received ketamine were more likely to be intubated (odds ratio [OR] = 8.77, 95% confidence interval [CI], 1.10-69.68) and were more likely to require additional chemical restraint when compared to haloperidol/benzodiazepine or physical restraint only (OR =2.94, 95% CI, 1.49-5.80, and OR =2.15, 95% CI, 1.07-4.31, respectively). There were no differences between the 2 chemical sedation groups in terms of ED length of stay or hospital admission rate.

Conclusion : This study demonstrates a lower intubation rate in patients administered ketamine than prior literature in association with a lower weight-based dosing regimen. Ketamine use was correlated with a higher frequency of intubation and a greater need for additional chemical restraint when compared with other restraint modalities, though exogenous factors such as provider preference may have impacted this result. There was no difference in ED length of stay or admission rate between the ketamine and haloperidol plus benzodiazepine groups. Further prospective study is needed to determine whether there is a subset of patients for whom ketamine would be beneficial compared to other therapies.

Conclusion (proposition de traduction) : Cette étude démontre un taux d'intubation inférieur chez les patients traités à la kétamine par rapport à la littérature antérieure, associé à un schéma posologique basé sur le poids. La consommation de kétamine était corrélée à une fréquence d'intubation plus élevée et à un besoin accru de contention chimique supplémentaire par rapport à d'autres modalités de contention, bien que des facteurs exogènes tels que la préférence du prestataire aient pu influer sur ce résultat. Il n'y avait aucune différence dans la durée du séjour aux urgences ou le taux d'admission entre les groupes kétamine et halopéridol plus benzodiazépine. Une étude prospective supplémentaire est nécessaire pour déterminer s’il existe un sous-ensemble de patients pour lesquels la kétamine serait bénéfique par rapport aux autres traitements.

Qualité et faisabilité de la mesure sonographique du diamètre de la gaine du nerf optique pour estimer le risque d'augmentation de la pression intracrânienne après une lésion traumatique du cerveau en milieu préhospitalier |

Quality And Feasibility of Sonographic Measurement of the Optic Nerve Sheath Diameter to Estimate the Risk of Raised Intracranial Pressure After Traumatic Brain Injury in Prehospital Setting.
Houzé-Cerfon CH, Bounes V, Guemon J, Le Gourrierec T, Geeraerts T. | Prehosp Emerg Care. 2019 Mar-Apr;23(2):277-283
DOI: https://doi.org/10.1080/10903127.2018.1501444
Keywords: prehospital; sonographic; traumatic brain injury

Preliminary Reports

Introduction : In patients with traumatic brain injury (TBI), early detection and subsequent prompt treatment of elevated intracranial pressure (ICP) is a challenge in the prehospital setting, because physical examination is limited in comatose patients and invasive device placement is not possible. The aim of this study was to evaluate the quality and feasibility of optic nerve sheath diameter (ONSD) measurements obtained during the prehospital management of patients with TBI.

Méthode : This study was a prospective, observational study of 23 patients with moderate and severe TBI during prehospital medical care. The primary endpoint was the quality of ONSD measurements expressed as the percentage of ONSD validated by the experts. Secondary endpoints included the feasibility of ONSD measurements as the percentage of ONSD performed and assessment by operators of ease and duration to perform.

Résultats : Ultrasound ONSD was performed in 19 (82%) patients and 80% of ONSD measurements were validated by the experts. The ONSD measurements were possible in 15 (79%) cases. The physicians have assessed the ease of use at 8 (interquartile range [IQR] = 2.5-8) on 10 for and the median time to obtain ONSD measurement was 4 min (IQR = 3-5). ONSD measurement was performed in 12 (63%) cases during the transport and in 7 (37%) cases on scene, with 58% (n = 7) and 71% (n = 5) validated ONSD, respectively. The success rate in the helicopter was 43% compared to 80% in the ambulance.

Conclusion : This study shows that it is feasible to obtain high-quality ONSD measurements in the management of patients with TBI in a prehospital setting. A randomized study evaluating the usefulness of ONSD to guide management of TBI in the prehospital phase may be of great interest.

Conclusion (proposition de traduction) : Cette étude montre qu'il est possible d'obtenir des mesures de haute qualité du diamètre de la gaine du nerf optique dans la prise en charge des patients souffrant de lésions cérébrales traumatiques en milieu préhospitalier. Une étude randomisée évaluant l'utilité du diamètre de la gaine du nerf optique pour guider la prise en charge des traumatismes crâniens pendant la phase préhospitalière pourrait être d'un grand intérêt.

Commentaire : Consulter l'article de Messerer M. and al. :
Intérêt de l’échographie du diamètre de l’enveloppe du nerf optique pour la détection non invasive de l’hypertension intracrânienne. Neurochirurgie. 2013 Apr;59(2):55-9  .

Enregistrement de la prise en charge d'un arrêt cardiaque extra-hospitalier via une application pour téléphone portable : une étude de faisabilité par simulation |

Recording Out-of-Hospital Cardiac Arrest Treatment via a Mobile Smartphone Application: A Feasibility Simulation Study.
Sondheim SE, Devlin J, Seward WH 4th, Bernard AW, Feinn RS, Cone DC. | Prehosp Emerg Care. 2019 Mar-Apr;23(2):284-289
DOI: https://doi.org/10.1080/10903127.2018.1490838
Keywords: cardiopulmonary resuscitation; emergency medical services; high-fidelity simulation training; mobile applications; out-of-hospital cardiac arrest

Preliminary Reports

Introduction : Given the demanding nature of out-of-hospital cardiac arrest (OHCA) resuscitations, recordings of the times of interventions in EMS patient care reports (PCRs) are often inaccurate. The American Heart Association developed Full Code Pro (FCP), a smartphone application designed to assist EMS personnel in recording the timing of interventions performed. Through OHCA simulations, this study assessed the group size necessary to use the FCP recording functions accurately and safely without compromising patient care. Program evaluation was based on participant feedback surveys, data accuracy, delays between recording and performing interventions, and delays in care attributed to using the application, stratified by group size.

Méthode : Simulations of a standard OHCA scenario using the Gaumard TraumaHal mannequin and a dedicated iPhone 5 preloaded with FCP version 3.4 were run with group sizes of 2-6 participants, with group sizes determined by participant availability. Participants included Connecticut certified paramedics and paramedic students who had completed the appropriate coursework. A 7-item feedback survey using a Likert scale established participant feedback on the application. Videos of the simulations were analyzed to assess for delays. One-way analysis of variance with trend analysis was used to test whether outcomes differed by group size and whether differences tended in one direction in parallel with group size.

Résultats : There were 37 simulations, including 142 participants. The feedback survey questions achieved a Cronbach's alpha of 0.91, signifying high reliability, and demonstrated a linear trend supporting greater satisfaction with FCP as group size increases (p < 0.001). Similarly, increasing group size displayed linear trends with greater numbers of interventions recorded (p = 0.009) and fewer missed and false recordings (p = 0.002). Delays revealed significant linear trends (p = 0.018 for delays in recording and p < 0.001 for delays in care), as increasing group size corresponded with lesser delays. Greatest improvement was noted to be between groups of 3 and 4 participants.

Conclusion : OHCA simulations using FCP demonstrate increased provider comfort, increased recording accuracy, and decreased delays as the group size increased. While the application may improve recordings for PCRs and future research, the data suggest a sufficient number of EMS personnel (>3) should be present to achieve reliable data without compromising patient care.

Conclusion (proposition de traduction) : Les simulations d'arrêt cardiaque extra-hospitalier à l'aide de Full Code Pro démontrent un confort accru du prestataire, une précision d'enregistrement accrue et des délais réduits à mesure que la taille du groupe augmente. Bien que l'application puisse améliorer l'enregistrement des rapports sur les soins aux patients et les recherches futures, les données suggèrent qu'un nombre suffisant de membres du personnel EMS (> 3) devrait être présent pour obtenir des données fiables sans compromettre les soins aux patients.données fiables sans compromettre les soins aux patients.

Commentaire : L'application Full Code Pro de l'American Heart Association (AHA) n'est téléchargeable que sur iTunes .

Naissance extra-hospitalière inopinée et facteurs de risque d'évolution périnatale défavorable : résultats d'une cohorte prospective | Accès libre

Unplanned out-of-hospital birth and risk factors of adverse perinatal outcome: findings from a prospective cohort.
Javaudin F, Hamel V, Legrand A, Goddet S, Templier F, Potiron C, Pes P, Bagou G, Montassier E. | Scand J Trauma Resusc Emerg Med. 2019 Mar 2;27(1):26
DOI: https://doi.org/10.1186/s13049-019-0600-z | Télécharger l'article au format
Keywords: Birth before arrival; Emergency medical services; Out of hospital birth; Out-of-hospital delivery; Prehospital delivery; Unplanned delivery.

ORIGINAL RESEARCH

Introduction : In France, while most babies are delivered at hospital, emergency medical services (EMS) weekly manage calls for unplanned out-of-hospital births. The objective of our study was to describe neonatal morbidity and mortality, defined as death or neonatal intensive care unit hospitalization at Day 7, in a prospective multicentric cohort of unplanned out-of-hospital births.

Méthode : We prospectively analyzed out-of-hospital births from 25 prehospital EMS units in France. The primary outcome was neonatal morbidity and mortality, and the secondary outcome was risk factors associated with neonatal morbidity and mortality. A univariate logistic regression was first made, followed by a multivariate logistic regression with backward selection.

Résultats : From October 2011 to August 2018, a total of 1670 unplanned out-of-hospital births were included. Of these, 1652 (99.2%) were singleton and 1537 (93.5%) had prenatal care. Maternal mean age of the study population was 30 ± 5.5 (range 15 to 48). The majority of women were multiparous, but 13% were nulliparous. Overall, 45.3% of these unplanned out-of-hospital births were medically-driven, either by phone during medical regulation (12.5%) or on scene by the prehospital emergency medical service units (32.9%). The prevalence of neonatal morbidity and mortality was 6.3% (n = 106) after an unplanned out-of-hospital birth (death before Day 7: n = 20; 1.2%). The multivariate logistic regression found that multiparity (adjusted Odds Ratio = 70.7 [4.7-1062]), prematurity (adjusted Odds Ratio = 6.7 [2.1-21.4]), maternal pathology (adjusted Odds Ratio = 2.8 [1.0-7.5]) and hypothermia (adjusted Odds Ratio = 2.8 [1.1-7.6]) were independent predictive factors of neonatal morbidity and mortality.

Conclusion : Our study assessed for the first time risk factors for adverse perinatal outcome in a large and multicenter cohort of unplanned out-of-hospital births. We have to improve temperature management in the out-of-hospital field and future trials are required to investigate strategies to optimize newborns management in the prehospital area.

Conclusion (proposition de traduction) : Notre étude a évalué pour la première fois les facteurs de risque d'évolution périnatale défavorable dans une vaste cohorte multicentrique de naissances inopinée en dehors de l'hôpital. Nous devons améliorer la gestion de la température dans le domaine extra-hospitalier et de futurs essais sont nécessaires pour étudier des stratégies visant à optimiser la gestion des nouveau-nés dans l'environnement préhospitalier.

Buprénorphine sublinguale versus morphine intraveineuse ou intramusculaire dans le traitement de la douleur aiguë : revue systématique et méta-analyse d'essais contrôlés randomisés |

Sublingual buprenorphine versus intravenous or intramuscular morphine in acute pain: A systematic review and meta-analysis of randomized control trials.
Vlok R, An GH, Binks M, Melhuish T, White L. | Am J Emerg Med. 2019 Mar;37(3):381-386
DOI: https://doi.org/10.1016/j.ajem.2018.05.052
Keywords: Acute pain; Analgesia; Buprenorphine; Opioids

Original Contribution

Introduction : Buprenorphine is a potent analgesic agent with several unique and favourable features such as its sublingual formulation. The aim of this study is to compare the effectiveness of sublingual versus intramuscular and intravenous buprenorphine in acute pain.

Méthode : Five major databases were systematically searched until April 2018. All randomized control trials comparing sublingual buprenorphine with intravenous or intramuscular morphine in acute pain were included in this review. These studies were assessed for level of evidence and risk of bias. The data was then analyzed both qualitatively and where appropriate by meta-analysis. The primary outcomes were analgesic effect up to six hours and rescue analgesia requirement. The secondary outcomes were incidence of respiratory depression, nausea, vomiting, dizziness and hypotension.

Résultats : Nine studies comparing sublingual and intramuscular or intravenous buprenorphine were identified and included 826 patients. There was no difference in pain at any time point before six hours or need for rescue analgesia between the two agents. There was no difference in secondary outcomes between the two agents.

Conclusion : Sublingual buprenorphine offers an effective alternative to intravenous or intramuscular analgesia in acute pain. Sublingual buprenorphine appears to be a viable option in patients where intravenous access is difficult or not favourable.

Conclusion (proposition de traduction) : La buprénorphine sublinguale offre une alternative efficace à l'analgésie intraveineuse ou intramusculaire dans les cas de douleur aiguë. La buprénorphine par voie sublinguale semble être une option viable chez les patients pour lesquels l'accès veineuse est difficile ou non envisagé.

Administration d'épinéphrine dans l'arrêt cardiaque extra-hospitalier avec rythme cardiaque non chocable |

Epinephrine administration in non-shockable out-of-hospital cardiac arrest.
Jouffroy R, Saade A, Alexandre P, Philippe P, Carli P, Vivien B. | Am J Emerg Med. 2019 Mar;37(3):387-390
DOI: https://doi.org/10.1016/j.ajem.2018.05.055
Keywords: Aucun

Original Contribution

Introduction : Epinephrine is recommended for the treatment of non-shockable out of hospital cardiac arrest (OHCA) to obtain return of spontaneous circulation (ROSC). Epinephrine efficiency and safety remain under debate.
OBJECTIVE: We propose to describe the association between the cumulative dose of epinephrine and the failure of ROSC during the first 30 min of advanced life support (ALS).

Méthode : A retrospective observational cohort study using the Paris SAMU 75 registry including all non-traumatic OHCA. All OHCA receiving epinephrine during the first 30 min of ALS were enrolled. Cumulative epinephrine dose given during ALS to ROSC was retrieved from medical reports.

Résultats : Among 1532 patients with OHCA, 776 (51%) had initial non-shockable rhythm. Fifty-four patients were excluded for missing data. The mean value of cumulative dose of epinephrine was 10 ± 4 mg in patients who failed to achieve ROSC (ROSC-) and 4 ± 3 mg (p = 0.04) for those who achieved ROSC. ROC curve analysis indicated a cut-off point of 7 mg total cumulative epinephrine associated with ROSC- (AUC = 0.89 [0.86-0.92]). Using propensity score analysis including age, sex and no-flow duration, association with ROSC- only remained significant for epinephrine > 7 mg (p ≤10-3, OR [CI95] = 1.53 [1.42-1.65]).

Conclusion : An association between total cumulative epinephrine dose administered during OHCA resuscitation and ROSC- was reported with a threshold of 7 mg, best identifying patients with refractory OHCA. We suggest using this threshold in this context to guide the termination of ALS and early decide on the implementation of extracorporeal life support or organ harvesting in the first 30 min of ALS.

Conclusion (proposition de traduction) : Une association entre la dose cumulée totale d'épinéphrine administrée au cours de la réanimation d'un arrêt cardiaque extra-hospitalier et le retour à une circulation spontanée a été obtenu avec un seuil de 7 mg, permettant de mieux identifier les patients présentant un arrêt cardiaque réfractaire extra-hospitalier.
Nous suggérons d’utiliser ce seuil dans ce contexte pour guider l'arrêt de la réanimation cardiaque avancée (médicalisée ou ALS) et décider au plus tôt de la mise en œuvre d’une intervention extracorporelle de maintien de la vie (ECLS) ou du prélèvement d’organes au cours des 30 premières minutes de réanimation cardiaque avancée.

Mesure du lactate au service des urgences : analyse rétrospective sur deux ans |

Blood lactate measurement within the emergency department: A two-year retrospective analysis.
Contenti J, Occelli C, Lemoel F, Ferrari P, Levraut J. | Am J Emerg Med. 2019 Mar;37(3):401-406
DOI: https://doi.org/10.1016/j.ajem.2018.05.065
Keywords: Emergency; Incidence; Lactate; Unselected patients

Original Contribution

Editorial : We evaluate in this retrospective cohort, the clinical situations leading emergency physicians to take a blood lactate sample, the prevalence of hyperlactatemia and its impact on short-term adverse outcome. ED patients requiring a blood lactate measurement (BLM) during a two-year period were included. Early patients' outcomes were extracted and discharge diagnoses were classified into 12 diagnostic categories. A total of 118,737 patients were analyzed. A BLM was carried out in 13,089 of them. Surprisingly, the proportion of patients having a BLM was higher in those admitted for seizure (31.4%) than in those admitted for infection (27.9%). Ten percent of patients who had a blood lactate test had a lactate level >4 mmol/l (1,315). Among them, 23.2% were admitted for infections, 20% for seizures, and 11% for cardiovascular diseases. After excluding the patients older than 75 years from the analysis in order to prevent a selection bias, the patient's severity was independently associated to an age over 65 years (OR: 1.26), an arterial blood sampling (OR: 2.77) and the blood lactate level (OR: 1.31). The blood lactate level was very informative to detect the sicker patients in the infection group whereas its interest was poor in the group of patients admitted for seizures. In conclusion, blood lactate testing has become routine in emergency departments and a large proportion of patients have abnormal blood lactate levels. The most frequent causes of high blood lactate in the ED are infection and seizures but the prognostic value of blood lactate seems to be different from one diagnostic category to the other.

Conclusion : The present study describes the utilization of blood lactate measurement by emergency physicians in a large cohort of unselected ED patients. We report a high incidence of blood lactate measurement during broad clinical situations. This biomarker is now widely used by emergency physicians for both diagnostic and prognostic purposes and seems to be useful to predict bad outcomes in a broad population of ED patients. However, the utilization of blood lactate measurement is not an absolute tool and it requires, like all other biomarkers, to take into account the clinical context.

Conclusion (proposition de traduction) : La présente étude décrit l'utilisation de la mesure du lactate dans le sang par les urgentistes dans une vaste cohorte de patients non sélectionnés au service des urgences. Nous rapportons une incidence élevée de la mesure du lactate dans le sang lors de situations cliniques générales. Ce biomarqueur est maintenant largement utilisé par les urgentistes à des fins diagnostiques et pronostiques et semble utile pour prédire les mauvais résultats dans une large population de patients du service des urgences. Cependant, l'utilisation de la mesure du lactate dans le sang n'est pas un outil absolu et elle nécessite, comme tous les autres biomarqueurs, de prendre en compte le contexte clinique.

Risque de blessures occasionnés par les sports d'hiver chez les enfants |

The risk of snow sport injury in pediatric patients.
McLoughlin RJ, Green J, Nazarey PP, Hirsh MP, Cleary M, Aidlen JT. | Am J Emerg Med. 2019 Mar;37(3):439-443
DOI: https://doi.org/10.1016/j.ajem.2018.06.006
Keywords: Blunt trauma; Pediatric trauma; Skiing; Snowboarding

Original contribution

Introduction : In 2015, approximately 13,436 snowboarding or skiing injuries occurred in children younger than 15. We describe injury patterns of pediatric snow sport participants based on age, activity at the time of injury, and use of protective equipment.

Méthode : A retrospective analysis was performed of 10-17 year old patients with snow-sport related injuries at a Level-1 trauma center from 2005 to 2015. Participants were divided into groups, 10-13 (middle-school, MS) and 14-17 years (high-school, HS) and compared using chi-square, Student's t-tests, and multivariable logistic regression.

Résultats : We identified 235 patients. The HS group had a higher proportion of females than MS (17.5% vs. 7.4%, p = 0.03) but groups were otherwise similar. Helmet use was significantly lower in the HS group (51.6% vs. 76.5%, p < 0.01). MS students were more likely to suffer any head injury (aOR 4.66, 95% CI: 1.70-12.8), closed head injury (aOR 3.69 95% CI: 1.37-9.99), or loss of consciousness (aOR 5.56 95% CI 1.76-17.6) after 4 pm. HS students engaging in jumps or tricks had 2.79 times the risk of any head injury (aOR 2.79 95% CI: 1.18-6.57) compared to peers that did not. HS students had increased risk of solid organ injury when helmeted (aOR 4.86 95% CI: 1.30-18.2).

Conclusion : Injured high-school snow sports participants were less likely to wear helmets and more likely to have solid organ injuries when helmeted than middle-schoolers. Additionally, high-schoolers with head injuries were more like to sustain these injures while engaging in jumps or tricks. Injury prevention in this vulnerable population deserves further study.

Conclusion (proposition de traduction) : Les sportifs blessés pratiquant les sports d'hiver au lycée étaient moins susceptibles de porter un casque et plus susceptibles de se blesser sérieusement aux organes s'ils étaient casqués que les collégiens. De plus, les lycéens blessés à la tête étaient plus enclins à subir ces blessures tout en effectuant des sauts ou des figures. La prévention des blessures chez cette population vulnérable mérite une étude plus approfondie.

Évaluation de l'utilisation de l'acide tranexamique chez les patients traumatisés : une analyse quantitative rétrospective |

Evaluation of tranexamic acid in trauma patients: A retrospective quantitative analysis.
Ng M, Perrott J2, Burgess S. | Am J Emerg Med. 2019 Mar;37(3):444-449
DOI: https://doi.org/10.1016/j.ajem.2018.06.010
Keywords: Hemorrhage; Tranexamic acid; Trauma

Original contribution

Introduction : Tranexamic acid (TXA) has been shown to decrease mortality in adult trauma patients with or at significant risk of hemorrhage when administered within 3 h of injury. The use and appropriateness of TXA in adult trauma patients presenting to Royal Columbian Hospital (RCH) was investigated.

Méthode : This retrospective chart review utilized the British Columbia Trauma Registry to identify 100 consecutive trauma patients that presented to the emergency department at RCH between April 2012 to June 2015 and met the following indications for TXA: systolic blood pressure <90 mm Hg and/or heart rate >110 bpm and presentation within 8 h of injury. Primary outcomes included: percentage that met indications for TXA, received TXA according to the CRASH-2 protocol, received a pre-hospital dose, and received TXA ≤1, >1 to ≤3, or >3 h from injury.

Résultats : During the given time period, 117 subjects (2.7%) met indications for TXA. 67 patients (57%) received TXA in any dose, with 10 subjects (8.5%) receiving TXA according to the CRASH-2 protocol. Of the 67 patients who received any TXA, 76% did so ≤3 h. 22 patients (19%) received TXA as a pre-hospital dose.

Conclusion : <10% of adult trauma patients that met the indication for TXA received it according to the CRASH-2 protocol. Of those patients that received TXA, 76% did so within 3 h. Further inquiry to identify reasons trauma patients are not receiving TXA as well as quality improvement initiatives in trauma care are required.

Conclusion (proposition de traduction) : Moins de 10 % des patients adultes traumatisés répondant à l'indication de l'acide tranexamique l'ont reçu conformément au protocole CRASH-2. Parmi les patients ayant reçu de l'acide tranexamique, 76 % l'ont fait dans les 3 heures. Des recherches supplémentaires sont nécessaires pour identifier les raisons pour lesquelles les patients traumatisés ne reçoivent pas d'acide tranexamique. Des initiatives d'amélioration de la qualité des soins traumatologiques sont nécessaires.

Comparaison des scores de risque clinique pour le tri des patients présentant une douleur thoracique à haut risque au service des urgences |

Comparison of clinical risk scores for triaging high-risk chest pain patients at the emergency department.
Al-Zaiti SS, Faramand Z, Alrawashdeh MO, Sereika SM, Martin-Gill C, Callaway C. | Am J Emerg Med. 2019 Mar;37(3):461-467
DOI: https://doi.org/10.1016/j.ajem.2018.06.020
Keywords: Acute coronary syndrome; Chest pain; HEART; TIMI

Original contribution

Introduction : Many of the clinical risk scores routinely used for chest pain assessment have not been validated in patients at high risk for acute coronary syndrome (ACS). We performed an independent comparison of HEART, TIMI, GRACE, FRISC, and PURSUIT scores for identifying chest pain due to ACS and for predicting 30-day death or re-infarction in patients arriving through Emergency Medical Services (EMS).

Méthode : We enrolled consecutive EMS patients evaluated for chest pain at three emergency departments. A reviewer blinded to outcome data retrospectively reviewed patient charts to compute each risk score. The primary outcome was ACS diagnosed during the primary admission, and the secondary outcome was death or re-infarction within 30-days of initial presentation.

Résultats : Our sample included 750 patients (aged 59 ± 17 years, 42% female), of whom 115 (15.3%) had ACS and 33 (4.4%) had 30-day death or re-infarction. The c-statistics of HEART, TIMI, GRACE, FRISC, and PURSUIT for identifying ACS were 0.87, 0.86, 0.73, 0.84, and 0.79, respectively, and for predicting 30-day death or re-infarction were 0.70, 0.73, 0.72, 0.72, and 0.62, respectively. Sensitivity/negative predictive value of HEART ≥ 4 and TIMI ≥ 3 for ACS detection were 0.94/0.98 and 0.87/0.97, respectively.

Conclusion : In chest pain patients admitted through EMS, HEART and TIMI outperform other scores for identifying chest pain due to ACS. Although both have similar negative predictive value, HEART has better sensitivity and lower rate of false negative results, thus it can be used preferentially over TIMI in the initial triage of this population.

Conclusion (proposition de traduction) : Chez les patients souffrant de douleurs thoraciques admis admis par les services médicaux d'urgence, HEART et TIMI surpassent les autres scores pour identifier les douleurs thoraciques dues à un syndrome coronarien aigu. Bien que les deux aient une valeur prédictive négative similaire, HEART a une meilleure sensibilité et un taux plus faible de résultats faussement négatifs. Il peut donc être utilisé de préférence par rapport à TIMI lors du triage initial de cette population.

Capacité des urgentistes à prévoir l'admission à l'hôpital au moment du triage |

Emergency medicine physicians' ability to predict hospital admission at the time of triage.
Vlodaver ZK, Anderson JP, Brown BE, Zwank MD. | Am J Emerg Med. 2019 Mar;37(3):478-481
DOI: https://doi.org/10.1016/j.ajem.2018.06.023
Keywords: Hospital admission; Patient flow; Prediction; Triage

Original contribution

Introduction : We seek to determine if experienced emergency medicine physicians can accurately predict the likelihood of admission for patients at the time of triage. Such predictions, if proven to be accurate, could decrease the time spent in the ED for patients who will ultimately be admitted by hastening downstream workflow.

Méthode : This is a prospective cohort study of experienced physicians at a large urban hospital. Physicians were asked to predict the likelihood of admission for patients based only on information available in the EMR at the time of triage. Physicians also predicted the service to which the patients would be admitted. Physicians provided a confidence level of their prediction. Measures of predictive accuracy were calculated, including sensitivity, specificity, and area under the receiver operating characteristic curve.

Résultats : 35 physicians evaluated 398 patient charts and made predictions. Sensitivity of determining admission for the entire cohort was 51.8%. The specificity was 89.1%. For those predictions made with a confidence level of >90%, sensitivity was 61.5% and specificity was 95.7%. Among physicians correctly predicting admission, the admitting service was predicted accurately 88.6% of the time.

Conclusion : Physicians performed poorly at predicting which patients would be admitted at the time of triage, even when they were confident in their predictions. Conversely, physicians accurately predicted who would be discharged. Physicians predicted with reasonable accuracy the service to which patients were ultimately admitted. More research and operational assessment needs to be performed to determine if these predictions can help improve ED efficiency.

Conclusion (proposition de traduction) : Les médecins prédisaient mal quels patients seraient admis au moment du triage, même lorsqu'ils avaient confiance en leurs prévisions. Inversement, les médecins ont prédit avec exactitude qui serait renvoyé. Les médecins prédisaient avec une précision raisonnable le service auquel les patients seraient finalement admis.
Davantage de recherche et d'évaluation opérationnelle doivent être réalisées pour déterminer si ces prévisions peuvent aider à améliorer l'efficacité des services d'urgence.

Bloc nerveux périphérique de l'avant-bras guidé par échographie pour la prise en charge des fractures digitales dans un service d'urgence pédiatrique |

Ultrasound-guided peripheral forearm nerve block for digit fractures in a pediatric emergency department.
Mori T, Nomura O, Ihara T. | Am J Emerg Med. 2019 Mar;37(3):489-493
DOI: https://doi.org/10.1016/j.ajem.2018.11.033
Keywords: Children; Digit fracture; Ultrasound-guided nerve block

Brief Reports

Editorial : Although ultrasound-guided peripheral nerve block (UGPNB) has recently been introduced into pediatric emergency departments (EDs), knowledge of its use is still limited among pediatric emergency physicians. Ultrasound-guided ulnar nerve block (UGUNB) is a form of peripheral nerve block available for controlling the pain caused by phalangeal injuries, but studies of its use in pediatric patients are still scarce. The aim of this case series was to describe the experience of UGUNB use for pediatric phalangeal fractures in a pediatric ED setting. In all the patients with phalangeal fractures, the ulnar nerve was successfully visualized using a hockey-stick type transducer. Approximately 0.1-0.2 mg/kg of 1% lidocaine was used as the nerve block. The procedure was effective for pain control, and fracture reduction was successfully performed without the need for rescue analgesia. This case series demonstrated that UGUNB has the potential to be a useful alternative to conventional pain management in pediatric fifth digit injuries.

Conclusion : UGUNB has the potential to be a useful alternative to conventional forms of analgesia in the treatment of pediatric fifth phalangeal frac- tures although the indications need to be carefully verified.

Conclusion (proposition de traduction) : Le bloc nerveux périphérique guidé par échographie pourrait constituer une alternative utile aux formes conventionnelles d'analgésie dans le traitement des fractures de la cinquième phalange chez l'enfant, bien que les indications doivent être soigneusement vérifiées.

Prévalence des troubles de la natrémie chez les patients âgés sans insuffisance rénale chronique |

The prevalence of dysnatremia in the elderly patients without CKD.
Imai N, Shibagaki Y. | Am J Emerg Med. 2019 Mar;37(3):499-501
DOI: https://doi.org/10.1016/j.ajem.2018.12.004
Keywords: Aucun

Brief Reports

Introduction : Dysnatremia is one of the most commonly encountered electrolyte disorders in the emergency department (ED). Few studies have reported the prevalence of dysnatremia in elderly patients without chronic kidney disease (CKD). We investigated the prevalence of dysnatremia in elderly patients without CKD in an emergency department in Japan.

Méthode : We reviewed 10,558 patients presenting to the ED between July 2015 and December 2017. The adult group consisted of 4562 patients aged between 18 and 64 years old, and the elderly group consisted of 5996 patients aged over 65 years. Information collected included age, gender, serum sodium and serum creatinine. Hyponatremia was defined as serum sodium level < 135 mEq/L, and severe hyponatremia was defined as a serum sodium level < 125 mEq/L. Hypernatremia was defined as a serum sodium level > 145 mEq/L, and moderate to severe hypernatremia was defined as a serum sodium level ≧ 150 mEq/L.

Résultats : In the adult group, the prevalence of hyponatremia was 2.8% in patients without CKD and 10.3% in patients with CKD (P < 0.001). On the other hand, in the elderly group, the prevalence of hyponatremia was 14.8% in patients without CKD and 12.9% in patients with CKD (P = 0.034). In the adult group, the prevalence of hypernatremia was 0.7% in patients without CKD and 2.0% in patients with CKD (P = 0.003). Similarly, in the elderly group, the prevalence of hypernatremia was 1.5% in patients without CKD and 3.5% in patients with CKD (P < 0.001).

Conclusion : In elderly patients, the prevalence of hyponatremia was higher in patients without CKD than in patients with CKD. Special attention should be paid to elderly patients without CKD in order to prevent severe hyponatremia.

Conclusion (proposition de traduction) : Chez les patients âgés, la prévalence de l'hyponatrémie était plus élevée chez les patients non atteints d'IRC que chez les patients atteints d'IRC. Une attention particulière doit être portée aux patients âgés sans IRC afin de prévenir une hyponatrémie sévère.

Indice de choc ajusté par la respiration pour l'identification d'une hypoperfusion tissulaire occulte (ou tableau de choc débutant) et le niveau de soins chez les patients présentant un sepsis |

Respiratory adjusted shock index for identifying occult shock and level of Care in Sepsis Patients.
Jiang L, Caputo ND, Chang BP. | Am J Emerg Med. 2019 Mar;37(3):506-509
DOI: https://doi.org/10.1016/j.ajem.2019.01.026
Keywords: Screening; Sepsis; Shock index

Brief Reports

Introduction : Early identification of shock allows for timely resuscitation. Previous studies note the utility of bedside calculations such as the shock index (SI) and quick sepsis-related organ failure assessment (qSOFA) to detect occult shock. Respiratory rate may also be an important marker of occult shock. The goal of our study was to evaluate whether using a modified SI with respiratory rate would improve identification of emergency department sepsis patients admitted to an ICU or stepdown unit.

Méthode : A prospective, observational cohort study of the respiratory adjusted shock index (RASI), defined as HR/SBP × RR/10, was conducted. RASI was calculated from triage vital signs and compared to serum lactate. Primary outcome was admission to a higher level of care defined as ICU or stepdown unit. A multivariable logistic regression model including RASI, SI, lactate, age and sex was performed with disposition as the outcome variable. Areas under the curve (AUC) were calculated to detect occult shock and level of care for RASI, SI, and qSOFA.

Résultats : 408 patients were enrolled, 360 were included in the analysis. Regression analysis revealed that lactate (OR 1.55, z = 4.38, p < 0.0001) and RASI (OR 2.27, z = 3.03, p < 0.002) were predictive of need for higher level of care. The AUC for RASI, SI, and qSOFA to detect occult shock were 0.71, 0.6, and 0.61 respectively. RASI also had a significant AUC in predicting level of care at 0.75 compared to SI (0.64) and qSOFA (0.62).

Conclusion : RASI may have utility as a rapid bedside tool for predicting critical illness in sepsis patients.

Conclusion (proposition de traduction) : L'indice de choc ajusté par la respiration peut être utile en tant qu'outil rapide au chevet du patient pour prédire une maladie grave chez les patients présentant un sepsis.

Épinéphrine à dose standard versus placebo dans l'arrêt cardiaque extra-hospitalier : revue systématique et méta-analyse |

Standard dose epinephrine versus placebo in out of hospital cardiac arrest: A systematic review and meta-analysis.
Kempton H, Vlok R, Thang C, Melhuish T, White L. | Am J Emerg Med. 2019 Mar;37(3):511-517
DOI: https://doi.org/10.1016/j.ajem.2018.12.055
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Epinephrine; Meta-analysis

Reviews

Introduction : Out of hospital cardiac arrest (OHCA) is a time critical and heterogeneous presentation. The most appropriate management strategies remain an issue for debate. The aim of this systematic review and meta-analysis was to determine the association of epinephrine versus placebo with return of spontaneous circulation, survival to hospital admission, survival to hospital discharge and neurological outcomes in out of hospital cardiac arrest.

Méthode : A systematic review of five databases was performed from inception to August 2018. Only randomised controlled trials were considered eligible for inclusion. The primary outcome was survival to hospital discharge. Secondary outcomes were ROSC, survival to hospital admission, neurological function on discharge and three-month survival. All studies were assessed for level of evidence and risk of bias.

Résultats : Five randomised controlled trials with 17,635 patients were identified for inclusion. Use of epinephrine was associated with increased ROSC (OR = 3.10; 95% CI = 2.16 to 4.45; I2 = 74%; p < 0.0001) and increased survival to hospital admission OR = 2.52; 95% CI = 1.63 to 3.88; I2 = 94%; p < 0.0001). However, epinephrine was not associated with increased survival to discharge (OR = 1.09; 95% CI = 0.48 to 2.47; I2 = 77%; p = 0.84) or differences in neurological outcomes (OR = 0.81; 95% CI = 0.34 to 1.96).

Conclusion : This study was a systematic review and meta-analysis of epinephrine versus placebo in OHCA. The use of epinephrine was associated with improved ROSC and survival to hospital admission. However, use of epinephrine was not associated with a significant difference in survival to hospital discharge, neurological outcomes or survival to 3 months. Further research is required to control for the confounders during inpatient management.

Conclusion (proposition de traduction) : Cette étude était une revue systématique et une méta-analyse sur l'épinéphrine par rapport à un placebo dans les cas d'arrêt cardiaque extra-hospitalier. L'utilisation d'épinéphrine a été associée à l'amélioration du nombre de retour à une circulation spontanée et à la survie à l'entrée à l'hôpital. Cependant, l'utilisation d'épinéphrine n'a pas été associée à une différence significative dans la survie à la sortie de l'hôpital, les résultats neurologiques ou la survie à 3 mois.
Des recherches supplémentaires sont nécessaires pour contrôler les facteurs de confusion lors de la prise en charge des patients hospitalisés.

La nuit est associée à une diminution de la survie en cas d’arrêt cardiaque extra-hospitalier : méta-analyse d’études observationnelles |

Nighttime is associated with decreased survival for out of hospital cardiac arrests: A meta-analysis of observational studies.
Lin P, Shi F, Wang L, Liang ZA. | Am J Emerg Med. 2019 Mar;37(3):524-529
DOI: https://doi.org/10.1016/j.ajem.2019.01.004
Keywords: Cardiac arrest; Emergency care system; Pre-hospital care

Reviews

Introduction : The relationship between time of day and the clinical outcomes of patients with out-of-hospital cardiac arrest (OHCA) remains inconclusive. We undertook a meta-analysis to assess the available evidence on the relationship between nighttime and prognosis for patients with OHCA.

Méthode : PubMed and EMBASE were searched through June 20, 2018, to identify all studies assessing the relationship between nighttime and prognosis for patients with OHCA. Random effects modes were used to estimate odds ratios (ORs) with 95% confidence intervals (CIs).

Résultats : Eight observational studies met the inclusion criteria. Meta-analysis of 8 studies showed that compared with nighttime, the daytime OHCA patients had higher 1-month/in-hospital survival (OR, 1.25; 95% CI, 1.15-1.37; P = 0.00), with high heterogeneity among the studies (I2 = 82.8%, P = 0.00).

Conclusion : Patients who experienced OHCA during the nighttime had lower 1-month/in-hospital survival than those with daytime OHCA. In addition to arrest event and pre-hospital care factors, patients' comorbidity and hospital-based care may also be responsible for lower survival at night.

Conclusion (proposition de traduction) : Les patients qui ont subi un arrêt cardiaque extra-hospitalier pendant la nuit avaient un taux de survie d'un mois de moins ou moins que ceux qui ont subi un arrêt cardiaque extra-hospitalier pendant la journée. En plus des facteurs liés à l'arrêt cardiaque et aux soins préhospitaliers, la comorbidité et les soins en milieu hospitalier peuvent également être responsables d'un taux de survie plus faible la nuit.

Esmolol comparé à l'amiodarone dans le traitement de la fibrillation atriale récente (RAF) : étude de validité externe en médecine d'urgence |

Esmolol Compared with Amiodarone in the Treatment of Recent-Onset Atrial Fibrillation (RAF): An Emergency Medicine External Validity Study.
Milojevic K, Beltramini A, Nagash M, Muret A, Richard O, Lambert Y. | J Emerg Med. 2019 Mar;56(3):308-318
DOI: https://doi.org/10.1016/j.jemermed.2018.12.010
Keywords: atrial fibrillation; emergency medicine; esmolol

Pharmacology in Emergency Medicine

Introduction : Recent-onset atrial fibrillation (RAF) is the most frequent supraventricular dysrhythmia in emergency medicine. Severely compromised patients require acute treatment with injectable drugs OBJECTIVE: The main purpose of this external validity study was to compare the short-term efficacy of esmolol with that of amiodarone to treat severe RAF in an emergency setting.

Méthode : This retrospective survey was conducted in mobile intensive care units by analyzing patient records between 2002 and 2013. We included RAF with (one or more) severity factors including: clinical shock, angina pectoris, ST shift, and very rapid ventricular rate. A blind matching procedure was used to constitute esmolol group (n = 100) and amiodarone group (n = 200), with similar profiles for age, gender, initial blood pressure, heart rate, severity factors, and treatment delay. The main outcome measure was the percentage of patients with a ventricular rate control defined as heart frequency ≤ 100 beats/min. More stringent (rhythm control) and more humble indicators (20% heart rate reduction) were analyzed at from 10 to 120 min after treatment initiation.

Résultats : Patient characteristics were comparable for both groups: age 66 ± 16 years, male 71%, treatment delay < 1 h 36%, 1-2 h 29%, > 2 h 35%, chest pain 61%, ST shift 62%, ventricular rate 154 ± 26 beats/min, and blood pressure 126/73 mm Hg. The superiority of esmolol was significant at 40 min (64% rate control with esmolol vs. 25% with amiodarone) and for all indicators from 10 to 120 min after treatment onset.

Conclusion : In "real life emergency medicine," esmolol is better than amiodarone in the treatment of RAF

Conclusion (proposition de traduction) : Dans la réalité (« vraie vie ») en médecine d'urgence, l'esmolol est meilleur que l'amiodarone dans le traitement de la fibrillation auriculaire récente.

Un nouveau changement de paradigme dans les accidents vasculaires cérébraux ischémiques aigus, les occlusions de gros vaisseaux et le traitement endovasculaire |

A New Paradigm Shift in Acute Ischemic Stroke, Large Vessel Occlusions, and Endovascular Therapy.
Rezaie SR, Swaminathan A, Koyfman A, Long B. | J Emerg Med. 2019 Mar;56(3):258-266
DOI: https://doi.org/10.1016/j.jemermed.2018.10.022
Keywords: endovascular; large vessel; occlusion; stroke; thrombolysis

Clinical Reviews

Introduction : In the past three years, there have been several major studies published on the use of endovascular therapy (EVT) in large vessel occlusion (LVO) acute ischemic stroke. With multiple publications in such a short amount of time, it is difficult to keep up with the evolving landscape of ischemic stroke therapy.

Méthode : This narrative review discusses recent randomized controlled trials evaluating EVT and its effects on acute ischemic stroke management.

Résultats : Ischemic stroke is the most common type of stroke overall, and recanalization is the predominant focus in stroke therapy to improve outcomes. Treatment first focused on systemic thrombolysis for ischemic stroke, followed by studies evaluating the use of thrombolysis with EVT. Early research did not find a benefit to EVT; however, recent studies using current devices and with narrow selection criteria demonstrate significant benefit to EVT in LVOs. In patients with LVOs and perfusion mismatches, reperfusion rates are higher with EVT compared with systemic thrombolysis alone. Recognition of patients with small infarct cores and large areas of ischemic but salvageable brain tissue up to 24 h after symptom onset stresses the need for advanced imaging to recognize the target group.

Conclusion : EVT technology for acute ischemic stroke has now become more efficient, minimizing complications and improving the efficacy of EVT. Several viable interventions for a small subgroup of patients with ischemic stroke up to 24 h after symptoms onset can significantly improve patient outcomes.

Conclusion (proposition de traduction) : La technique de traitement endovasculaire pour les accidents ischémiques aigus est maintenant plus efficace, minimisant les complications et améliorant l'efficacité du traitement endovasculaire. Plusieurs interventions viables pour un petit sous-groupe de patients victimes d'un AVC ischémique jusqu'à 24 h après l'apparition des symptômes peuvent améliorer de manière significative les résultats pour les patients.

Sufentanil intranasal versus morphine intraveineuse pour douleur aiguë au service des urgences : essai pilote randomisé |

Intranasal Sufentanil Versus Intravenous Morphine for Acute Pain in the Emergency Department: A Randomized Pilot Trial.
Sin B, Jeffrey I, Halpern Z, Adebayo A, Wing T, Lee AS, Ruiz J, Persaud K, Davenport L, de Souza S, Williams M. | J Emerg Med. 2019 Mar;56(3):301-307
DOI: https://doi.org/10.1016/j.jemermed.2018.12.002
Keywords: acute pain; intranasal; sufentanil analgesia

Pharmacology in Emergency Medicine

Introduction : Patients in the United States frequently seek medical attention in the emergency department (ED) to address their pain. The intranasal (i.n.) route provides a safe, effective, and painless alternative method of drug administration. Sufentanil is an inexpensive synthetic opioid with a high therapeutic index and rapid onset of action, making it an attractive agent for management of acute pain in the ED.
OBJECTIVE: The objective of our study was to evaluate the safety and efficacy of i.n. sufentanil as the primary analgesic for acute pain in the ED.

Méthode : This was a single-center, prospective, randomized, double-blind, double-dummy, controlled trial that evaluated the use of i.n. sufentanil 0.7 μg/kg via mucosal atomizer device vs. intravenous morphine 0.1 mg/kg in adult patients who presented to the ED with acute pain. The primary outcome was patient's pain score at 10 min after administration of intervention. Secondary outcomes were adverse events, the need for rescue analgesia, and patient satisfaction after treatment.

Résultats : Thirty patients were enrolled in each group. There was no significant difference in pain scores at 10 min after administration of intervention (sufentanil: 2.0, interquartile range = 2.0-3.3 vs. morphine: 3.0, interquartile range = 2.0-5.3, p = 0.198). No serious adverse events were reported. Rescue analgesia was not requested in either group. No significant difference in median satisfaction scores was found.

Conclusion : The use of i.n. sufentanil at 0.7 μg/kg/dose resulted in rapid and safe analgesia with comparable efficacy to i.v. morphine for up to 30 min in patients who presented with acute pain in the ED.

Conclusion (proposition de traduction) : L'utilisation de sufentanil par voie intranasale à raison de 0,7 µg/kg/dose a permis d'obtenir une analgésie rapide et sans danger avec une efficacité comparable à celle obtenue par voie intraveineuse de morphine pendant 30 minutes maximum chez les patients présentant une douleur aiguë au service des urgences.

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Bibliographie de Médecine d'Urgence

Mois de mars 2019

Academic Emergency Medicine

Annals of Emergency Medicine

BMC Emergency Medicine

Canadian Journal of Emergency Medicine

Emergency Medicine Journal

Internal and Emergency Medicine

Journal Européen des Urgences et de Réanimation

Journal of Antimicrobial Chemotherapy

Pediatric Emergency Care

Prehospital Emergency Care

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

The American Journal of Emergency Medicine

The Journal of Emergency Medicine

Mois de mars 2019