A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings.
Yadav K, Meeker D3, Mistry RD, Doctor JN, Fleming-Dutra KE, Fleischman RJ, Gaona SD, Stahmer A, May L. | Acad Emerg Med. 2019 Jun 19
DOI: https://doi.org/10.1111/acem.13690
Keywords: Aucun

EDITOR'S PICK

Introduction : Antibiotics are commonly prescribed during emergency department (ED) and urgent care center (UCC) visits for viral acute respiratory infection (ARI). We evaluate the comparative effectiveness of an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) to a stewardship intervention that additionally incorporates behavioral nudges (enhanced intervention) in reducing inappropriate prescriptions.

Méthode : This study was a pragmatic, cluster-randomized clinical trial conducted in three academic health systems comprising five adult and pediatric EDs and four UCCs. Randomization of the nine sites was stratified by health system; all providers at each site received either the adapted or the enhanced intervention. The main outcome was the proportion of antibiotic-inappropriate ARI diagnosis visits that received an outpatient antibiotic prescription by individual providers. We estimated a hierarchical mixed-effects logistic regression model comparing visits during the influenza season for 2016 to 2017 (baseline) and 2017 to 2018 (intervention).

Résultats : There were 44,820 ARI visits among 292 providers across all nine cluster sites. Antibiotic prescribing for ARI visits dropped from 6.2% (95% confidence interval [CI] = 4.5% to 7.9%) to 2.4% (95% CI = 1.3% to 3.4%) during the study period. We found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.2% (95% CI = 1.0% to 3.4%) to 1.5% (95% CI = 0.7% to 2.3%) with an odds ratio of 0.67 (95% CI = 0.54 to 0.82). Difference-in-differences between the two interventions was not significantly different.

Conclusion : Implementation of antibiotic stewardship for ARI is feasible and effective in the ED and UCC settings. More intensive behavioral nudging methods were not more effective in high-performance settings.

Conclusion (proposition de traduction) : La mise en œuvre d'une gestion responsable des antibiotiques pour les infections respiratoires aiguës est faisable et efficace dans les contextes des urgences et des établissements de soins d'urgence. Les méthodes d'encouragements comportementaux plus intensives n'étaient pas plus efficaces dans les environnements à hautes performances.

High-flow Oxygen Therapy for Treating Bronchiolitis in Infants.
Gordon I, Khan AS. | Acad Emerg Med. 2019 Jul;26(7):826-828
DOI: https://doi.org/10.1111/acem.13681
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Bronchiolitis is the most common reason for hospitalization in infants worldwide. Current recommendations by the American Academy of Pediatrics are for supportive care including maintenance of hydration and oxygen support for hypoxemia. Other interventions such as the use of bronchodilators have failed to show any benefit when compared to supportive care alone. However, it has been proposed that the obstructive process of bronchiolitis that causes increased work of breathing, hypoxia and hypercapnea might respond to the moderate positive pressure provided by high flow oxygen therapy.

Conclusion : In conclusion, high-flow oxygen therapy in infants with bronchiolitis reduces the risk of treatment failure and the need for escalation of care. However, it does not offer any benefit as far as direct patient-centered outcomes are concerned. Therefore, we assign a color recommendation of Yellow (unclear benefits) to this intervention. However, this trial still has clinical implications. It appears that for patients with bronchiolitis who do not respond to low- flow oxygen therapy (first line of therapy) based on criteria used in this trial or other institutional criteria, high-flow oxygen therapy should be considered as the next logical step before employing other more aggressive measures.

Conclusion (proposition de traduction) : En conclusion, l'oxygénothérapie à haut débit chez le nourrisson présentant une bronchiolite réduit le risque d'échec du traitement et la nécessité d'une intensification des soins. Cependant, cela n'offre aucun avantage en ce qui concerne les résultats directs axés sur le patient. Par conséquent, nous attribuons une recommandation de couleur jaune (avantages incertains) à cette intervention. Cependant, cet essai a encore des implications cliniques. Il semble que pour les patients atteints de bronchiolite qui ne répondent pas à l'oxygénothérapie à faible débit (première ligne de traitement) selon les critères utilisés dans cet essai ou d'autres critères institutionnels, l'oxygénothérapie à débit élevé devrait être considérée comme la prochaine étape logique avant de recourir à d'autres mesures plus agressives.

Point-of-care Ultrasound for the Diagnosis of Thoracoabdominal Injuries After Blunt Trauma.
Gottlieb M, Koyfman A, Long B. | Acad Emerg Med. 2019 Jul;26(7):829-831
DOI: https://doi.org/10.1111/acem.13722
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Trauma is a major cause of morbidity and mortality, representing one of the top ten causes of both death and disability-adjusted life years by the World Health Organization. Point-of-care ultrasound (POCUS) is commonly performed during or after the primary survey to identify whether significant thoracic injuries or abdominal free fluid are present, particularly when patients are unstable or cannot receive a computed tomogram (CT). However, it is important to determine the accuracy of this modality to ensure proper application in trauma patients.

Introduction : The Cochrane Review discussed here4 included retrospective and prospective studies assessing the diagnostic accuracy of POCUS for thoracoabdominal injuries in patients with blunt trauma (defined as any non-penetrating force). The reference standard included CT scan, magnetic resonance imaging (MRI), laparotomy or laparoscopy, thoracotomy, or autopsy.

Méthode : he primary outcome was the diagnosis of any thoracoabdominal injury, which was defined as: free fluid in the thoracic or abdominal cavity, retroperitoneum, pericardium, or mediastinum; organ injury (e.g. splenic, other solid organ, hollow viscera, or other organ laceration); a vascular lesion (e.g. dissection of rupture of aorta or other vessels); and other injuries (e.g. pneumothorax). Subgroup analyses were performed for pediatric patients versus adult patients, as well as abdominal versus thoracic injury.4 Approximately, half of the trials were conducted in the United States, and half of the study subjects were enrolled in level 1 trauma centers.

Conclusion : Based on the existing evidence, POCUS appears to be highly sensitive and specific for identifying significant thoracic injury. Additionally, POCUS appears to be highly specific but insufficiently sensitive to exclude abdominal injury. This suggests that a positive POCUS is strongly suggestive of an abdominal injury and should prompt subsequent targeted intervention, particularly in unstable patients. However, a negative POCUS examination does not exclude significant injury and should be followed by advanced imaging (e.g. CT), especially in pediatric patients. Keeping the limitation of this diagnostic modality in mind, this non-invasive and rapid test could provide useful information to the clinician and guide the proper diagnosis and treatment. Therefore, we have assigned a color recommendation of Green (Benefit > Harm) to the use of POCUS for identifying thoracoabdominal injuries after blunt trauma.

Conclusion (proposition de traduction) : Sur la base des preuves existantes, l'échographie au point d'intervention semble être très sensible et spécifique pour identifier une lésion thoracique significative. En outre, l'échographie au point d'intervention semble être très spécifique mais insuffisamment sensible pour exclure une lésion abdominale. Ceci suggère qu'une échographie au point d'intervention positive suggère fortement une lésion abdominale et devrait inciter à une intervention ciblée ultérieure, en particulier chez les patients instables. Cependant, un examen d'échographie au point d'intervention négatif n’exclut pas une lésion importante et doit être suivi d’une imagerie avancée (scanner, par exemple), en particulier chez les patients pédiatriques. En gardant à l'esprit les limites de cette modalité de diagnostic, ce test rapide et non invasif pourrait fournir des informations utiles au clinicien et guider le diagnostic et le traitement appropriés. Par conséquent, nous avons attribué une recommandation de couleur de vert (avantages > dommages) à l'utilisation de l'échographie au point d'intervention pour identifier les lésions thoraco-abdominales après un traumatisme contondant.

Tranexamic acid for upper gastrointestinal bleeding.
Beyda R, Johari D. | Acad Emerg Med. 2019 Jul 22
DOI: https://doi.org/10.1111/acem.13835
Keywords: Gastrointestinal Hemorrhage; Hematemesis; Tranexamic Acid

The Brass Tacks: Concise Reviews of Published Evidence

Editorial : Upper gastrointestinal bleeding is common and accounts for at least half of the nearly 500,000 annual U.S. hospitalizations for gastrointestinal bleeding.1 In the acute setting, severe bleeding is treated with intravenous fluids, blood products, antiulcer therapy, and hemostasis by endoscopy.2 Tranexamic acid (TXA) is an antifibrinolytic agent shown to reduce bleeding.3,4 TXA has been proven to be effective in improving patient-centered outcomes after severe hemorrhage due to trauma.5 The authors of this systematic review sought to evaluate the benefit of TXA administration specifically for upper gastrointestinal bleeding. This article is protected by copyright. All rights reserved.

Conclusion : We have assigned a color recommendation of Yellow (unclear benefits) to this intervention. Limitations of the reported data, particularly the lost to follow-up and dropout rates, the high risk of bias, and the presence of significant heterogeneity justify this rating. A large pragmatic double-blind controlled trial with a target sample size of 12,000 subjects is currently ongoing.7 We are hopeful this trial will provide better evidence. Despite TXA’s lack of demonstrated benefit compared to standard treatments with respect to the endpoints of mortality or re-bleeding, given the relative safety, lack of significant adverse events, and low cost of the medication, it may be reasonable to consider TXA in severe upper gastrointestinal bleeding as an adjunct to standard therapy, or if standard therapy fails.

Conclusion (proposition de traduction) : Nous avons attribué à cette intervention une recommandation de couleur Jaune (avantages peu clairs). Les limites des données déclarées, en particulier les taux de perte de suivi et d'abandon, le risque élevé de biais et la présence d'une hétérogénéité importante, justifient ce classement. Un grand essai clinique pragmatique à double insu et contrôlé avec un échantillon cible de 12 000 sujets est actuellement en cours. Nous espérons que cet essai fournira de meilleures données probantes.
Malgré l'absence d'avantages démontrés de l'acide tranexamique par rapport aux traitements standard en ce qui concerne les critères d'évaluation de la mortalité ou du saignement, étant donné l'innocuité relative, l'absence d'événements indésirables importants et le faible coût du médicament, il peut être raisonnable de considérer le recours à l'acide tranexamique en cas de hémorragie digestive supérieure grave comme un complément au traitement standard, ou si le traitement standard échoue.

Risk Factors for Sedation-related Events During Acute Agitation Management in the Emergency Department.
Yap CYL, Taylor DM, Kong DCM, Knott JC, Taylor SE; Sedation for Acute Agitation in Emergency Department Patients: Targeting Adverse Events (SIESTA) Collaborative Study Group. | Acad Emerg Med. 2019 Jul 2
DOI: https://doi.org/10.1111/acem.13826
Keywords: Aucun

Original Contribution

Introduction : The objective was to describe the incidence, nature, and risk factors for adverse events (AEs) among patients who received parenteral sedation for acute agitation in an emergency department (ED) setting.

Méthode : We undertook a prospective observational study and a clinical trial of parenteral sedation for the management of acute agitation. We included agitated adult patients who required parenteral sedation from 2014 to 2017 in 12 Australian EDs, excluding those with incomplete information or aged under 18 years. The primary outcome was the number of patients who experienced at least one AE. Multivariable logistic regression was used to determine factors associated with AEs.

Résultats : A total of 904 patients were included in the analyses (62.3% male; median age = 34 years, range = 18 to 95 years). Of these, 144 (15.9%) patients experienced at least one AE. The most common AEs were oxygen desaturation (7.4%), airway obstruction (3.6%), bradycardia (1.9%), hypotension (1.7%), and prolonged QTc interval (1.3%). No deaths or serious AEs were reported. The following factors had an increased adjusted odds ratio (OR) for experiencing an AE: age 65 years and older (OR = 2.8, 95% confidence interval [CI] = 1.2 to 7.2), more than one type of parenteral sedation administered within 60 minutes (OR = 2.1, 95% CI = 1.4 to 3.1), and alcohol intoxication (OR = 1.8, 95% CI = 1.2 to 2.6).

Conclusion : Sedation-related AEs are common, especially respiratory events. Elderly patients, sedation with multiple sedatives within 60 minutes, and alcohol intoxication increased the risk.

Conclusion (proposition de traduction) : Les événements indésirables liés à la sédation sont courants, en particulier les événements respiratoires. Des patients âgés, une sédation avec plusieurs sédatifs dans les 60 minutes et une intoxication alcoolique augmentent le risque.

Multicenter Comparison of Nonsupine Versus Supine Positioning During Intubation in the Emergency Department: A National Emergency Airway Registry (NEAR) Study.
Stoecklein HH, Kelly C, Kaji AH, Fantegrossi A, Carlson M, Fix ML, Madsen T, Walls RM, Brown CA 3rd; NEAR Investigators. | Acad Emerg Med. 2019 May 22
DOI: https://doi.org/10.1111/acem.13805
Keywords: Aucun

Original Contribution

Introduction : Head-up positioning for preoxygenation and ramping for morbidly obese patients are well-accepted techniques, but the effect of head-up positioning with full torso elevation for all intubations is controversial. We compared first-pass success, adverse events, and glottic view between supine (SP) and nonsupine (NSP) positioning for emergency department (ED) patients undergoing orotracheal intubation.

Méthode : We performed a retrospective analysis of prospectively collected data for ED intubations over a 2-year period from 25 participating centers in the National Emergency Airway Registry (NEAR). We compared characteristics and outcomes for adult patients intubated orotracheally in SP and NSP positions with either a direct or video laryngoscope. We report odds ratios (OR) with 95% confidence interval (CI) for categorical variables and interquartile ranges with 95% CI for continuous variables. Our primary outcome was first-attempt intubation success and secondary outcomes were glottic views and peri-intubation adverse events.

Résultats : Of 11,480 total intubations, 5.8% were performed in NSP. The NSP group included significantly more obese patients (OR = 2.2 [95% CI = 1.9-2.6]) and patients with a suspected difficult airway (OR = 1.8 [95% CI = 1.6-2.2]). First-pass success (adjusted OR = 1.1 [95% CI = 0.9-1.4]) and overall rate of grade I glottic views (OR = 1.1 [95% CI = 0.9-1.2]) were similar between groups while NSP had a significantly higher rate of grade I views when direct laryngoscopy was employed (OR = 1.27 [95% CI = 1.04-1.54]). NSP was associated with higher odds of any adverse event (OR = 1.4 [95% CI = 1.1-1.7]).

Conclusion : ED providers utilized SP in most ED intubations but were more likely to use NSP for patients who were obese or in whom they predicted a difficult airway. We found no differences in first-pass success between groups but total adverse events were more likely in NSP. A randomized trial comparing patient positioning during intubation in the ED is warranted.

Conclusion (proposition de traduction) : Les prestataires de services d'urgence utilisaient la position EN décubitus dorsal dans la plupart des intubations au service des urgences, mais ils étaient plus susceptibles d'utiliser une position non en décubitus dorsal chez les patients obèses ou chez qui ils prévoyaient une difficulté des voies respiratoires. Nous n'avons constaté aucune différence dans le succès du premier essai d'intubation entre les groupes, mais les effets indésirables totaux étaient plus probables chez les patients non en décubitus dorsal. Un essai randomisé comparant le positionnement du patient pendant l'intubation aux urgences est justifié.

Consensus Core Point-of-care Ultrasound Applications for Pediatric Emergency Medicine Training.
Shefrin AE, Warkentine F, Constantine E, Toney A, Uya A, Doniger SJ, Sivitz AB, Horowitz R, Kessler D. | AEM Educ Train. 2019;3(3):251-258
DOI: https://doi.org/10.1002/aet2.10332
Keywords: Aucun

Original contributions

Introduction : Pediatric emergency medicine (PEM) physicians have variably incorporated point-of-care ultrasound (POCUS) into their practice. Prior guidelines describe the scope of POCUS practice for PEM physicians; however, consensus does not yet exist about which applications should be prioritized and taught as fundamental skills for PEM trainees. Members of the PEM POCUS Network (P2Network) conducted a consensus-building process to determine which applications to incorporate into PEM fellowship training.

Méthode : A multinational group of experts in PEM POCUS was recruited from the P2Network and greater PEM POCUS community if they met the following criteria: performed over 1,000 POCUS scans and had at least 3 years of experience teaching POCUS to PEM fellows, were a local academic POCUS leader, or completed a formal PEM POCUS fellowship. Experts rated 60 possible PEM POCUS applications for their importance to include as part of a PEM fellowship curriculum using a modified Delphi consensus-building technique.

Résultats : In round 1, 66 of 92 (72%) participants responded to an e-mail survey of which 48 met expert criteria and completed the survey. Consensus was reached to include 18 items in a PEM fellowship curriculum and to exclude two items. The 40 remaining items and seven additional items were considered in round 2. Thirty-seven of 48 (77%) experts completed round 2 reaching consensus to include three more items and exclude five. The remaining 39 items did not reach consensus for inclusion or exclusion.

Conclusion : Experts reached consensus on 21 core POCUS applications to include in PEM fellowship curricula.

Conclusion (proposition de traduction) : Les experts sont parvenus à un consensus sur 21 situations d'utilisation de l'échographie au point d'intervention de base à inclure dans les programmes d’études en médecine d’urgence pédiatrique.

Meta-Analysis of Acetylsalicylic Acid Desensitization in Patients With Acute Coronary Syndrome.
Chopra AM, Díez-Villanueva P, Córdoba-Soriano JG, Lee JKT, Al-Ahmad M, Ferraris VA, Mehta M, Kowalski ML. | Am J Cardiol. 2019 Jul 1;124(1):14-19
DOI: https://doi.org/10.1016/j.amjcard.2019.03.047
Keywords: Aucun

Coronary Artery Disease

Introduction : Acetylsalicylic acid (ASA) hypersensitivity represents a clinical challenge in acute coronary syndrome (ACS) patients urgently requiring ASA for antiplatelet therapy. ASA desensitization has been reported with successful outcomes in cardiac patients. The aim of this review is to determine the safety and efficacy of ASA desensitization therapy in ACS patients.

Méthode : A PubMed database search was conducted for articles containing combinations of keywords, "aspirin desensitization" or "aspirin hypersensitivity" and "acute coronary syndrome" between January 1, 1990 and August 1, 2018. The primary end point was desensitization protocol success. Secondary end points included hypersensitivity adverse events and ASA discontinuation due to hypersensitivity adverse events at follow-up.

Résultats : Fifteen reports consisting of 480 ACS patients with previous hypersensitivity to ASA were included. The pooled desensitization success rate was 98.3% (95% confidence interval: 97.2% to 99.5%). There was no statistical difference in outcomes between protocols ≤ 2 hours and > 2 hours in duration (96.3[92.3 to 100.3]% vs 97.2[94.6 to 99.8]%; p = 0.71). Protocols with > 6 dose escalations were associated with higher success rates compared to those with ≤ 6 doses (99.2[97.9 to 100.4]% vs 95.4[93 to 97.8]%; p = 0.007). At follow-up between 1 and 46 months (mode 12 months), zero hypersensitivity adverse events were reported. Consequently, no ASA discontinuations were related to hypersensitivity adverse events.

Conclusion : In conclusion, ASA desensitization therapy is safe and effective in patients with ACS. Protocols with > 6 dose escalations may be optimal for ASA desensitization in ACS patients.

Conclusion (proposition de traduction) : En conclusion, le traitement de désensibilisation à l'acide acétylsalicylique est sûr et efficace chez les patients présentant un syndrome coronarien aigu. Les protocoles avec plus de 6 augmentations de doses peuvent être optimaux pour la désensibilisation à l'acide acétylsalicylique chez les patients présentant un syndrome coronarien aigu.

Thibon E, Bobbia X, Blanchard B, Masia T, Palmier L, Tendron L, de La Coussaye JE, Claret PG. | Ann Fr Med Urgence. 2019;9:229-234
DOI: https://doi.org/10.3166/afmu-2019-0151
Keywords: Adult, Crowding, Emergency service, Hospital mortality, Length of stay, Propensity score

Article original

Introduction : Notre objectif principal est de comparer, dans un centre hospitalier universitaire (CHU) français et chez les patients hospitalisés pour étiologies médicales à partir de la structure des urgences (SU), le taux de mortalité intrahospitalière entre ceux qui n’attendent pas faute de place en service et ceux en attente (boarding).

Méthode : Il s’agit d’une étude quasi expérimentale, monocentrique, observationnelle, rétrospective, par recueil d’informations à partir des dossiers patients informatisés. Nous avons appliqué un score de propension pour ajuster les critères de jugement aux variables mesurées dans les deux groupes, c’est-à-dire les données : 1) démographiques (âge et sexe) ; 2) médicales (niveau de triage) ; 3) biologiques (numération leucocytaire, hémoglobinémie, natrémie, kaliémie, taux sérique de CRP, créatininémie) ; 4) d’imageries (réalisation ou non de radiographie, d’échographie, d’imagerie par résonance magnétique, de tomodensitométrie).

Résultats : En 2017, la SU du CHU a admis 60 062 patients adultes. Sur les 15 496 patients hospitalisés après admission en SU, 6 997 l’ont été pour une étiologie médicale, dont 2 546 (36 %) sans attente et 4 451 (64 %) après une attente. Après pondération, le taux de mortalité intrahospitalière était plus important dans le groupe en attente : 7,8 vs 6,3 % ; p < 0,05. De même, la durée médiane d’hospitalisation était plus importante dans le groupe en attente : 7,6 [4,7– 12,0] vs 7,1 j [4,3–11,5] ; p < 0,01.

Conclusion (proposition de traduction) : Les taux de mortalité et de la durée de séjour intrahospitaliers sont plus importants chez les patients étudiés qui attendent en SU faute de place en service. Nos résultats sont concordants avec la littérature internationale. Il est nécessaire de trouver des solutions pour réduire cette surmortalité.

Ultrasonographic Guidance to Improve First-Attempt Success in Children With Predicted Difficult Intravenous Access in the Emergency Department: A Randomized Controlled Trial.
Vinograd AM, Chen AE, Woodford AL, Fesnak S, Gaines S, Elci OU, Zorc JJ. | Ann Emerg Med. 2019 Jul;74(1):19-27
DOI: https://doi.org/10.1016/j.annemergmed.2019.02.019
Keywords: Aucun

Pediatrics

Introduction : We determine whether ultrasonographically guided intravenous line placement improves the rate of first-attempt success by 20% for children with predicted difficult intravenous access. Secondary objectives included determining whether ultrasonographically guided intravenous line placement reduces the attempt number, improves time to access or parental satisfaction, or affects intravenous line survival and complications.

Méthode : This was a prospective, randomized controlled trial conducted in an urban tertiary care pediatric emergency department that enrolled a convenience sample of children requiring an intravenous line and who were predicted to have difficult intravenous access according to a previously validated score. Participants were randomized to traditional or ultrasonographically guided intravenous line placement on first attempt and stratified by aged 0 to 3 versus older than 3 years.

Résultats : One hundred sixty-seven patients were enrolled and randomized to traditional intravenous line or to a care bundle with a multidisciplinary team trained to place ultrasonographically guided intravenous lines. First-attempt success was increased in the ultrasonographically guided intravenous line placement arm (n=83) compared with the traditional intravenous line arm (n=84) (85.4% versus 45.8%; relative risk 1.9; 95% confidence interval [CI] 1.5 to 2.4). There were fewer attempts in the ultrasonographically guided intravenous line placement arm than in the traditional intravenous line arm (median 1 versus 2; median difference 1; 95% CI 0.8 to 1.2) and a shorter time from randomization to intravenous line flush (median 14 minutes [interquartile range 11 to 20] versus 28 minutes [interquartile range 16 to 42]). A Kaplan-Meier survival analysis demonstrated that ultrasonographically guided intravenous lines survived longer than traditional ones (median 7.3 days [95% CI 3.7 to 9.5] versus 2.3 days [95% CI 1.8 to 3.3]). There was no difference in complications between the groups. Parents were more satisfied with ultrasonographically guided intravenous line placement.

Conclusion : Ultrasonographically guided intravenous line placement in children with predicted difficult intravenous access improved first-attempt success and intravenous line longevity when conducted by a team of trained providers.

Conclusion (proposition de traduction) : L'échoguidage de la pose de voie veineuse, chez les enfants ayant un accès veineux prévu difficile, a amélioré la réussite lors de la première tentative, et la durée d'utilisation de la voie intraveineuse, lorsqu’elle est réalisé par une équipe de soignants formés.

Are Corticosteroids Beneficial in the Treatment of Community-Acquired Pneumonia?.
Seagraves T, Gottlieb M. | Ann Emerg Med. 2019 Jul;74(1):e1-e3
DOI: https://doi.org/10.1016/j.annemergmed.2018.05.001
Keywords: Aucun

Infectious Disease

Méthode : The authors searched the Cochrane Acute Infections Group’s Specialized Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Latin American and Caribbean Health Sciences Literature from inception through March 2017 for eligible studies, without language or publication restrictions. The reference lists of all included studies and previous systematic reviews were searched manually. In addition, the authors searched conference proceedings of major infectious disease and intensive care meetings, as well as multiple ongoing trial registries.
STUDY SELECTION: Eligible studies included adults or children with radiographically- confirmed community-acquired pneumonia, health care–associated pneumonia, hospital-acquired pneumonia, and ventilator- associated pneumonia who were randomly assigned to corticosteroids versus either placebo or no treatment. Studies of neonates, Pneumocystis jiroveci pneumonia, and patients with HIV were excluded. There were no limitations on the dose, route, or duration of corticosteroid use. Eligible studies reported on at least one of the following outcomes: all- cause mortality, early clinical failure (defined as death from any cause, radiographic progression, or clinical instability within 5 to 7 days), time to clinical cure, development of respiratory failure (defined as the need for invasive or noninvasive mechanical ventilation), development of shock, transfer to the ICU, duration of hospital stay, duration of ICU stay, pneumonia complications (defined by the individual study), secondary infections greater than or equal to 72 hours postrandomization, and adverse events. Two authors independently reviewed studies for inclusion, with disagreements resolved by consensus with the addition of a third reviewer if needed.

Résultats : Two authors independently abstracted data from the individual studies, with disagreements resolved by discussion and, as necessary, in consultation with a third reviewer. Risk ratios were calculated for dichotomous data and mean differences for continuous data. Bias was assessed with the Cochrane Risk of Bias tool and overall quality of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation tool. All differences were resolved through discussion between the 2 reviewers. Heterogeneity was assessed with the I2 statistic.

Conclusion : For adult patients with severe community-acquired pneumonia, corticosteroids reduce morbidity and mortality. For pediatric patients and adults with nonsevere community-acquired pneumonia, corticosteroids appear to reduce morbidity, but not mortality.

Conclusion (proposition de traduction) : Pour les patients adultes présentant une pneumopathie communautaire grave, les corticostéroïdes réduisent la morbidité et la mortalité.
Pour les patients de pédiatrie et l'adulte atteints de pneumopathie non sévère acquise communautaire, les corticostéroïdes semblent réduire la morbidité, mais pas la mortalité.

Managing the Frightened Child.
Krauss BA, Krauss BS. | Ann Emerg Med. 2019 Jul;74(1):30-35
DOI: https://doi.org/10.1016/j.annemergmed.2018.12.011  | Télécharger l'article au format  
Keywords: Aucun

Pediatrics/EXPERT CLINICAL MANAGEMENT

Editorial : Medical encounters are often frightening for children and stressful for their families. When children are afraid, they resist cooperating and responding to verbal reasoning, inhibiting assessment and treatment.2-4 For children to cooperate with physical examination and minor procedures, clinicians must first establish a trusting relationship with them.5,6 Although establishing trust is fundamental to effective interactions with children, there is no systematic approach to teaching this skill. This article describes and demonstrates a practical approach to rapidly establishing trust with children in the emergency department. We deconstruct the elements of clinician-child interactions and elucidate the underlying principles and methods of an approach to establishing trust. Our objective is to place a framework and a set of tools around what emergency physicians are doing intuitively, to enhance effectiveness in their interactions with children. Although what is described below is based on established child development and nonverbal communication research, we have developed much of the practical format and nomenclature presented.

Conclusion : We present a systematic approach to rapidly establishing trust with children and their families during medical encounters, which results in cooperation and the effective management of the child’s emotional state.

Conclusion (proposition de traduction) : Nous présentons une approche systématique pour établir rapidement la confiance avec les enfants et leurs familles lors de rencontres médicales, ce qui se traduit par une coopération et une gestion efficace de l’état émotionnel de l’enfant.

Evaluating Effectiveness of Nasal Compression With Tranexamic Acid Compared With Simple Nasal Compression and Merocel Packing: A Randomized Controlled Trial.
Akkan S, Çorbacıoğlu ŞK, Aytar H, Emektar E, Dağar S, Çevik Y. | Ann Emerg Med. 2019 Jul;74(1):72-78
DOI: https://doi.org/10.1016/j.annemergmed.2019.03.030  | Télécharger l'article au format  
Keywords: Aucun

Trauma

Introduction : The primary objective of this study is to compare the effectiveness of 3 treatment protocols to stop anterior epistaxis: classic compression, nasal packing, and local application of tranexamic acid. It also aims to determine the frequency of rebleeding after each of these protocols.

Méthode : This single-center, prospective, randomized controlled study was conducted with patients who had spontaneous anterior epistaxis. The study compared the effect of 3 treatment options, tranexamic acid with compression but without nasal packing, nasal packing (Merocel), and simple nasal external compression, on the primary outcome of stopping anterior epistaxis bleeding within 15 minutes.

Résultats : Among the 135 patients enrolled, the median age was 60 years (interquartile range 25% to 75%: 48 to 72 years) and 70 patients (51.9%) were women. The success rate in the compression with tranexamic acid group was 91.1% (41 of 45 patients); in the nasal packing group, 93.3% (42 of 45 patients); and in the compression with saline solution group, 71.1% (32 of 45 patients). There was an overall statistically significant difference among the 3 treatment groups but no significant difference in pairwise comparison between the compression with tranexamic acid and nasal packing groups. In regard to no rebleeding within 24 hours, the study found rates of 86.7% in the tranexamic acid group, 74% in the nasal packing group, and 60% in the compression with saline solution group.

Conclusion : Applying external compression after administering tranexamic acid through the nostrils by atomizer stops bleeding as effectively as anterior nasal packing using Merocel. In addition, the tranexamic acid approach is superior to Merocel in terms of decreasing rebleeding rates.

Conclusion (proposition de traduction) : La compression externe après l'administration d'acide tranexamique par spray au niveau des narines arrête les saignements aussi efficacement que la compression nasale antérieure avec Merocel.
De plus, l’acide tranexamique est supérieur au Merocel en termes de diminution du taux de récidive.

The Effect of Tranexamic Acid on Functional Outcomes: An Exploratory Analysis of the CRASH-2 Randomized Controlled Trial.
Nishijima DK, Kuppermann N, Roberts I, VanBuren JM, Tancredi DJ. | Ann Emerg Med. 2019 Jul;74(1):79-87
DOI: https://doi.org/10.1016/j.annemergmed.2018.11.018
Keywords: Aucun

Trauma

Introduction : Tranexamic acid improves survival in severely injured adults. However, its effectiveness on overall functional outcome is unknown. We hypothesized that tranexamic acid improves overall functional outcome compared with placebo in severely injured adults and conduct an exploratory analysis of the Clinical Randomization of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) data to investigate this hypothesis.

Méthode : We included injured adults from the CRASH-2 trial who were randomized 3 hours or less from injury. The primary outcome measure was functional status at hospital discharge or on day 28 if the subject was still in the hospital. Functional status was measured with the modified Oxford Handicap Scale, a 6-category ordinal functional outcome scale. We conducted 3 separate analyses using 3 different outcome measures to evaluate the effectiveness of tranexamic acid versus placebo on functional outcomes, including the mean utility-weighted modified Oxford Handicap Scale score (overall functional outcome), the area under the curve (based on functional outcome and rate of recovery), and a sliding dichotomy analysis (favorable versus unfavorable functional outcome) stratified by baseline mortality risk (stratified analysis).

Résultats : There were 13,432 patients (6,679 randomized to placebo and 6,753 to tranexamic acid) included in the study cohort. The mean utility-weighted modified Oxford Handicap Scale score was 0.66 (SD 0.33) for patients randomized to tranexamic acid compared with a mean of 0.64 (SD 0.34) for those randomized to placebo (mean difference 0.02; 95% confidence interval [CI] 0.01 to 0.03). The area under the curve analysis demonstrated that patients randomized to tranexamic acid had a higher 28-day mean utility-weighted modified Oxford Handicap Scale score compared with those randomized to placebo (mean score 0.55 [SD 0.30] versus 0.53 [SD 0.31]; mean difference 0.02 [95% CI 0.01 to 0.03]). The sliding dichotomy analysis demonstrated heterogeneity of treatment effects across risk groups. The overall proportion of patients with favorable functional outcomes was higher in the tranexamic acid group (5,360/6,753 [79.4%]; 95% CI 78.4% to 80.3%) compared with the placebo group (5,174/6,679 [77.5%]; 95% CI 76.5% to 78.5%; difference 1.9% [95% CI 0.5% to 3.3%]; number needed to treat=52). When each risk group was tested separately, only the lowest-risk group (<6% baseline mortality risk) demonstrated a statistically significant effect of tranexamic acid toward favorable functional outcomes (tranexamic acid versus placebo adjusted odds ratio 0.78; 95% CI 0.67 to 0.90). There were no differences between tranexamic acid and placebo in the other risk groups.

Conclusion : Across 3 exploratory analyses, severely injured adult patients randomized within 3 hours from injury demonstrated better functional outcomes with tranexamic acid compared with placebo. When heterogeneity of treatment effects across risk groups was evaluated, only the lowest-risk group demonstrated a significant effect of tranexamic acid toward favorable outcomes. Given the overall safety and cost-effectiveness of tranexamic acid use in injured adults, our results further support the use of tranexamic acid for this population. Future trauma trials that evaluate tranexamic acid use should also consider functional status as an important outcome.

Conclusion (proposition de traduction) : Dans le cadre de trois analyses exploratoires de données, les patients adultes gravement blessés, répartis au hasard dans les trois heures suivant le traumatisme, ont obtenu de meilleurs résultats fonctionnels avec l'acide tranexamique comparativement au placebo.
Lorsque l'hétérogénéité des effets du traitement entre les groupes à risque a été évaluée, seul le groupe à plus faible risque a démontré un effet significatif de l'acide tranexamique avec des résultats favorables. Étant donné l'innocuité et le rapport coût-efficacité global de l'utilisation de l'acide tranexamique chez les adultes blessés, nos résultats appuient davantage l'utilisation de l'acide tranexamique pour cette population.
Les futurs essais sur les traumatismes qui évalueront l'utilisation de l'acide tranexamique devraient également considérer l'état fonctionnel comme un résultat important.

What Is the Incidence of Intracranial Hemorrhage Among Anticoagulated Patients With Minor Head Trauma?.
Gottlieb M, Thottathil SM, Holton JP. | Ann Emerg Med. 2019 Jul;74(1):98-100
DOI: https://doi.org/10.1016/j.annemergmed.2018.11.015  | Télécharger l'article au format  
Keywords: Aucun

Trauma

Introduction : Minor head injury is a common presentation to the ED, with greater than 1 million patients presenting each year. Although all patients with altered mental status should receive advanced imaging as long as they are stable enough to leave the ED, the man- agement of anticoagulated pa- tients with a normal GCS score is more controversial. Most decision rules excluded patients receiving anticoagulation, prompting many providers to obtain imaging on all anticoagulated patients with head trauma.

Méthode : DATA SOURCES: PubMed, EMBASE, the Cochrane databases, and the Database of Abstracts of Reviews of Effects were searched through March 2018. Google Scholar, bibliographies of included articles, and previous reviews were assessed for additional references. The authors also contacted topic experts and hand searched abstracts from academic emergency medicine research conferences to identify unpublished data.
TUDY SELECTION: Two authors independently screened articles for inclusion, with discrepancies resolved by consensus with a minimum of 3 authors. Only studies of unselected emergency department (ED) patients receiving anticoagulation therapy who presented with a head injury and which reported the incidence of diagnosed intracranial hemorrhage were included. Anticoagulation therapy included vitamin K antagonists, dabigatran, edoxaban, apixaban, rivaroxaban, fondaparinux, and low-molecular- weight heparin. The search was limited to prospective studies and included published studies, unpublished studies, and conference abstracts. There were no language restrictions. Studies with fewer than 20 eligible participants, those that reported only a subset of anticoagulated patients with head injury, those that reported patients receiving antiplatelet medications alone, and those that reported only the incidence of delayed intracranial hemorrhage were excluded.

Résultats : Four reviewers independently abstracted data, with discrepancies resolved by consensus. The primary outcome was the incidence of intracranial hemorrhage among anticoagulated patients with a Glasgow Coma Scale (GCS) score of 15. When data included multiple GCS scores, authors of eligible studies were contacted and only the data on patients who had a GCS score of 15 were included. Risk of bias was assessed with the Tool to Assess Risk of Bias in Longitudinal Symptom Research Studies Aimed at the General Population.1 Statistical heterogeneity was reviewed with I2. A random-effects model was used, and a sensitivity analysis was performed with exclusion of high-risk studies.

Conclusion : Among anticoagulated patients presenting with minor head trauma, 9% may have an intracranial hemorrhage.

Conclusion (proposition de traduction) : Parmi les patients sous anticoagulants victime d'un traumatisme crânien mineur, 9 % peuvent présentent une hémorragie intracrânienne.

Triage Performance in Emergency Medicine: A Systematic Review.
Hinson JS, Martinez DA, Cabral S, George K, Whalen M, Hansoti B, Levin S. | Ann Emerg Med. 2019 Jul;74(1):140-152
DOI: https://doi.org/10.1016/j.annemergmed.2018.09.022
Keywords: Aucun

The Practice of Emergency Medicine

Introduction : Rapid growth in emergency department (ED) triage literature has been accompanied by diversity in study design, methodology, and outcome assessment. We aim to synthesize existing ED triage literature by using a framework that enables performance comparisons and benchmarking across triage systems, with respect to clinical outcomes and reliability.

Méthode : PubMed, EMBASE, Scopus, and Web of Science were systematically searched for studies of adult ED triage systems through 2016. Studies evaluating triage systems with evidence of widespread adoption (Australian Triage Scale, Canadian Triage and Acuity Scale, Emergency Severity Index, Manchester Triage Scale, and South African Triage Scale) were cataloged and compared for performance in identifying patients at risk for mortality, critical illness and hospitalization, and interrater reliability. This study was performed and reported in adherence to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Résultats : A total of 6,160 publications were identified, with 182 meeting eligibility criteria and 50 with sufficient data for inclusion in comparative analysis. The Canadian Triage and Acuity Scale (32 studies), Emergency Severity Index (43), and Manchester Triage Scale (38) were the most frequently studied triage scales, and all demonstrated similar performance. Most studies (6 of 8) reported high sensitivity (>90%) of triage scales for identifying patients with ED mortality as high acuity at triage. However, sensitivity was low (<80%) for identification of patients who had critical illness outcomes and those who died within days of the ED visit or during the index hospitalization. Sensitivity varied by critical illness and was lower for severe sepsis (36% to 74%), pulmonary embolism (54%), and non-ST-segment elevation myocardial infarction (44% to 85%) compared with ST-segment elevation myocardial infarction (56% to 92%) and general outcomes of ICU admission (58% to 100%) and lifesaving intervention (77% to 98%). Some proportion of hospitalized patients (3% to 45%) were triaged to low acuity (level 4 to 5) in all studies. Reliability measures (κ) were variable across evaluations, with only a minority (11 of 42) reporting κ above 0.8.

Conclusion : We found that a substantial proportion of ED patients who die postencounter or are critically ill are not designated as high acuity at triage. Opportunity to improve interrater reliability and triage performance in identifying patients at risk of adverse outcome exists.

Conclusion (proposition de traduction) : Nous avons constaté qu'une proportion importante des patients du service des urgences qui décèdent à l'arrivée, ou qui sont gravement malades, ne sont pas considérés comme présentant une gravité élevée au triage. Il existe une opportunité d'améliorer la fiabilité et le triage inter-opérateurs dans l'identification des patients présentant un risque d'évolution défavorable.

Does the Addition of Vasopressin to Catecholamine Vasopressors Affect Outcomes in Patients With Distributive Shock?.
Roumpf SK, Hunter BR. | Ann Emerg Med. 2019 Jul;74(1):153-155
DOI: https://doi.org/10.1016/j.annemergmed.2018.10.001  | Télécharger l'article au format  
Keywords: Aucun

The Practice of Emergency Medicine

Méthode : DATA SOURCES: The authors searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from inception through February 25, 2018. Trial registries were searched through http:// www.isrctn.com for unpublished or ongoing trials. References of eligible articles were reviewed and experts were consulted to identify additional trials. Additionally, the authors hand searched the last 2 years’ worth of conference proceedings for the European Society of Intensive Care Medicine, the Society of Critical Care Medicine, and the American Thoracic Society.
/ STUDY SELECTION: Studies included randomized trials comparing vasopressin (or analogues), with or without catecholamine vasopressors, with catecholamine vasopressors alone in adults with distributive shock. Distributive shock was defined as septic shock, post–cardiovascular surgery vasoplegia, neurogenic shock, or anaphylaxis. Any dose, duration, and other cointerventions were allowed. Two reviewers independently screened studies for eligibility and exclusion, with disagreements resolved through discussion.

Résultats : Two reviewers independently abstracted data on the intervention and outcomes. The primary outcome was the incidence of atrial fibrillation. Planned secondary outcomes included mortality, need for renal replacement therapy, myocardial injury, stroke, ventricular arrhythmias, and length- of-stay metrics. Digital ischemia and acute kidney injury were post hoc secondary outcomes. Primary study authors were contacted for clarifications and outcome data not listed in primary reports. Quality was assessed for individual studies with the Cochrane Risk of Bias Tool, and Grading of Recommendations Assessment, Development and Evaluation was used to define the overall quality of evidence. Meta-analyses were conducted with random effects in instances of low clinical heterogeneity. The primary analyses are reported as relative risk with 95% confidence intervals. Sensitivity analyses were performed including only studies at low risk of bias.

Conclusion : In patients with distributive (eg, septic) shock, the addition of vasopressin or vasopressin analogues to catecholamine therapy may decrease the rate of atrial fibrillation and need for renal replacement therapy but may also increase the risk of digital ischemia.

Conclusion (proposition de traduction) : Chez les patients présentant un choc distributif (par exemple, septique), l'adjonction de vasopressine ou d'analogues de la vasopressine au traitement par la catécholamine peut réduire le taux de fibrillation atriale et le besoin d'un traitement de substitution rénale, mais peut également augmenter le risque d'ischémie périphérique au niveau des doigts.

Bag-Valve-Mask Ventilation After Induction for Intubation: PreVenting Hypoxemia?.
Davis WT, Radecki RP, Spiegel RJ. | Ann Emerg Med. 2019 Jul;74(1):160-162
DOI: https://doi.org/10.1016/j.annemergmed.2019.05.021
Keywords: Aucun

Guest Contributors

Editorial : DISCUSSION POINTS
1. Discuss specific elements of the bag-valve-mask ventilation intervention in the referenced study.
2. The incidence of aspiration events was similar between patients in the bag-valve-mask ventilation and no ventilation arms of the referenced study.
Discuss differences in characteristics of patients requiring intubation in the ED versus the ICU that limit generalizability of this study finding to the ED setting.
3. The primary outcome of the study was the lowest oxygen saturation measured by pulse oximetry during induction and the immediate postintubation period. Discuss why the authors chose that outcome and the difference between surrogate and clinical outcomes.

Conclusion : Bag-valve-mask ventilation could be considered during the apneic period after induction for intubation in emergency department (ED) patients assessed to be at high risk for hypoxemia. Important caveats include the specific techniques used for bag-valve-mask ventilation in this study and unclear generalizability of aspiration risk in ED patients.

Conclusion (proposition de traduction) : Une ventilation au BAVU pourrait être envisagée pendant la période apnéique après l'induction pour intubation chez les patients des services d'urgence considérés à risque élevé d'hypoxémie. Les mises en garde importantes incluent les techniques spécifiques utilisées dans la présente étude pour la ventilation au BAVU et la généralisabilité peu claire du risque d'inhalation chez les patients des services d'urgence.

Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial.
Pellatt R, Fomin I, Pienaar C, Bindra R, Thomas M, Tan E, Mervin C, Zhang P, Keijzers G. | Ann Emerg Med. 2019 Jul;74(1):88-97
DOI: https://doi.org/10.1016/j.annemergmed.2019.01.032
Keywords: Aucun

Trauma

Introduction : We compare buddy taping with plaster casting for uncomplicated fifth metacarpal (boxer's) fractures. We hypothesize buddy taping will give superior functional outcomes at 12 weeks, defined as a 10-point difference on the Shortened Disabilities of the Arm, Shoulder and Hand (quickDASH) score.

Méthode : This randomized controlled trial included patients aged 18 to 70 years, with uncomplicated boxer's fractures in 2 hospitals in Queensland, Australia. The intervention consisted of buddy taping of the ring and little fingers on the affected side, in which the control group received plaster casting. Primary outcome was hand function as measured by quickDASH score (0 to 100, with 0 indicating no disability) at 12 weeks. Secondary outcomes measured at 3, 6, and 12 weeks included time off work and activities, pain, satisfaction, and the EuroQol 5-Dimension 3-Level score (measure of overall health).

Résultats : Ninety-seven patients with primary endpoint data were available for analysis, 48 in the buddy taping group and 49 in the plaster group. At 12 weeks, median quickDASH scores were the same for both groups (buddy 0, interquartile range [IQR] 0 to 2.3; plaster 0, IQR 0 to 4; difference 0; 95% confidence interval of the difference 0 to 0). Patients in the buddy taping group missed a median 0 days (IQR 0 to 7) of work compared with the plaster group's 2 days (IQR 0 to 14). Other secondary outcome measures were the same in both groups.

Conclusion : We found that patients with boxer's fractures who were randomized to buddy taping had functional outcomes similar to those of patients randomized to plaster cast at 12 weeks. We advocate a minimal intervention such as buddy taping for uncomplicated boxer's fractures.

Conclusion (proposition de traduction) : Nous avons constaté que les patients présentant des fractures du boxeur (fracture de la tête du cinquième métacarpienne non complicaquée) randomisés pour le traitement par syndactylie avaient des résultats fonctionnels similaires à ceux des patients randomisés pour l'immobilisation plâtre, à 12 semaines.
Nous préconisons une intervention minimale telle que la syndactylie pour les fractures simples du boxeur.

Commentaire : Concernait les fractures de la tête du cinquième métacarpienne avec une angulation jusqu'à 70°.

Patients’ time perception in the waiting room of an ambulatory emergency unit: a cross-sectional study.
Spechbach H, Rochat J, Gaspoz JM, Lovis C, Ehrler F. | BMC Emerg Med. 2019;19:41
DOI: https://doi.org/10.1186/s12873-019-0254-1  | Télécharger l'article au format  
Keywords: Patient satisfaction, Emergency department, Waiting time, Perceived waiting time, Service-oriented health care

Research article

Introduction : Patient satisfaction has become an increasingly important element in a service-oriented healthcare market. Although satisfaction is influenced by many factors, the waiting time to be seen by medical staff has been shown to be one of the key criteria. However, waiting is not an objective experience and several factors can influence its perception.

Méthode : We conducted a questionnaire-based, cross-sectional study among patients attending the emergency unit of a Swiss university hospital in order to explore the key factors influencing wait perception.

Résultats : A total of 509 patients participated in the study. Appropriate assessment of emergency level by caregivers, the feeling of being forgotten, respect of privacy, and lack of information on the exact waiting time were identified as significant variables for wait perception.

Conclusion : Our study confirmed the existence of a ‘golden hour’ when the patient is willing to wait until the medical encounter. In case the wait cannot be limited, an appropriate assessment of the emergency level by caregivers and avoiding the patients of feeling being forgotten are very important factors to avoid a negative perception of the waiting time before seeing a doctor.

Conclusion (proposition de traduction) : Notre étude a confirmé l’existence d’une « golden hour » lorsque le patient est disposé à attendre jusqu’à la consultation médicale. Au cas où l'attente ne pourrait être limitée, une évaluation appropriée du niveau d'urgence par les soignants et le fait d'éviter aux patients de se sentir oubliés sont des facteurs très importants pour éviter une perception négative du temps d'attente avant de voir un médecin.

Just the facts: Management of life-threatening bleeding with oral anticoagulant use in the emergency department.
Ho ML, Carrier M. | CJEM. 2019 Jul;21(4):460-463
DOI: https://doi.org/10.1017/cem.2019.345
Keywords: Bleeding; emergency department; oral anticoagulant

Just the Facts

Conclusion : •Life-threatening bleeding associated with oral anticoagulant use should first be managed with supportive care and local hemostatic measures.
• With warfarin, it is important to measure an INRto help guide dosing of a reversal agent. Reversal is performed using vitamin K, 10 mg IV, and PCC at 25–50 units/kg IV.
• It is important to determine renal function and time since the last dose for dabigatran, apixaban, rivaroxaban, and edoxaban.With normal renal function, their half-lives are 14, 8, 12, and 10 hours, respectively. Anticoagulant effects are minimal after 3–5 half-lives.
• With dabigatran, a normal aPTT probably excludes excess levels of dabigatran, but a TTor dTTexcludes clinically relevant dabigatran anticoagulant activity. Reversal is performed using idarucizumab 2.5 g IV as a bolus followed by 2.5 g IV over 15 minutes.
• With apixaban, rivaroxaban, or edoxaban, the anticoagulant activity can be measured using specifically calibrated anti-Xa assays, though these assays are not commonly available. Reversal is performed using PCC at 25–50 units/kg.
• The main complication when reversing the effects of oral anticoagulants is thromboembolic complications, which can occur approximately in 2%–5% of cases. Aggressive reversal strategies should, therefore, be reserved for life-threatening bleeding.
• The Thrombosis Canada Bleed Management tool is a free online tool that estimates anticoagulant levels and guides clinical management in cases of bleeding with oral anticoagulant use.

Conclusion (proposition de traduction) : • Les saignements menaçant le pronostic vital liés à l'utilisation des anticoagulants oraux doivent tout d'abord être gérés avec des soins de support (continuité et globalité des soins, traitement symptomatique) et des mesures hémostatiques locales.
• Avec la warfarine, il est important de mesurer l'INR afin de guider la posologie d'un agent de réversion. La réversion est effectuée en utilisant de la vitamine K, 10 mg IV et un concentré de complexe prothrombinique (CCP aussi appelé PPSB) à 25–50 unités/kg IV.
• Il est important de déterminer la fonction rénale et le délai écoulé depuis la dernière dose de dabigatran (Pradaxa, anti-IIa direct), d'apixaban (Eliquis, anti-Xa direct), de rivaroxaban (Xarelto, anti-Xa direct) et d'édoxaban (Lixiana, anti-Xa direct). Avec une fonction rénale normale, leurs demi-vies sont de 14, 8, 12 et 10 heures, respectivement. Les effets anticoagulants sont minimes après 3 à 5 demi-vies.
• Avec le dabigatran (Pradaxa, anti-IIa direct), un temps de coagulation activé (TCA) normal exclut probablement un taux excessif de dabigatran, mais un temps de thrombine plasmatique ou un temps de thrombine dilué exclut l'activité anticoagulante du dabigatran cliniquement pertinente. La réversion est effectuée en utilisant 2,5 g d'idarucizumab IV sous forme de bolus, suivis de 2,5 g par voie IV pendant 15 minutes.
• Avec l'apixaban, le rivaroxaban ou l'édoxaban, l'activité anticoagulante peut être mesurée à l'aide de tests anti-Xa spécifiquement calibrés, bien que ces tests ne soient pas couramment disponibles. La réversion est effectuée en utilisant un concentré de complexe prothrombinique (PPSB) à 25–50 unités/kg.
• La complication principale lors de la réversion des effets des anticoagulants oraux est la complication thromboembolique, qui peut survenir dans environ 2 % à 5 % des cas. Les stratégies d'inversion agressive doivent donc être réservées aux saignements mettant la vie en danger.
• L’outil «  Thrombosis Canada Bleed Management   raquo; est un outil en ligne gratuit qui permet d’estimer les niveaux d’anticoagulant et d’orienter la gestion clinique des saignements liés à l’utilisation d’un anticoagulant oral.

Commentaire : Référentiel à consulter sur le sujet :
Prise en charge des surdosages en antivitamines K, des situations à risque hémorragique et des accidents hémorragiques chez les patients traités par antivitamines K en ville et en milieu hospitalier
  . HAS, avril 2008.

Concentré de complexe prothrombinique (CCP aussi appelé PPSB) de même classe pharmaco-thérapeutique :
KANOKAD, OCTAPLEX & KASKADIL.

Inhaled methoxyflurane for the reduction of acute anterior shoulder dislocation in the emergency department.
Umana E, Kelliher JH, Blom CJ, McNicholl B. | CJEM. 2019 Jul;21(4):468-472
DOI: https://doi.org/10.1017/cem.2018.493
Keywords: Methoxyflurane; propofol; sedation; shoulder dislocation

Original Research

Introduction : Le méthoxyflurane en inhalation est un analgésique utilisé au service des urgences (SU), qui a de très faibles propriétés sédatives. L’étude avait pour objectif principal d’évaluer le taux de réussite de la réduction des luxations antérieures de l’épaule (LAE), en phase aiguë, au SU, à l'aide du méthoxyflurane et, pour objectif secondaire, d’évaluer l'effet du méthoxyflurane sur le flux des patients au SU, comparativement à celui du propofol.

Méthode : Il y a eu un examen des dossiers médicaux de tous les patients qui ont subi une réduction d'une LAE à l'aide du méthoxyflurane ou du propofol sur une période de 13 mois (décembre 2016 – décembre 2017). Le principal critère d’évaluation consistait en la détermination du taux de réussite des réductions réalisées à l'aide du méthoxyflurane, et les critères d’évaluation secondaires, en la comparaison de mesures comme le temps de rétablissement et la durée du séjour (DS) au SU, entre le méthoxyflurane et le propofol. Étaient exclus de l’étude les cas de fracture avec luxation de l’épaule, de polytrauma, d'administration intraveineuse ou intramusculaire d'opioïdes en phase préhospitalière, de réduction sans sédation d'une LAE ou de recours à d'autres techniques de sédation ou d'analgésie en vue de la réduction d'une LAE.

Résultats : Au total, 151 patients ont été examinés au SU pour une LAE durant la période d’étude et, sur ce nombre, 82 satisfaisaient aux critères de sélection. Dans l'ensemble, 52 patients ont été traités par le propofol contre 30, par le méthoxyflurane pour la réduction d'une LAE. Le taux de réussite des réductions a atteint 80% (IC à 95% : 65,69% – 94,31%) chez les blessés traités par le méthoxyflurane. Les valeurs médianes du temps de rétablissement et de la DS au SU étaient de 30 minutes [19,3–44] et de 70,5 minutes [49,3-105], ce qui représente des valeurs plus faibles dans le groupe de traitement par le méthoxyflurane, dans les cas de réussite, que dans le groupe de sédation par le propofol.

Conclusion : Methoxyflurane was used successfully in 30% of the 82 patients undergoing reduction for ASD, while potentially improving ED efficiency.

Conclusion (proposition de traduction) : Le méthoxyflurane a atteint un taux de réussite de 30% chez les 82 patients qui ont subi une réduction d'une LAE et pourrait, de ce fait, accroître l'efficacité au SU.

Commentaire : Extrait des résultats :
• Groupe méthoxyflurane. La réduction a été réalisée avec succès chez 80 % (65,69 % à 94,31 % des patients) des 30 patients traités par méthoxyflurane (intervalle de confiance [IC] de 65,69 %). Six patients n'ont pas pu être réduits avec le méthoxyflurane et ont eu besoin d'une sédation par le propofol (dose : médiane [plage interquartile; IQR] 85 mg [55–100]) pour obtenir la réduction. Le temps médian de récupération était de 30 minutes (IQR de 19,3 à 44) et la durée médiane du séjour aux urgences était de 70,5 minutes (IQR 49,3-105) pour le groupe méthoxyflurane chez ceux pour qui la réduction avait été un succès. Aucun événement indésirable n'a été documenté.
• Groupe Propofol. Dans le groupe propofol, 98 % (IC 95 % : 94,2 % à 100 %) la réduction a été un succès. Chez un seul patient la réduction a été un échec avec le propofol et a finalement du être admis pour une réduction sans ouverture articulaire sous anesthésie générale. Le temps médian de récupération pour les réductions réussies était de 47 minutes (IQR 32-68), et le temps médian de récupération était de 135 minutes (IQR 77-211) dans le groupe propofol. Le temps médian de rétablissement et la durée du séjour aux urgences étaient plus longs dans le groupe propofol que dans le groupe méthoxyflurane ( p < 0,004 et p < 0,001, respectivement). Aucun effet indésirable n'a été documenté.

Outcomes and emergency medical services resource utilization among patients with syncope arriving to the emergency department by ambulance.
Yau L, Mukarram MA, Kim SM, Arcot K, Thavorn K, Stiell IG, Taljaard M, Rowe BH, Sivilotti MLA, Thiruganasambandamoorthy V. | CJEM. 2019 Jul;21(4):499-504
DOI: https://doi.org/10.1017/cem.2018.464
Keywords: clinical decision aid; emergency department; emergency medical services; prehospital; resource utilization; severe adverse events; syncope

Original Research

Introduction : es syncopes motivent 1 % des consultations au service des urgences (SU), mais le malaise entraîne peu d’événements indésirables graves (EIG). Ainsi, deux tiers des patients ayant subi une syncope sont transportés en ambulance au SU, ce qui impose un lourd fardeau sur les services médicaux d’urgence (SMU), et pourtant bon nombre de transports effectués seraient non nécessaires. Aussi l’étude visait-elle à estimer la proportion de patients ayant subi une syncope dont l’état serait jugé à faible risque d’après le diagnostic de syncope vasovagale posé au SU ainsi que d’après l’absence d’intervention faite par les SMU, d’hospitalisation ou d’EIG.

Méthode : Il s’agit d’une étude prospective de cohortes, multicentrique, menée chez des adultes qui ont subi une syncope et qui ont été transportés en ambulance au SU, sur une période de 13 mois. Ont été recueillies des données démographiques ainsi que les notes sur les interventions effectuées par les SMU; à cela s’ajoute un suivi de 30 jours aux fins de collecte de renseignements sur tout EIG : mort, arythmie, infarctus du myocarde, dissection de l’aorte, embolie pulmonaire, hémorragie sous-arachnoïdienne, hémorragie importante et gestes interventionnels liés aux troubles en question.

Résultats : Au total, 990 patients (67,2 %) ont été transportés en ambulance au SU; sur ce nombre, 121 ont subi des interventions pratiquées par les SMU; 137 ont connu un EIG au cours des 30 jours suivant le malaise; 393 (39,7 %; IC à 95 % : 36,6-42,8) ont été jugés à faible risque; 41 ayant fait une syncope vasovagale ont été perdus de vue durant le suivi; et 298, ont fait une syncope non vasovagale. Durant le transport, 121 patients (12,2 %; IC à 95 % : 10,2-14,3) ont subi une forme quelconque d’intervention par les SMU et, au cours des 30 jours de suivi, 137 (14,6 %; IC à 95 % : 12,4-16,9) ont connu un EIG.

Conclusion : About 40% of patients transported to the ED by ambulance are at low risk and may not benefit from paramedic care or transport to a hospital. A robust clinical decision tool would help identify patients safe for treat-and-release, diversion to alternative care, or rapid offload into low-acuity ED areas, potentially reducing EMS workload and cost.

Conclusion (proposition de traduction) : Environ 40 % des patients transportés en ambulance au SU connaissent un faible risque et, dans leur cas, la prestation de soins paramédicaux ou le transport à l’hôpital pourraient ne pas être nécessaires. Un outil d’aide à la décision clinique qui soit digne de confiance pourrait faciliter le repérage des patients dont l’état se prêterait au traitement suivi du congé, à une orientation vers d’autres types de soins ou à un passage rapide dans des zones de petites urgences, ce qui permettrait à la fois de réduire la charge de travail des SMU ainsi que les coûts.

The association of paramedic rapid sequence intubation and survival in out-of-hospital stroke.
Fouche PF, Smith K, Jennings PA, Boyle M, Bernard S. | Emerg Med J. 2019 Jul;36(7):416-422
DOI: https://doi.org/10.1136/emermed-2019-208613
Keywords: airway; emergency ambulance systems

CLINICAL CONTROVERSIES: PREHOSPITAL AIRWAY MANAGEMENT

Introduction : Ambulance transport of patients with stroke is common, with rapid sequence intubation (RSI) to secure the airway used regularly. Randomised controlled trial evidence exists to support the use of RSI in traumatic brain injuries (TBIs), but it is not clear whether the RSI evidence from TBI can be applied to the patient with stroke. To this end, we analysed a retrospective stroke dataset to compare survival of patients with RSI compared with patients that did not receive RSI.

Méthode : This study was a retrospective analysis of 10 years of in-hospital and out-of-hospital data for all patients with stroke attended by Ambulance Victoria, in Victoria Australia. Generalised boosted logistic regression was used to predict propensity scores, with initial vital signs, age and demographic variables as well as measures of illness severity and comorbidity included in the prediction model. This analysis employed a 1:1 nearest-neighbour matching which was applied to generate a dataset from which we calculated the OR of survival to hospital discharge of patients receiving RSI versus no-RSI. The sensitivity of these results to unmeasured confounding was assessed with deterministic sensitivity analysis.

Résultats : The propensity score-matched cohort showed a decreased survival for RSI in strokes with an OR 0.61 (95% CI 0.45 to 0.82; p=0.001) when compared with no-RSI. A subgroup analysis showed no significant survival difference for ischaemic strokes: OR 0.66 (95% CI 40 to 1.07; p=0.09). The survival for haemorrhagic stroke was OR 0.60 (95% CI 0.41 to 0.90; p=0.01) lesser for RSI. Results were likely robust to unmeasured confounding and missing data.

Conclusion : Our retrospective analysis shows a decrease in survival when RSI is utilised by paramedics for stroke. Since RSI is commonly used for strokes, controlled trial evidence to support this practice is urgently needed.

Conclusion (proposition de traduction) : Notre analyse rétrospective montre une diminution de la survie lorsque l'ISR est pratiquée par des ambulanciers paramédicaux dans l'AVC. Étant donné que l'ISR est couramment utilisé pour les accidents vasculaires cérébraux, il est urgent de disposer de preuves expérimentales contrôlées à l'appui de cette pratique.

Confirmed cardiac output on emergency medical services arrival as confounding by indication: an observational study of prehospital airway management in patients with out-of-hospital cardiac arrest.
Sakurai A, Kinoshita K, Maeda Y, Homma Y, Tahara Y, Yonemoto N, Nagao K, Yaguchi A, Morimura N; SOS-KANTO 2012 Study Group. | Emerg Med J. 2019 Jul;36(7):410-415
DOI: https://doi.org/10.1136/emermed-2018-208107  | Télécharger l'article au format  
Keywords: Aucun

CLINICAL CONTROVERSIES: PREHOSPITAL AIRWAY MANAGEMENT

Introduction : Many registry studies on patients with out-of-hospital cardiac arrest (OHCA) have reported that conventional bag-valve-mask (BVM) ventilation is independently associated with favourable outcomes. This study aimed to compare the data of patients with OCHA with confirmed cardiac output on emergency medical services (EMS) arrival and consider the confounding factors in prehospital airway management studies.

Méthode : This was a cohort study using the registry data for survivors after out-of hospital cardiac arrest in the Kanto region at 2012 in Japan (SOS-KANTO 2012). Survivors who received advanced airway management (AAM) group and a BVM group were compared for confirmed cardiac output on EMS arrival and neurolgical outcome at 1 month. Favourable neurological outcome was defined as a score of one or two on the Cerebral Performance Categories Scale. Multivariable logistic regression was used to adjust the neurological outcome by age, gender, cardiac aetiology, witnessed arrest, shockable rhythm, cardiopulmonary resuscitation performed by a bystander, BVM at prehospital ventilation and presence of confirmed cardiac output on EMS arrival.

Résultats : A total of 16 452 patients were enrolled in the SOS-KANTO 2012 study, and of those data 12 867 were analysed; 5893 patients comprised the AAM group and 6974 comprised the BVM group. Of the study participants, 386 (2.9%) had confirmed cardiac output on EMS arrival; 340 (2.6%) of the entire study group had a favourable neurological outcome. The proportion of patients with confirmed cardiac output on EMS arrival was significantly higher in the BVM group (272: 3.9%) than in the AAM group (114: 1.9%) (95% CI: 1.65 to 2.25). The proportion of patients with favourable neurological outcomes was 30% (117/386) in those with cardiac output on EMS arrival compared with 1.8% (223/12481) in those without. The OR for a good neurological outcome with BVM decreased from 3.24 (2.49 to 4.20) to 2.60 (1.97 to 3.44) when confirmed cardiac output on EMS arrival was added to the multivariable model analysis.

Conclusion : Confirmed cardiac output on EMS arrival should be considered as confounding by indication in observational studies of prehospital airway management.

Conclusion (proposition de traduction) : Un débit cardiaque confirmé à l'arrivée des services médicaux d'urgence doit être considéré comme biais d'indication dans les études d'observation de la gestion préhospitalière des voies respiratoires.

Commentaire : Dans les enquêtes épidémiologiques d’observation, le biais d’indication désigne le fait qu’une intervention ait été prescrite plus souvent chez les sujets à risque élevé de maladie que chez les sujets à faible risque.
Il s’agit d’un cas particulier de biais de confusion.

Prehospital tranexamic acid shortens the interval to administration by half in Major Trauma Networks: a service evaluation.
Marsden MER, Rossetto A, Duffield CAB, Woolley TGD, Buxton WP, Steynberg S, Bagga R, Tai NRM. | Emerg Med J. 2019 Jul;36(7):395-400
DOI: https://doi.org/10.1136/emermed-2018-208118
Keywords: fibrinolysis; haemorrhage; multiple trauma; tranexamic acid; trauma centres

INJURY

Introduction : Tranexamic acid (TXA) reduces bleeding and mortality. Recent trials have demonstrated improved survival with shorter intervals to TXA administration. The aims of this service evaluation were to assess the interval from injury to TXA administration and describe the characteristics of patients who received TXA pre-hospital and in-hospital.

Méthode : We reviewed Trauma and Audit Research Network records and local trauma registries to identify patients of any age that received TXA at all London Major Trauma Centres and Queen's Medical Centre, Nottingham, during 2017. We used the 2016 NICE Guidelines (NG39) which state that TXA should be given within 3 hours of injury.

Résultats : We identified 1018 patients who received TXA, of whom 661 (65%) had sufficient data to assess the time from injury to TXA administration. The median interval was 74 min (IQR: 47-116). 92% of patients received TXA within 3 hours from injury, and 59% within 1 hour. Half of the patients (54%) received prehospital TXA. The median time to TXA administration when given prehospital was 51 min (IQR: 39-72), and 112 min (IQR: 84-160) if given in-hospital (p<0.001). In-hospital TXA patients had less haemodynamic derangement and lower base deficit on admission compared with patients given prehospital TXA.

Conclusion : Prehospital administration of TXA is associated with a shorter interval from injury to drug delivery. Identifying a proportion of patients at risk of haemorrhage remains a challenge. However, further reinforcement is needed to empower pre-hospital clinicians to administer TXA to trauma patients without overt signs of shock.

Conclusion (proposition de traduction) : L'administration préhospitalière d'acide tranexamique est associée à un délai plus court entre la blessure et la délivrance du médicament. Identifier une proportion de patients à risque d'hémorragie reste un défi.
Cependant, un consolidation des résultats supplémentaire est nécessaire pour permettre aux cliniciens préhospitaliers d'administrer du TXA à des patients traumatisés sans signes apparents de choc.

A comparison of airway management devices in simulated entrapment-trauma: a prospective manikin study.
Pap R, van Loggerenberg C. | Int J Emerg Med. 2019 Jul 8;12(1):15
DOI: https://doi.org/10.1186/s12245-019-0233-z  | Télécharger l'article au format  
Keywords: Airway management; Endotracheal intubation; Laryngeal mask airway; Traffic accidents

Original Research

Introduction : In the patient entrapped after a motor vehicle collision (MVC), advanced airway management may need to be performed before extrication. The aim of this study was to compare four airway management devices utilized by paramedics in a simulated entrapped patient.

Méthode : Twenty-six paramedics performed advanced airway management on a manikin seated in the driver's seat (right side) of a car. Access was through the opened door only. The airway devices were the Macintosh laryngoscope and the Airtraq optical laryngoscope to facilitate the endotracheal intubation (ETI), the laryngeal mask airway (LMA) Supreme and the laryngeal tube (LT). Time to first successful ventilation and number of attempts required for successful placement were measured. Following each placement, participants rated the degree of difficulty. For ETI, participants ranked the achieved glottic view using Cormack-Lehane grades (CLG). Finally, participants were asked which airway management device they preferred.

Résultats : The LMA Supreme had the shortest mean time to first successful ventilation (16.7 s, CI [0.95] 14.9-18.6). Insertion of the LMA Supreme and ETI with the Macintosh laryngoscope had 100% first-attempt success. The LMA Supreme was rated least difficult to insert (mean score 1.7/10 (CI [0.95] 1.2-2.1)). Compared to the Macintosh, the Airtraq laryngoscope facilitated superior laryngoscopy (CLG I view 46.2% and 80.8%, respectively). Most participants (10/26; 38%) chose the Macintosh laryngoscope as their preferred technique, followed closely by the LMA Supreme (9/26; 35%).

Conclusion : The LMA Supreme took the least amount of time and was the easiest to be inserted. Extraglottic airway devices may be beneficial alternative airway management devices to be considered by paramedics in the entrapped patient. Endotracheal intubation using the Macintosh laryngoscope was performed competently by participating paramedics. The Airtraq enabled superior laryngoscopy but resulted in poorer first-pass success rate.

Conclusion (proposition de traduction) : Le masque laryngé des voies aériennes de marque Suprême prenait le moins de temps et était le plus facile à insérer. Les dispositifs de gestion des voies aériennes supraglottiques peuvent constituer des dispositifs alternatifs intéressant à prendre en compte par les ambulanciers paramédicaux chez le patient incarcérés. L'intubation endotrachéale à l'aide du laryngoscope Macintosh a été réalisée avec compétence par les ambulanciers paramédicaux participants. L'Airtraq a permis une laryngoscopie supérieure mais a entraîné un taux de réussite au premier passage plus faible.

Association Between Initial Emergency Department Lactate and Use of Vasoactive Medication in Children With Septic Shock.
Miescier MJ, Lane RD, Sheng X, Larsen GY. | Pediatr Emerg Care. 2019 Jul;35(7):455-460
DOI: https://doi.org/10.1097/PEC.0000000000000981
Keywords: Aucun

Original Articles

Introduction : Current guidelines emphasize early recognition of pediatric septic shock using clinical examination findings. Elevated serum lactate has been associated with increased mortality in adult patients with septic shock. Our objective was to determine the association between the initial serum lactate obtained in the pediatric emergency department (PED) from patients treated for septic shock and the use of vasoactive medication within 24 hours.

Méthode : This was a retrospective study from 2008 through 2012 of PED patients at a tertiary care children's hospital. Patients younger than 18 years treated for septic shock were included if they had a serum lactate obtained in the PED.

Résultats : Eight hundred sixty-four PED encounters met inclusion criteria. Median initial PED lactate was 2.1 mmol/L (interquartile range, 1.4-3.2 mmol/L). Overall, 121 patients (14%) received vasoactive medication within 24 hours of the initial PED lactate. A multivariable logistic regression analysis demonstrated associations between initial lactate levels of 3.1 to 5 mmol/L (odds ratio, 1.82; 95% confidence interval, 1.02-3.26) and 5.1 mmol/L or greater (odds ratio, 5.00; 95% confidence interval, 2.56-9.76) and the use of vasoactive medication within 24 hours. Other factors associated with use of vasoactive medication within 24 hours included hypotension, abnormal pulses, and mental status changes.

Conclusion : Increased initial lactate is associated with use of vasoactive medication within 24 hours in PED patients with septic shock.

Conclusion (proposition de traduction) : Une augmentation initiale du lactate est associée à l'utilisation de médicaments vasoactifs dans les 24 heures chez les patients des urgences pédiatriques présentant un choc septique.

Emergency Department Care of Young Children at Risk for Traumatic Brain Injury: What Are We Doing and Do Parents Understand?.
Reilly C, Zhang N, Babcock L, Wade SL, Rhine T. | Pediatr Emerg Care. 2019 Jul;35(7):468-473
DOI: https://doi.org/10.1097/PEC.0000000000001042
Keywords: Aucun

Original articles

Introduction : The aims of the study were to describe emergency department (ED) management of young children with head injury and to assess parental comfort level and perceptions of ED care.

Méthode : This was a prospective observational study of children younger than 5 years who presented to a pediatric ED after head injury. Children were eligible if clinical observation was an appropriate ED management option per the Pediatric Emergency Care Academic Research Network's neuroimaging clinical decision rule. Demographics, injury variables, and ED clinician surveys explaining the care provided were collected at time of study enrollment. Parents were subsequently contacted to assess understanding of ED management and comfort with care.

Résultats : One hundred four children were enrolled with a mean (standard deviation) age of 1.19 (1.34) years. Thirty (29%) had emergent neuroimaging and 59 (57%) were placed into a period of observation per clinician report. A total of 37 children received a head computed tomography, of which 21 (57%) were normal. Eighty-four parents (81%) completed the phone follow-up. Of these children, there was a significant difference between whether parents and clinicians reported that the child had been clinically observed in the ED (P < 0.0001). Parents of children who did not receive a head CT were more likely to be uncomfortable with the decision to obtain neuroimaging compared with those who did receive a head CT (P = 0.003).

Conclusion : Parents are not always comfortable with the medical care practices provided and are often unaware of clinical observation when it does occur. Better parent-clinician communication could improve parental understanding and reduce overall discomfort.

Conclusion (proposition de traduction) : Les parents ne sont pas toujours à l'aise avec les pratiques de soins médicaux fournies et ignorent souvent l'observation clinique lorsqu'elle se produit. Une meilleure communication parents-cliniciens pourrait améliorer la compréhension parentale et réduire l'inconfort général.

Does the Use of a Vein Visualization Device for Peripheral Venous Catheter Placement Increase Success Rate in Pediatric Patients?.
Demir D, Inal S. | Pediatr Emerg Care. 2019 Jul;35(7):474-479
DOI: https://doi.org/10.1097/PEC.0000000000001007
Keywords: Aucun

Original articles

Introduction : Peripheral intravenous catheterization is one of the most frequently encountered medical procedures for hospitalized children and is one that can often be painful. Pediatric nurses should therefore use techniques that increase the success rate or shorten the duration of peripheral intravenous catheterization.
Objectifs : This study was performed with the objective of determining the effect of using a vein visualization device on the success of the procedure. Success was determined based on the number of attempts per patient, the duration of the procedure, and the first stick success rate.

Méthode : This was a randomized, controlled experimental study on 129 children aged 3 to 18 years.

Résultats : The duration of peripheral intravenous catheterization was shorter in the study group (S) than in the control (C) patients (37.24 ± 20.07 vs 172.65 ± 153.21 seconds; P = 0.001), with fewer attempts (S, 1.08 ± 0.28; C, 2.23 ± 1.57; P < 0.01). The first stick success rate was higher in the control group (S, 91.7%; C, 47.4%; P = 0.001).

Conclusion : Peripheral intravenous catheterization using vein visualization device support reduces the number of attempts per patient and the operation duration but increases the rate of first stick success. We may therefore state that vein visualization device support improves the success of peripheral intravenous catheterization.

Conclusion (proposition de traduction) : Le cathétérisme intraveineux périphérique guidé par un dispositif de visualisation des veines réduit le nombre de tentatives par patient et la durée de l'opération mais augmente le taux de succès de la première insertion. Nous pouvons donc affirmer que le support du dispositif de visualisation de la veine améliore le succès du cathétérisme intraveineux périphérique.

Commentaire : Voir l'article :
Inal S, Demir D. Impact of Peripheral Venous Catheter Placement With Vein Visualization Device Support on Success Rate and Pain Levels in Pediatric Patients Aged 0 to 3 Years. Pediatr Emerg Care. 2018 May 15
  .

Improved Team Performance During Pediatric Resuscitations After Rapid Cycle Deliberate Practice Compared With Traditional Debriefing: A Pilot Study.
Lemke DS, Fielder EK, Hsu DC, Doughty CB. | Pediatr Emerg Care. 2019 Jul;35(7):480-486
DOI: https://doi.org/10.1097/PEC.0000000000000940
Keywords: Aucun

Original articles

Introduction : Simulation-based medical education (SBME) improves medical knowledge compared with no intervention. In traditional SBME, more time is spent debriefing than practicing skills. Rapid cycle deliberate practice (RCDP) simulation allows learners to practice skills repetitively, receive brief interspersed feedback, and has been shown to improve individual performance of resuscitation skills in simulation; it has not been compared with traditional simulation methods.
titre_en_plus :The aim of the study was to compare traditional and RCDP SBME.

Méthode : Four pediatric resuscitation cases (3 for teaching and 1 for testing) were developed. For the RCDP arm, traditional cases were deconstructed into sequences of progressively difficult rounds. The last RCDP round served as the traditional arm scenario.Learners received 1 type of instruction on 2 separate days. Pretest and posttest performance during simulation were video recorded and scored using the Simulation Team Assessment Tool; satisfaction surveys were collected.

Résultats : Pretest team performance was similar in both groups. Simulation Team Assessment Tool score improvement for RCDP was 7.2% (95% confidence interval, 3.4% to 11%) and traditional was 0.8% (95% confidence interval, -11% to 13%). The difference in improvement of the human factors subscore was statistically significant; RCDP improved 10.2% and traditional improved 1.7% (P = 0.013). The RCDP technique was well received by learners but caused fatigue.

Conclusion : This pilot study showed a trend toward greater improvement in team performance and significantly greater improvement for human factors with RCDP compared with traditional simulation. Future studies comparing RCDP with other methods are needed to identify best practices and applications of RCDP, including which learners and learning objectives are best suited to RCDP.

Conclusion (proposition de traduction) : Cette étude pilote a montré une tendance à l'amélioration des performances des équipes et à une amélioration significativement supérieure des facteurs humains avec le RCDP par rapport à la simulation traditionnelle. De futures études comparant le RCDP à d'autres méthodes sont nécessaires pour identifier les meilleures pratiques et applications du RCDP, notamment les objectifs d'apprentissage et les objectifs d'apprentissage les mieux adaptés au RCDP.

Commentaire : 
La simulation en santé - Le débriefing clés en mains de Denis Oriot et Guilaume Alinier. Ed. Elsevier Health Sciences, 5 févr. 2019 - 188 pages

Voir sur le sujet : Weezic. Pratique délibérée : la clé du succès ?
 [en ligne]. 27 janvier 2014 [consulté le 12 août 2017]. Disponible sur : https://clubprofsweezic.wordpress.com  .
Pour récapituler, la pratique délibérée, c’est :
1) Une pratique concentrée exclusivement sur l’amélioration des résultats
2) Des exercices facilement répétables
3) Recevoir un feedback immédiat
4) Pas vraiment plaisant
5) Mentalement intense
En suivant ces 5 principes, la pratique délibérée mène automatiquement, au fil des séances, à l'expertise.

Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population.
McKee CH, Heffernan RW, Willenbring BD, Schwartz RB, Liu JM, Colella MR, Lerner EB. | Prehosp Emerg Care. 2019 Jul 31:1-8
DOI: https://doi.org/10.1080/10903127.2019.1641579
Keywords: CareFlight; SALT; START; Triage Sieve; accuracy; disaster; mass casualty triage

Article

Introduction : To use a previously published criterion standard to compare the accuracy of 4 different mass casualty triage systems (Sort, Assess, Lifesaving Interventions, Treatment/Transport [SALT], Simple Triage and Rapid Treatment [START], Triage Sieve, and CareFlight) when used in an emergency department-based adult population.

Méthode : We performed a prospective, observational study of a convenience sample of adults aged 18 years or older presenting to a single tertiary care hospital emergency department. A co-investigator with prior emergency medical services (EMS) experience observed each subject's initial triage in the emergency department and recorded all data points necessary to assign a triage category using each of the 4 mass casualty triage systems being studied. Subjects' medical records were reviewed after their discharge from the hospital to assign the "correct" triage category using the criterion standard. The 4 mass casualty triage system assignments were then compared to the "correct" assignment. Descriptive statistics were used to compare accuracy and over- and under-triage rates for each triage system.

Résultats : A total of 125 subjects were included in the study. Of those, 53% were male and 59% were transported by private vehicle. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (52%; 95% CI 43-60) compared to START (36%; 95% CI 28-44), CareFlight (36%; 95% CI 28-44), and TriageSieve (37%; 95% CI 28-45). SALT also had the lowest under-triage rate (26%; 95% CI 19-34) compared to START (57%; 95% CI 48-66), CareFlight (58%; 95% CI 49-66), and TriageSieve (58%; 95% CI 49-66). SALT had the highest over-triage rate (22%; 95% CI 14-29) compared to START (7%; 95% CI 3-12), CareFlight (6%; 95% CI 2-11) and TriageSieve (6%; 95% CI 2-11).

Conclusion : We found that SALT triage most often correctly triaged adult emergency department patients when compared to a previously published criterion standard. While there are no target under- and over-triage rates that have been published for mass casualty triage, all 4 systems had relatively high rates of under-triage.

Conclusion (proposition de traduction) : Nous avons constaté que le triage SALT triait le plus souvent correctement les patients adultes du service des urgences par rapport à une norme de critère publiée antérieurement. Bien qu'il n'y ait pas de taux cibles de sous-triage et de surtriage publiés pour le triage en masse des victimes, les 4 systèmes présentaient des taux de sous-triage relativement élevés.

Commentaire : Cone DC1, Serra J, Burns K, MacMillan DS, Kurland L, Van Gelder C. Pilot test of the SALT mass casualty triage system. Prehosp Emerg Care. 2009 Oct-Dec;13(4):536-40
  .

Effect of Implementation of Cardiopulmonary Resuscitation-Targeted Multi-Tier Response System on Outcomes After Out-of-Hospital Cardiac Arrest: A Before-and-After Population-Based Study.
Lee SY, Song KJ, Shin SD. | Prehosp Emerg Care. 2019 Jul 10:1
DOI: https://doi.org/10.1080/10903127.2019.1624900
Keywords: ambulance multi-tier response system; cardiopulmonary resuscitation; out-of-hospital cardiac arrest; outcomes

Article

Introduction : A multi-tiered response (MTR) system has been controversial in terms of cost-effectiveness and outcome improvement. It remains uncertain whether a cardiopulmonary resuscitation (CPR)-targeted tiered response system is associated with better outcomes after out-of-hospital cardiac arrest (OHCA). This study aimed to investigate the effect of an MTR on OHCA outcomes.

Méthode : A natural experimental study was conducted for resuscitation-attempted adult OHCAs. The MTR system was implemented in Korea by the National Fire Agency in 2015 across the country where the single-tiered ambulance response system existed. The MTR program had the following 3 components: 1) detection of OHCA by dispatcher, 2) dispatch of ambulance or fire engine in addition to routine dispatch of ambulance, and 3) performance of team CPR. The study period of 2015-2016 was divided by 6 months (phases I [reference], II, III, and IV). The endpoints were prehospital defibrillation, prehospital return of spontaneous circulation (PROSC), survival to discharge and good neurological recovery. A multivariable logistic regression analysis was performed to evaluate the effect of the intervention, and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated, adjusting for potential confounders.

Résultats : A total of 32,663 eligible OHCA cases were evaluated during the study period. As the intervention program spread, the MTR with ambulance increased (from 7.0% in phase I to 53.7% in phase IV, p for trend < 0.01). During the study period, prehospital defibrillation increased from 23.6% in phase I to 26.9% in phase IV and the study outcome was improved from 7.4 to 12.6% for PROSC, from 6.7 to 9.1% for survival to discharge, and from 4.5 to 5.8% for good neurological outcome (p for trend < 0.01 for all). Compared with phase I, the AORs (95% CI) of phase IV were 1.16 (1.08-1.25) for prehospital defibrillation, 1.82 (1.63-2.04) for PROSC, 1.37 (1.21-1.56) for survival to discharge, and 1.23 (1.06-1.43) for good neurological outcome.

Conclusion : The nationwide implementation of a multi-tiered response system for OHCA was associated with increased prehospital defibrillation and improved outcomes of OHCA patients.

Conclusion (proposition de traduction) : La mise en œuvre à l'échelle nationale d'un système de réponse à plusieurs niveaux pour les arrêts cardiaques extra-hospitalier a été associée à une défibrillation préhospitalière accrue et à de meilleurs résultats pour les patients en arrêt cardiaque en dehors de l'hôpital.

Association Between Intravenous Fluid Bolus and Biomarker Trajectory During Prehospital Care.
Brant EB, Kennedy J, Martin-Gill C, Jackson V, Peck Palmer OM, Callaway CW, Kahn JM, Yealy DM, Angus DC, Seymour CW. | Prehosp Emerg Care. 2019 Jul 1:1-8
DOI: https://doi.org/10.1080/10903127.2019.1629134
Keywords: biomarkers; fluids; prehospital; sepsis; trajectory

Article

Introduction : Patients with acute illness who receive intravenous (IV) fluids prior to hospital arrival may have a lower in-hospital mortality. To better understand whether this is a direct treatment effect or epiphenomenon of downstream care, we tested the association between a prehospital fluid bolus and the change in inflammatory cytokines measured at prehospital and emergency department timepoints in a sample of non-trauma, non-cardiac arrest patients at risk for critical illness.

Méthode : In a prospective cohort study, we screened 4,013 non-trauma, non-cardiac arrest encounters transported by City of Pittsburgh Emergency Medical Services (EMS) to 2 hospitals from August 2013 to February 2014. In 345 patients, we measured prehospital biomarkers (IL-6, IL-10, and TNF) at 2 time points: the time of prehospital IV access placement by EMS and at ED arrival. We determined the relative change for marker X as: ([XED - XEMS]/XEMS). We determined the risk-adjusted association between prehospital IV fluid bolus and relative change for each marker using multivariable linear regression.

Résultats : Among 345 patients, 88 (26%) received a prehospital IV fluid bolus and 257 (74%) did not. Compared to patients who did not receive prehospital fluids, median prehospital IL-6 was greater initially in subjects receiving a prehospital IV fluid bolus (22.3 [IQR 6.4-113] vs. 11.5 [IQR 5.5-47.6]). Prehospital IL-10 and TNF were similar in both groups (IL-10: 3.5 [IQR 2.2-25.6] vs. 3.0 [IQR 1.9-9.0]; TNF: 7.5 [IQR 6.4-10.4] vs. 6.9 [IQR 6.0-8.3]). After adjustment for demographics, illness severity, and prehospital transport time, we observed a relative decrease in IL-6 at hospital arrival in those receiving a prehospital fluid bolus (adjusted β = -10.0, 95% CI: -19.4, -0.6, p = 0.04), but we did not detect a significant change in IL-10 (p = 0.34) or TNF (p = 0.53).

Conclusion : Among non-trauma, non-cardiac arrest patients at risk for critical illness, a prehospital IV fluid bolus was associated with a relative decrease in IL-6, but not IL-10 or TNF.

Conclusion (proposition de traduction) : Parmi les patients non traumatisés et ne présentant pas d'arrêt cardiaque, présentant un risque de maladie grave, un bolus intraveineux de fluide intraveineux était associé à une diminution relative de l'IL-6, mais pas de l'IL-10 ni du TNF.

Guiding Cardiopulmonary Resuscitation with Focused Echocardiography: A Report of Five Cases.
Liu RB, Bogucki S, Marcolini EG, Yu CY, Wira CR, Kalam S, Daley J, Moore CL, Cone DC. | Prehosp Emerg Care. 2019 Jul 1:1-6
DOI: https://doi.org/10.1080/10903127.2019.1626955
Keywords: cardiac arrest; cardiopulmonary resuscitation; echocardiography; emergency medicine; point-of-care ultrasound

Article

Introduction : Focused transthoracic echocardiography has been used to determine etiologies of cardiac arrest and evaluate utility of continuing resuscitation after cardiac arrest. Few guidelines exist advising ultrasound timing within the advanced cardiac life support algorithm. Natural timing of echocardiography occurs during the pulse check, when views are unencumbered by stabilization equipment or vigorous movements. However, recent studies suggest that ultrasound performance during pulse checks prolongs the pause duration of cardiopulmonary resuscitation. Transesophageal echocardiography studies have demonstrated benefits in this regard, but there have been no transthoracic echocardiography studies assessing the physical performance of compressions during cardiopulmonary resuscitation.

Méthode : Focused transthoracic echocardiography has been used to determine etiologies of cardiac arrest and evaluate utility of continuing resuscitation after cardiac arrest. Few guidelines exist advising ultrasound timing within the advanced cardiac life support algorithm. Natural timing of echocardiography occurs during the pulse check, when views are unencumbered by stabilization equipment or vigorous movements. However, recent studies suggest that ultrasound performance during pulse checks prolongs the pause duration of cardiopulmonary resuscitation. Transesophageal echocardiography studies have demonstrated benefits in this regard, but there have been no transthoracic echocardiography studies assessing the physical performance of compressions during cardiopulmonary resuscitation.

Conclusion : Providers using focused echocardiography to evaluate cardiac arrest patients should consider initiating scans at the start of compressions to identify the optimal location for compression delivery and to detect inadequate compressions. Subsequent visualization of full left ventricular compression may be seen after a location change, and combined with end tidal carbon dioxide values, gives indication for improved forward circulatory flow. Although it is not possible in all patients, doing so hastens provision of quality compressions that affect hemodynamic parameters without causing prolongations to the pulse check pause. Further research is needed to determine patient outcomes from both out-of-hospital and in-hospital cardiac arrest when cardiopulmonary resuscitation is visually guided by focused echocardiography.

Conclusion (proposition de traduction) : Les prestataires qui utilisent une échocardiographie ciblée pour évaluer les patients en arrêt cardiaque devraient envisager de commencer l'analyse au début des compressions thoraciques afin d'identifier l'emplacement optimal pour l'administration des compressions et de détecter les compressions inadéquates. La visualisation ultérieure de la compression ventriculaire gauche complète peut être observée après un changement d'emplacement et, combinée aux valeurs de EtCO2, donne une indication sur l'amélioration du débit circulatoire direct. Bien que cela ne soit pas possible chez tous les patients, cela accélère la mise en place de compressions de qualité qui affectent les paramètres hémodynamiques sans prolonger la pause de vérification du pouls.
Des recherches supplémentaires sont nécessaires pour déterminer les résultats pour les patients après un arrêt cardiaque à la fois hospitalier et extra-hospitalier lorsque la réanimation cardiopulmonaire est guidée visuellement par une échocardiographie ciblée.

Whole-Body CT after Motor Vehicle Crash: No Benefit after High-Energy Impact and with Normal Physical Examination.
Belabbas D, Auger M, Lederlin M, Bonenfant J, Gandon Y, Aubé C, Paisant A. | Radiology. 2019 Jul;292(1):94-100
DOI: https://doi.org/10.1148/radiol.2019182806
Keywords: Aucun

Original Research

Introduction : Debate continues about the risks and benefits of systematic whole-body CT when no injury is clinically suspected. Risks of whole-body CT include high radiation exposure and iodine contrast agent, but its effectiveness in reducing mortality in low-risk motor vehicle crashes is unclear. Purpose To assess unsuspected injuries revealed at whole-body CT in patients following motor vehicle crash (MVC) meeting only kinetic elements of the Vittel criteria for the severity of trauma, with no evidence of trunk injury and a Glasgow Coma Scale score of 15.

Méthode : This retrospective study included all consecutive adult patients who consulted an emergency department of a level 1 trauma center between August 2016 and July 2017 if they underwent whole-body CT for one or more kinetic elements of the Vittel criteria, had a normal examination of the trunk, and had a Glasgow Coma Scale score of 15. Data of the MVC mechanism and physical and biologic examinations were collected, as well as patient treatment data after whole-body CT. Whole-body CT examinations were read by two double-blinded readers to help detect unsuspected injuries.

Résultats : Ninety-three patients were included; 72 were men with a mean age of 30.8 years ± 12.0 (standard deviation). Sixty-nine patients were occupants of a car. Seventeen patients were hit by a car while on motorbikes, three while on bicycles, and four as pedestrians. Unsuspected injuries were depicted at 11 whole-body CT examinations: eight lung contusions, one acetabular fracture, one sternal fracture, and one adrenal hematoma. None of these injuries required a specific treatment. One patient with lung contusion of more than 30% of lung volume was followed without requiring further treatment.

Conclusion : In this population, whole-body CT did not lead to any change in patient treatment. These results suggest whole-body CT should not be systematically performed when no evidence of trunk injury is observed in patients following motor vehicle crash meeting only kinetic elements of Vittel criteria.

Conclusion (proposition de traduction) : Dans cette population, le body scanner n'a entraîné aucun changement dans le traitement des patients. Ces résultats suggèrent que le body scanner ne devrait pas être systématiquement demandé lorsqu'aucun signe de lésion du tronc n'est observé chez les patients à la suite d'un accident de la route ne répondant qu'aux éléments cinétiques des critères de Vittel.

Commentaire : Commentaire dans  :
Munera F, Durso AM. Whole-Body CT after Motor Vehicle Crash: When Is It Necessary? Radiology. 2019 Jul;292(1):101-102. doi: 10.1148/radiol.2019190812  .

A novel ECG parameter for diagnosis of acute pulmonary embolism: RS time: RS time in acute pulmonary embolism.
Rencuzogullari I, Çağdaş M, Karabağ Y, Karakoyun S, Çiftçi H, Gürsoy MO, Karayol S, Çinar T, Tanik O, Hamideyin Ş. | Am J Emerg Med. 2019 Jul;37(7):1230-1236
DOI: https://doi.org/10.1016/j.ajem.2018.09.010
Keywords: Aucun

Original contribution

Introduction : Pulmonary embolism (PE) is one of the leading causes of cardiovascular mortality worldwide. Electrocardiography (ECG) may provide useful information for patients with acute PE. In this study, we aimed to investigate the diagnostic value of the QRS duration and RS time in inferolateral leads in patients admitted to the emergency department, and pre-diagnosed with acute PE.

Méthode : We retrospectively enrolled 136 consecutive patients, admitted to the emergency department, pre-diagnosed with the clinical suspicion of acute PE, and underwent computerized tomographic pulmonary angiography (CTPA) to confirm the PE diagnosis. The study subjects were divided into two groups according to the presence or absence of PE, and the independent predictors of PE were investigated.

Résultats : Sixty-eight patients (50%) had PE. Patients with PE had a longer RS time. Among the ECG parameters, only RS time was an independent predictor of PE (OR: 1.397, 95% CI: 1.171-1.667; p < 0.001). The ROC curve analyses revealed that the cut-off value of RS time for predicting acute PE was 64.20 ms with a sensitivity of 85.3% and a specificity of 79.4% (AUC: 0.846, 95%CI: 0.749-0.944; p < 0.001). In the correlation analyses; the RS time was correlated with RV end-diastolic diameter (r = 0.422; p < 0.001), RV/left ventricle (LV) ratio (r = 0.622; p < 0.001), and systolic pulmonary artery pressure (SPAP) (r = 0.508; p < 0.001).

Conclusion : As a novel ECG parameter, RS time could be measured for each patient. A longer RS time can be a very useful index for diagnosing acute PE as well as for estimating the RV end-diastolic diameter and SPAP.

Conclusion (proposition de traduction) : En tant que nouveau paramètre d'ECG, la durée de RS pourrait être mesuré pour chaque patient. Une durée allongée peut être un indice très utile pour diagnostiquer une embolie pulmonaire aiguë ainsi que pour estimer le diamètre diastolique du ventricule droit et la pression systolique dans l'artère pulmonaire.

Predictive performance of the SOFA and mSOFA scoring systems for predicting in-hospital mortality in the emergency department.
Rahmatinejad Z, Reihani H, Tohidinezhad F, Rahmatinejad F, Peyravi S, Pourmand A, Abu-Hanna A, Eslami S. | Am J Emerg Med. 2019 Jul;37(7):1237-1241
DOI: https://doi.org/10.1016/j.ajem.2018.09.011
Keywords: Emergency department; Iran; Performance measures; Prognostic models

Original contribution

Introduction : The Sequential Organ Failure Assessment (SOFA) and modified SOFA (mSOFA) are risk stratification systems which incorporate respiratory, coagulatory, liver, cardiovascular, renal, and neurologic systems to quantify the overall severity of acute disorder in the intensive care unit.
OBJECTIVE: To evaluate the prognostic performance of the SOFA and mSOFA scores at arrival for predicting in-hospital mortality in the emergency department (ED).

Méthode : All adult patients with an Emergency Severity Index (ESI) of 1-3 in the ED of Imam Reza Hospital, northeast of Iran were included from March 2016 to March 2017. The predictive performance of the SOFA or mSOFA scores were expressed in terms of accuracy (Brier Score, BS and Brier Skill Score, BSS), discrimination (Area Under the Receiver Operating Characteristic Curve, AUC), and calibration.

Résultats : A total of 2205 patients (mean age 61.8 ± 18.5 years, 53% male) were included. The overall in-hospital mortality was 19%. For SOFA and mSOFA the BS was 0.209 and 0.192 and the BSS was 0.11 and 0.09, respectively. The estimated AUCs of SOFA and mSOFA models were 0.751 and 0.739, respectively. No significant difference was observed between the AUCs (P = 0.186). The Hosmer-Lemeshow test did not show that the predictions deviated from the true probabilities. Also, the calibration plots revealed good agreement between the actual and predicted probabilities.

Conclusion : The SOFA and mSOFA scores demonstrated fair discrimination and good calibration in predicting in-hospital mortality when applied to ED. However, further external validation studies are needed before their use in routine clinical care.

Conclusion (proposition de traduction) : Les scores SOFA et mSOFA ont démontré une discrimination équivalente et un bon étalonnage dans la prédiction de la mortalité intrahospitalière lorsqu'ils sont appliqués aux urgences. Toutefois, d'autres études de validation externe sont nécessaires avant leur utilisation dans les soins cliniques de routine.

Sedative dose and patient variable impacts on postintubation hypotension in emergency airway management.
Kim JM, Shin TG, Hwang SY, Yoon H, Cha WC, Sim MS, Jo IJ, Song KJ, Rhee JE, Jeong YK. | Am J Emerg Med. 2019 Jul;37(7):1248-1253
DOI: https://doi.org/10.1016/j.ajem.2018.09.015
Keywords: Emergency intubation; Hemodynamic instability; Postintubation hypotension; Sedative

Original contribution

Introduction : Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department (ED) endotracheal intubation. This study aimed to evaluate the association between sedative dose adjustment and PIH during emergency airway management. We also investigated the impact of patient and procedural factors on the incidence of PIH.

Méthode : This was a single-center, retrospective study that used a prospectively collected registry of airway management performed at the ED from April 2014 to February 2017. Adult patients who received emergency endotracheal intubation were included. Multivariable logistic regression models were used to evaluate the association of PIH with sedative dose, patient variables, and procedural variables.

Résultats : Overall, 689 patients were included, and 233 (33.8%) patients developed PIH. In the patients overall, multivariable logistic regression demonstrated that age > 70 years, shock index >0.8, arterial acidosis (pH < 7.2), intubation indication, and use of non-depolarizing neuromuscular blocking agent were significantly related to PIH. In patients overall, the sedative dose was not related to PIH (overdose; OR: 1.09, 95%CI: 0.57-2.06), (reduction; OR: 0.93, 95%CI: 0.61-1.42), (none used; OR: 1.28, 95%CI: 0.64-2.53). In subgroup analysis, ketamine dose was not related to PIH (overdose; OR: 0.81, 95%CI: 0.27-2.38, reduction; OR: 1.41, 95%CI: 0.78-2.54). Reduction of etomidate dose was significantly associated with decreased PIH (reduction; OR: 0.46, 95%CI: 0.22-0.98, overdose; OR: 1.77, 95%CI: 0.79-3.93).

Conclusion : PIH was mainly related to predisposing patient-related factors. Only adjustment of etomidate dose was associated with the incidence of PIH.

Conclusion (proposition de traduction) : L'hypotension post-intubation était principalement liée à des facteurs prédisposants liés au patient (l’âge > 70 ans, l’indice de choc > 0,8, l’acidose artérielle (pH < 7,2) et l’indication de l'intubation). Seul l’ajustement de la dose d’étomidate a été associé à l’incidence de l’hypotension post-intubation.

Predicting of neuropsychosis in carbon monoxide poisoning according to the plasma troponin, COHb, RDW and MPV levels: Neuropsychoses in carbon monoxide poisoning.
Coşkun A, Eren FA, Eren ŞH, Korkmaz İ. | Am J Emerg Med. 2019 Jul;37(7):1254-1259
DOI: https://doi.org/10.1016/j.ajem.2018.09.017
Keywords: Carbon monoxide poisoning; Emergency department; Mean platelet volume; Neuropsychosis; Red blood cell distribution width

Original contribution

Introduction : Carbon monoxide (CO) poisoning is very common worldwide. In this study, we aimed to evaluate the predictivity of neuro psychosis in carbon monoxide poisoning by the admission levels of red cell distribution (RDW), mean platelet volume (MPV) and troponin I levels which can be measured quickly and easily in the emergency department (ED).

Méthode : This single center observational study included a total of 216 consecutive patients who presented to the ED due to CO poisoning between January 2009 and December 2013. The diagnosis of CO poisoning was made according to the medical history and carboxyhemoglobin (COHb) level of >5%. According to the carboxyhemoglobin levels, the patients were classified as mildly (COHb < 20%) and severely poisoned (COHb > 20%). In addition, patients were divided into 2 groups, i.e., those with positive (>0.05 ng/mL for our laboratory) and negative (<0.05 ng/mL for our laboratory) troponin levels.

Résultats : Patients mean age was 52.58 ± 10.58. 57.9% of the patients had high troponin levels and 51.9% were poisoned severely according to COHb levels. Patients with positive troponin and COHb had longer CO exposure time and higher neutrophil, lymphocyte, mean platelet volume (MPV), COHb and red cell distribution width (RDW) levels at the index admission following CO poisoning than patients with negative troponin (p < 0.05). Age, COHb level, CO exposure time, MPV and RDW (p = 0.001, p < 0.05) remained associated with an increased risk of troponin positivity following adjustment for the variables that were statistically significant.

Conclusion : In patients presenting to the ED with CO poisoning, RDW and MPV can be helpful for risk stratification of neuropsychosis.

Conclusion (proposition de traduction) : Chez les patients présentant une intoxication au CO aux urgences, l'indice de distribution des globules rouges (IDR) et le volume moyen des plaquettes peuvent être utiles pour la stratification du risque de survenue d'une atteinte neurologique post-intervallaire.

Pre-hospital qSOFA as a predictor of sepsis and mortality.
Shu E, Ives Tallman C, Frye W, Boyajian JG, Farshidpour L, Young M, Campagne D. | Am J Emerg Med. 2019 Jul;37(7):1273-1278
DOI: https://doi.org/10.1016/j.ajem.2018.09.025
Keywords: Aucun

Original contribution

Introduction : The quick sequential organ failure assessment score (qSOFA) has been proposed as a simple tool to identify patients with sepsis who are at risk for poor outcomes. Its utility in the pre-hospital setting has not been fully elucidated.

Méthode : This is a retrospective observational study of adult patients arriving by ambulance in September 2016 to an academic emergency department in Fresno, California. The qSOFA score was calculated from pre-hospital vital signs. We investigated its association with sepsis, ED diagnosis of infection, and mortality.

Résultats : Of 2292 adult medical patients transported by ambulance during the study period, the sensitivity of qSOFA for sepsis and in-hospital mortality were 42.9% and 40.6%, respectively. Specificity of qSOFA for sepsis and mortality were 93.8% and 91.9%, respectively. Of those with an ED diagnosis of infection compared to all patients, qSOFA was more specific but less sensitive for sepsis. Increasing qSOFA score was associated with a discharge diagnosis of sepsis (OR 4.21, 95% CI 3.41-5.21, p < 0.001), in-hospital mortality (OR 3.30, 95% CI 2.28-4.78, p < 0.001), and ED diagnosis of infection (OR 1.37, 95% CI 1.18-1.58, p < 0.001). Higher qSOFA score was associated with triage to a higher acuity zone and longer hospital and ICU length of stay, but not up-triage during ED stay.

Conclusion : Pre-hospital qSOFA is specific, but poorly sensitive, for sepsis and sepsis outcomes, especially among patients with an ED diagnosis of infection. Higher qSOFA score was associated with worse outcomes.

Conclusion (proposition de traduction) : Le qSOFA en pré-hospitalier est spécifique, mais peu sensible, pour prédire un sepsis et l'évolution du sepsis, en particulier chez les patients chez qui on porte un diagnostic d'infection aux urgences. Un score qSOFA plus élevé était associé à une évolution moins bonne.

A new clinical score for cranial CT in ED non-trauma patients: Definition and first validation.
Covino M, Gilardi E, Manno A, Simeoni B, Ojetti V, Cordischi C, Forte E, Carbone L, Gaudino S, Franceschi F. | Am J Emerg Med. 2019 Jul;37(7):1279-1284
DOI: https://doi.org/10.1016/j.ajem.2018.09.032  | Télécharger l'article au format  
Keywords: Clinical score; Computed tomography; Cranial; Emergency department

Original contribution

Introduction : Well recognized guidelines are available for the use of cranial computed tomography (CCT) in traumatic patients, while no definitely accepted standards exists to for CCT in patients without history of head injury. The aim of this study is to propose an easy clinical score to stratify the need of CCT in emergency department (ED) patients with suspect non-traumatic intracranial pathology.

Méthode : We retrospectively evaluated patients presenting to the ED for neurological deficit, postural instability, acute headache, altered mental status, seizures, confusion, dizziness, vertigo, syncope, and pre-syncope. We build a score for positive CCT prediction by using a logistic regression model on clinical factors significant at univariate analysis. The score was validated on a population of prospectively observed patients.

Résultats : We reviewed clinical data of 1156 patients; positivity of CCT was 15.2%. Persistent neurological deficit, new onset acute headache, seizures and/or altered state of consciousness, and transient neurological disorders were independent predictors of positive CCT. We observed 508 patients in a validation prospective cohort; CCT was positive in 11.3%. Our score performed well in validation population with a ROC AUC of 0.787 (CI 95% 0.748-0.822). Avoiding CT in score 0 patients would have saved 82 (16.2%) exams. No patients with score 0 had a positive CCT findings; score sensitivity was 100.0 (CI 95% 93.7-100.0).

Conclusion : A score for risk stratification of patients with suspect of intra-cranial pathology could reduce CT request in ED, avoiding a significant number of CCT while minimizing the risk of missing positive results.

Conclusion (proposition de traduction) : Un score de stratification du risque des patients suspects de pathologie intra-crânienne pourrait réduire le nombre de demandes de tomodensitométrie aux urgences, en évitant un nombre significatif de tomodensitométries crâniennes tout en minimisant le risque de résultats positifs manquants.

Investigation of age-adjusted D-dimer using an uncommon assay.
Parks C, Bounds R, Davis B, Caplan R, Laughery T, Zeserson E. | Am J Emerg Med. 2019 Jul;37(7):1285-1288
DOI: https://doi.org/10.1016/j.ajem.2018.09.035
Keywords: Age-adjusted D-dimer; D-dimer; Diagnostic test; Evidence-based practice; Pulmonary embolism

Original contribution

Introduction : Use of an age-adjusted D-dimer for the evaluation of acute pulmonary embolus (PE) has been prospectively validated in the literature and has become a practice recommendation from major medical societies. Most research on this subject involves the most common D-dimer assays reporting in Fibrinogen Equivalent Units (FEU) with a non-age-adjusted manufacturer-recommended cutoff of 500 ng/ml FEU. Limited research to date has evaluated age-adjustment in assays that report in D-Dimer Units (D-DU), which use a manufacturer-recommended cutoff of 230 ng/ml D-DU. Despite scant evidence, an age-adjusted formula using D-DU has been recently endorsed by the American College of Emergency Physicians (ACEP). This formula seems arbitrary in its derivation and unnecessarily deviates from existing thresholds, thus prompting the creation of our novel-age adjustment formula. The goal of this study was to retrospectively evaluate the test characteristics of our novel age-adjusted D-dimer formula using the D-DU assay in comparison to existing traditional and age-adjusted D-dimer thresholds for the evaluation of acute PE in the ED.

Méthode : This was a retrospective chart review at an academic quaternary health system with three EDs and 195,000 combined annual ED visits. Only patients with D-dimer testing and CT PE protocol (CTPE) imaging were included. Admission and discharge diagnosis codes were used to identify acute PE. Outcome measures were sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of an unadjusted traditional threshold (230) compared with both novel and ACEP-endorsed age adjusted thresholds, (Age × 5) - 20 and Age × 5 if >50, respectively. Estimates with their exact 95% threshold were performed.

Résultats : 4846 adult patients were evaluated from January 2012 to July 2017. Group characteristics include a mean age of 52 and a frequency of acute PE diagnosis by CTPE of 8.25%. Traditional D-dimer cutoff demonstrated a sensitivity of 99.8% (95% CI 98.6-100), specificity of 16.7% (95% CI 15.6-17.8) and NPV of 99.9% (95% CI 99.3-100). Our novel age-adjusted D-dimer thresholds had a sensitivity of 97.0% (95% CI 94.8-98.4), specificity of 27.9% (95% CI 26.6-29.2) and NPV of 99.0% (95% CI 98.3-99.5) with the ACEP-endorsed formula demonstrating similar test characteristics.

Conclusion : Use of an age-adjusted D-dimer on appropriately selected patients being evaluated for acute PE in the ED with a D-DU assay increases specificity while maintaining a high sensitivity and NPV. Both our novel formula and the ACEP-endorsed age-adjusted formula performed well, with our novel formula showing a trend towards improved testing characteristics.

Conclusion (proposition de traduction) : L'utilisation de D-dimères ajustées à l'âge chez des patients sélectionnés de manière appropriée et évalués pour un embolie pulmonaire aigüe aux urgence par un dosage de D-Dimères Units augmente la spécificité tout en maintenant une sensibilité élevée et une valeur prédictive négative.
Notre nouvelle formule et la formule ajustée en fonction de l'âge approuvée par l'American College of Emergency Physicians ont bien fonctionné, notre nouvelle formule montrant une tendance à l'amélioration des caractéristiques de test.

Initial evaluation and management of wide-complex tachycardia: A simplified and practical approach.
Littmann L, Olson EG, Gibbs MA. | Am J Emerg Med. 2019 Jul;37(7):1340-1345
DOI: https://doi.org/10.1016/j.ajem.2019.04.027
Keywords: Atrial fibrillation; Electrocardiogram; Supraventricular tachycardia; Ventricular tachycardia; Wide-complex tachycardia; Wolff-Parkinson-White syndrome

Reviews

Editorial : The evaluation and treatment of wide QRS-complex tachycardia remains a challenge, and mismanagement is quite common. Diagnostic aids such as wide-complex tachycardia algorithms perform poorly in the real-life setting. The purpose of this review is to offer a simple clinical-electrocardiographic approach for the initial evaluation and management of the adult patient with stable wide-complex tachycardia that does not require recollection of complex guidelines or algorithms.

Conclusion : In cases of wide-complex tachycardia, the ECG should never be evaluated without consideration of the clinical context. Regular wide-complex tachycardia in elderly patients and in patients with structural heart disease is almost always ventricular tachycardia. Demonstration of an inconsistent P-QRS relationship essentially confirms the diagnosis of ventricular tachycardia. If the rate is very fast or the patient has poor left ventricular systolic function, electric cardioversion should probably be performed. If the rate is not excessive and the tachycardia is tolerated, give IV procainamide. In younger patients with no known heart disease, especially if the QRS morphology resembles bundle branch block, supraventricular tachycardia is somewhat more likely; prove it with IV adenosine. Irregular wide-complex tachycardia in an elderly patient and in the patient with structural heart disease is almost always AF with bundle branch block; treat it according to atrial fibrillation guidelines. In patients with no known heart disease, especially when the ventricular rate is very fast and the QRS complexes are bizarre (fast, bizarre, irregular – FBI), atrial fibrillation with WPW is the likely diagnosis. When the heart rate is excessive or the patient has poor left ventricular systolic function, direct current electric cardioversion should be employed. If the ventricular rate is not excessive and the tachycardia is tolerated, treat it with IV procainamide. Patients with any type of wide-complex tachycardia that causes clinical or hemodynamic instability should undergo immediate electric cardioversion.

Conclusion (proposition de traduction) : Dans les cas de tachycardie à complexes larges, l'ECG ne doit jamais être évalué sans tenir compte du contexte clinique.
La tachycardie ventriculaire est presque toujours une tachycardie ventriculaire chez les patients âgés et chez les patients présentant une cardiopathie structurelle. La démonstration d'une relation P-QRS incohérente confirme essentiellement le diagnostic de tachycardie ventriculaire. Si le rythme est très rapide ou si le patient a une fonction systolique ventriculaire gauche faible, une cardioversion électrique devrait probablement être effectuée. Si le rythme n'est pas excessif et que la tachycardie est tolérée, administrer du procaïnamide IV (ndlr : N'est plus commercialisé en Belgique, France et en Suisse).
Chez les patients plus jeunes n'ayant pas de maladie cardiaque connue, surtout si la morphologie du QRS ressemble à celle d'un bloc de branche, la tachycardie supraventriculaire est un peu plus probable ; le prouver avec l'adénosine IV.
La tachycardie irrégulière à complexe large chez un patient âgé et chez un patient souffrant d'une cardiopathie structurelle est presque toujours une fibrillation auriculaire avec bloc de branche ; traitez-la selon les directives de fibrillation auriculaire. Chez les patients sans maladie cardiaque connue, surtout lorsque la fréquence ventriculaire est très rapide et que les complexes QRS sont bizarres (rapide, complexe large, irrégulier - FBI [Fast, Broad-complex, Irregular]), la fibrillation auriculaire avec un syndrome de Wolff-Parkinson-White est le diagnostic probable.
Lorsque la fréquence cardiaque est excessive ou que la fonction systolique du ventricule gauche du patient est faible, il faut utiliser une cardioversion électrique à courant continu. Si la fréquence ventriculaire n'est pas excessive et que la tachycardie est tolérée, traitez-la avec du procaïnamide IV. Les patients atteints de tout type de tachycardie à complexe large qui cause une instabilité clinique ou hémodynamique doivent subir immédiatement une cardioversion électrique.

Misconceptions and Facts About Beta-Blockers.
Argulian E, Bangalore S, Messerli FH. | Am J Med. 2019 Jul;132(7):816-819
DOI: https://doi.org/10.1016/j.amjmed.2019.01.039
Keywords: Aucun

Reviews

Editorial : Beta-blockers are commonly used medications, and they have been traditionally considered "cardioprotective." Their clinical use appears to be more widespread than the available evidence base supporting their role in cardioprotection. Beta-blockers counteract neurohumoral activation in heart failure with reduced ejection fraction and offer both symptomatic improvement and reduction in adverse events. On the other hand, the use of beta-blockers in uncomplicated hypertension results in suboptimal outcomes compared to the established first-line antihypertensive agents. Providers at all levels should be familiar with common misconceptions regarding beta-blocker use in routine clinical practice.

Conclusion : Beta-blockers are an essential part of medical armamentarium and have an important niche in the modern cardiology, especially in patients with heart failure. At the same time, their clinical use appears widespread beyond the established evidence base.2 Provider education may decrease the gap between perceived and proven benefits of BB therapy.

Conclusion (proposition de traduction) : Les bêta-bloquants sont une partie essentielle de l'arsenal médical et occupent une place importante dans la cardiologie moderne, en particulier chez les patients souffrant d'insuffisance cardiaque. Dans le même temps, leur utilisation clinique semble être largement répandue au-delà de la base de preuves établie. La formation des prescripteurs pourrait réduire l’écart entre les avantages perçus et prouvés du traitement par les bêta-bloquants.

Commentaire : Voir l'analyse de l'article sur le site de la Société Française d'Hypertension Artérielle : Fausses idées et faits concernant les bêta-bloquants  . Rédigé par le Pr. Bernard LEVY, Paris et le Dr. Marilucy LOPEZ-SUBLET, le 14/03/2019 :
Les bêta-bloquants sont des médicaments couramment utilisés et ils sont traditionnellement considérés comme « cardioprotecteurs ». Leur utilisation clinique semble être plus répandue que les données probantes disponibles à l’appui de leur rôle dans la cardioprotection. Les bêta-bloquants contrecarrent l’activation neurohumorale dans l’insuffisance cardiaque avec une fraction d’éjection réduite et offrent à la fois une amélioration symptomatique et une réduction des événements indésirables. D’autre part, l’utilisation de bêta-bloquants dans l’hypertension non compliquée entraîne des résultats sous-optimaux comparativement aux antihypertenseurs de première ligne établis. Les prestataires à tous les niveaux devraient être familiers avec les idées fausses courantes concernant l’utilisation des bêta-bloquants dans la pratique clinique courante.

Predicting Failure of Intravenous Access in Adults: The Value of Prior Difficulty.
Witting MD, Moayedi S, Hirshon JM, George NH, Schenkel SM. | J Emerg Med. 2019 Jul;57(1):1-5
DOI: https://doi.org/10.1016/j.jemermed.2019.02.011
Keywords: catheterization; crowding; decision-making; emergency service; hospital; peripheral intravenous

Original Contributions

Introduction : BACKGROUND: When intravenous access cannot be established using traditional methods of inspection/palpation, advanced methods are often required, leading to substantial delays in care. Knowing the likelihood of intravenous access failure can improve emergency department (ED) efficiency.
OBJECTIVE: Our aim was to validate prior need for an advanced technique to establish intravenous access as a predictor of failure to achieve access via traditional methods and to estimate the risk difference associated with this finding.

Méthode : We re-analyzed data collected for a clinical trial that randomized ED patients requiring intravenous access to one of two types of intravenous catheter; gauge size was selected by the inserter. The re-analysis pools data from both groups to examine predictors of failure to establish intravenous access by traditional methods, with failure defined as abandonment or use of an advanced technique (ultrasound guidance or external jugular vein catheterization). Confidence intervals for the difference between proportions were calculated using a normal binomial approximation.

Résultats : We obtained data from 600 patients, with a median age of 52 years (interquartile range 36-63 years). We noted failure of traditional methods in 28 (4.7%) patients, including 17 of 109 (16%) with prior need for advanced techniques. The risk difference for prior need for advanced techniques versus no prior difficulty was 14% (95% confidence interval 7-22).

Conclusion : Patients with a prior need for advanced techniques were 14% more likely to have failure of intravenous access by traditional methods than those without prior difficulty.

Conclusion (proposition de traduction) : Les patients ayant déjà eu besoin de techniques avancées (échoguidage ou cathétérisme de la veine jugulaire externe) étaient 14 % plus susceptibles de voir échouer la pose d'un accès intraveineux par les méthodes traditionnelles que ceux qui n'avaient pas eu de difficultés antérieures.

Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician.
Moussavi K, Fitter S, Gabrielson SW, Koyfman A, Long B. | J Emerg Med. 2019 Jul;57(1):36-42
DOI: https://doi.org/10.1016/j.jemermed.2019.03.043
Keywords: adverse drug event; hyperkalemia; hypoglycemia; insulin; renal impairment

Clinical Reviews

Introduction : BACKGROUND: Hyperkalemia is a common, potentially lethal clinical condition that accounts for a significant number of emergency department (ED) visits. Insulin and dextrose are frequently used to manage patients with hyperkalemia.
OBJECTIVE: This narrative review evaluates several myths concerning hyperkalemia treatment with insulin and dextrose in the ED and provides recommendations based on the current evidence.

Discussion : Hyperkalemia is a life-threatening condition requiring emergent therapy. One of these therapies includes insulin with glucose. However, hypoglycemia after insulin use is a frequent complication during hyperkalemia management. The published literature suggests that low pretreatment glucose, no history of diabetes mellitus, female gender, abnormal renal function, and lower body weight increase the risk of hypoglycemia. Several strategies can reduce the risk of hypoglycemia with insulin therapy, which include using insulin 5 units or 0.1 units/kg instead of 10 units, administering dextrose 50 g instead of 25 g, or administering dextrose as a prolonged infusion instead of a rapid intravenous bolus. Because insulin may have a duration of action that exceeds dextrose, patients receiving insulin for hyperkalemia should be monitored for hypoglycemia hourly for at least 4-6 h after administration.

Conclusion : Several myths surround hyperkalemia management with insulin and dextrose. This review evaluates the evidence concerning insulin and glucose for hyperkalemia and suggests several modifications to insulin and dextrose dosing to reduce the risk of hypoglycemia.

Conclusion (proposition de traduction) : Plusieurs mythes entourent la prise en charge de l’hyperkaliémie par insuline/glucose. Cette revue évalue les données probantes concernant l’insuline et le glucose pour l’hyperkaliémie et suggère plusieurs modifications à la posologie de l’insuline et du glucose afin de réduire le risque d’hypoglycémie.

Feasibility of a Modified Strategy for 2-Rescuer Cardiopulmonary Resuscitation.
Root CW, Deutsch BC, Lakha S, Shah A, Lin HM, Hyman JB. | J Emerg Med. 2019 Jul;57(1):51-58
DOI: https://doi.org/10.1016/j.jemermed.2019.03.009
Keywords: CPR; airway management; simulation

Selected Topics: Prehospital Care

Introduction : BACKGROUND: Cardiopulmonary resuscitation (CPR) requires effective chest compressions and ventilations to circulate and oxygenate blood. It has been established that a 2-handed mask seal is superior when providing bag-valve-mask (BVM) ventilations. However a 1-handed technique remains the standard with which health care providers are trained to perform 2-rescuer CPR.
OBJECTIVES: We sought to determine if a modified 2-rescuer CPR technique that incorporates a 2-handed mask seal during ventilations can be accomplished without compromising chest compression quality during a simulated cardiac arrest.

Méthode : Medical student volunteers were divided into an "intervention" arm, with 1 rescuer creating a 2-handed mask seal and the second rescuer performing chest compressions followed by that second rescuer squeezing the BVM bag to deliver ventilations during compression pauses, and a "control" arm, in which standard 2-rescuer CPR was performed. Both arms received a brief CPR refresher following a standard script. The 2 rescuer teams then performed 2 rounds of CPR on a manikin while being video recorded. Data were collected from real-time evaluation and post hoc video analysis.

Résultats : Forty-seven pairs of students enrolled in the study. There were no statistically significant differences between the intervention and control arms for median (interquartile range [IQR]) compression fraction (72% [69.5-75.7%] vs. 73.2% [69.1-76.1%]; p = 1.0), median time to complete 2 rounds of CPR (207.8 s [198.5-222.9 s] vs. 214.7 s [201.3-219.5 s]; p = 0.625), median hands-off time (49.8 s [46.2-63.0 s] vs. 55.4 s [50.4-65.2 s]; p = 0.278), or median time for 30 compressions (15.2 s [14.3-15.9 s] vs. 15.4 s [14.6-16.3 s]; p = 0.452).

Conclusion : Two-rescuer CPR incorporating a 2-handed face mask seal can be performed effectively without impacting chest compression quality during simulated cardiac arrest.

Conclusion (proposition de traduction) : La RCP à deux secouristes avec masque facial à deux mains peut être effectuée efficacement sans nuire à la qualité de la compression thoracique pendant un arrêt cardiaque sur simulateur.

Commentaire : Voir les articles sur le même sujet :
• Jesudian MC, Harrison RR, Keenan RL, Maull KI. Bag-valve-mask ventilation; two rescuers are better than one: preliminary report. Crit Care Med. 1985 Feb;13(2):122-3
  .
• European Resuscitation Council Guidelines for Resuscitation 2015. Section 3. Adult advanced life support. Starting in-hospital CPR  , page 106.
• Illustrations sur la technique :

Effect of Systolic and Diastolic Blood Pressure on Cardiovascular Outcomes.
Flint AC, Conell C, Ren X, Banki NM, Chan SL, Rao VA, Melles RB, Bhatt DL. | N Engl J Med. 2019 Jul 18;381(3):243-251
DOI: https://doi.org/10.1056/NEJMoa1803180
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : The relationship between outpatient systolic and diastolic blood pressure and cardiovascular outcomes remains unclear and has been complicated by recently revised guidelines with two different thresholds (≥140/90 mm Hg and ≥130/80 mm Hg) for treating hypertension.

Méthode : Using data from 1.3 million adults in a general outpatient population, we performed a multivariable Cox survival analysis to determine the effect of the burden of systolic and diastolic hypertension on a composite outcome of myocardial infarction, ischemic stroke, or hemorrhagic stroke over a period of 8 years. The analysis controlled for demographic characteristics and coexisting conditions.

Résultats : The burdens of systolic and diastolic hypertension each independently predicted adverse outcomes. In survival models, a continuous burden of systolic hypertension (≥140 mm Hg; hazard ratio per unit increase in z score, 1.18; 95% confidence interval [CI], 1.17 to 1.18) and diastolic hypertension (≥90 mm Hg; hazard ratio per unit increase in z score, 1.06; 95% CI, 1.06 to 1.07) independently predicted the composite outcome. Similar results were observed with the lower threshold of hypertension (≥130/80 mm Hg) and with systolic and diastolic blood pressures used as predictors without hypertension thresholds. A J-curve relation between diastolic blood pressure and outcomes was seen that was explained at least in part by age and other covariates and by a higher effect of systolic hypertension among persons in the lowest quartile of diastolic blood pressure.

Conclusion : Although systolic blood-pressure elevation had a greater effect on outcomes, both systolic and diastolic hypertension independently influenced the risk of adverse cardiovascular events, regardless of the definition of hypertension (≥140/90 mm Hg or ≥130/80 mm Hg).

Conclusion (proposition de traduction) : Bien que l'élévation de la pression artérielle systolique ait eu un effet plus important sur l'évolution cardiovasculaire, une hypertension systolique et une diastolique ont indépendamment influencé le risque d'événements cardiovasculaires indésirables, quelle que soit la définition de l'hypertension (≥ 140/90 mmHg ou ≥ 130/80 mmHg).

Commentaire : Voir l'analyse de l'article sur le site Medscape : Les 2 composantes systolique et diastolique de la PA influencent indépendamment le risque cardiovasculaire  . Rédigé par le Dr Jean-Claude Lemaire le 29 juillet 2019.

C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations.
Butler CC, Gillespie D, White P, Bates J, Lowe R, Thomas-Jones E, Wootton M, Hood K, Phillips R, Melbye H, Llor C, Cals JWL, Naik G, Kirby N, Gal M, Riga E, Francis NA. | N Engl J Med. 2019 Jul 11;381(2):111-120
DOI: https://doi.org/10.1056/NEJMoa1803185
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Point-of-care testing of C-reactive protein (CRP) may be a way to reduce unnecessary use of antibiotics without harming patients who have acute exacerbations of chronic obstructive pulmonary disease (COPD).

Méthode : We performed a multicenter, open-label, randomized, controlled trial involving patients with a diagnosis of COPD in their primary care clinical record who consulted a clinician at 1 of 86 general medical practices in England and Wales for an acute exacerbation of COPD. The patients were assigned to receive usual care guided by CRP point-of-care testing (CRP-guided group) or usual care alone (usual-care group). The primary outcomes were patient-reported use of antibiotics for acute exacerbations of COPD within 4 weeks after randomization (to show superiority) and COPD-related health status at 2 weeks after randomization, as measured by the Clinical COPD Questionnaire, a 10-item scale with scores ranging from 0 (very good COPD health status) to 6 (extremely poor COPD health status) (to show noninferiority).

Résultats : A total of 653 patients underwent randomization. Fewer patients in the CRP-guided group reported antibiotic use than in the usual-care group (57.0% vs. 77.4%; adjusted odds ratio, 0.31; 95% confidence interval [CI], 0.20 to 0.47). The adjusted mean difference in the total score on the Clinical COPD Questionnaire at 2 weeks was -0.19 points (two-sided 90% CI, -0.33 to -0.05) in favor of the CRP-guided group. The antibiotic prescribing decisions made by clinicians at the initial consultation were ascertained for all but 1 patient, and antibiotic prescriptions issued over the first 4 weeks of follow-up were ascertained for 96.9% of the patients. A lower percentage of patients in the CRP-guided group than in the usual-care group received an antibiotic prescription at the initial consultation (47.7% vs. 69.7%, for a difference of 22.0 percentage points; adjusted odds ratio, 0.31; 95% CI, 0.21 to 0.45) and during the first 4 weeks of follow-up (59.1% vs. 79.7%, for a difference of 20.6 percentage points; adjusted odds ratio, 0.30; 95% CI, 0.20 to 0.46). Two patients in the usual-care group died within 4 weeks after randomization from causes considered by the investigators to be unrelated to trial participation.

Conclusion : CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in a lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm.

Conclusion (proposition de traduction) : La prescription d'antibiotiques guidée par le taux de CRP dans les exacerbations de BPCO en soins primaires a permis un pourcentage plus faible de patients qui ont déclaré utiliser des antibiotiques et qui ont reçu des ordonnances d'antibiotiques, sans preuve de préjudice.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Intérêt d’une mesure immédiate de la CRP en cabinet de médecine générale pour guider les prescriptions d’antibiothérapie dans les exacerbations de Bronchopneumopathie chronique obstructive (BPCO)  . Rédigé par le Dr Pierre Tattevin le 16 septembre 2019.