Prophylactic Antibiotics In Cirrhotic Patients With Upper Gastrointestinal Bleeding.
Runde DP | Acad Emerg Med. 2020 Aug 6
DOI: https://doi.org/10.1111/acem.14103
Keywords: Mortality, infection during hospitalization (spontaneous peritoneal peritonitis, bacteremia, pneumonia, urinary tract infection)

The BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Cirrhotic patients often develop bleeding from gastric or esophageal varices that occur secondary to portal hypertension. Gastrointestinal (GI) bleeding is fatal in approximately 20% of these episodes and bacterial infections are an important contributor to this mortality. Patients with cirrhosis are also known to have impaired immune function and also at higher risk of translocation of bacteria from the gut into the bloodstream.1 Therefore, the administration of prophylactic antibiotics during the bleeding event might help prevent such infections.

Conclusion : Based on the existing evidence, we have assigned a color recommendation of Green (benefits outweigh harms), as the reported benefits are significant and clinically relevant. As noted above, further data would be welcome to better characterize the degree of benefit, and assess any adverse events associated with antibiotic prophylaxis.

Conclusion (proposition de traduction) : Sur la base des preuves existantes, nous avons attribué une recommandation de couleur verte (les avantages l'emportent sur les inconvénients), car les avantages rapportés sont significatifs et cliniquement pertinents. Comme indiqué ci-dessus, des données supplémentaires seraient les bienvenues pour mieux caractériser le degré de bénéfice et évaluer tout événement indésirable associé à l'antibioprophylaxie.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : UGIB + Cirrhosis = Antibiotics?  . Rédigé par Kevin Stoffer, le 2 septembre 2020.
Voir également l'article : Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, Soares-Weiser K, Uribe M. Antibioticprophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database SystRev. 2010 Sep 8;(9):CD002907  . Review.

Relationship Between Pain, Opioid Treatment, and Delirium in Older Emergency Department Patients.
Daoust R, Paquet J, Boucher V, Pelletier M, Gouin É, Émond M. | Acad Emerg Med. 2020 Aug;27(8):708-716
DOI: https://doi.org/10.1111/acem.14033  | Télécharger l'article au format  
Keywords: Aucun

Original contribution

Introduction : Emergency department (ED) stay and its associated conditions (immobility, inadequate hydration and nutrition, lack of stimulation) increase the risk of delirium in older patients. Poorly controlled pain and paradoxically opioid pain treatment have also been identified as triggers for delirium. The aim of this study was to assess the relationship between pain, opioid treatment, and delirium in older ED patients.

Méthode : A multicenter prospective cohort study was conducted in four hospitals across the province of Québec (Canada). Patients aged ≥ 65 years old, waiting for hospital admission between March and July 2015, who were nondelirious upon ED arrival, who were independent or semi-independent in their daily living activities, and who had an ED stay of at least 8 hours were included. Delirium assessments were conducted twice a day during the patient's entire ED stay and their first 24 hours on the hospital ward using the Confusion Assessment Method. Pain intensity was evaluated using a visual analog scale (VAS = 0-100) during the initial interview, and all opioid treatments were documented.

Résultats : A total of 338 patients were included; 51% were female, and mean (±SD) age was 77 (±8) years. Forty-one patients (12%) experienced delirium during their hospital stay occurring within a mean (±SD) delay of 47 (±19) hours after ED admission. Among patients with pain intensity ≥ 65 from VAS (0-100), 26% experienced delirium compared to 11% for patients with pain < 65 (p < 0.01), and no significant association was found between opioid consumption and delirium (p = 0.31). Logistic regression controlling for confounding factors showed that patients with pain intensity ≥ 65 are 3.3 (95% confidence interval = 1.4 to 7.9) times more likely to develop delirium than patients who had pain intensity of <65.

Conclusion : Severe pain, not opioids, is associated with the development of delirium during ED stay. Adequate pain control during the hospital stay may contribute to a decrease in delirium episodes.

Conclusion (proposition de traduction) : La douleur intense, et pas les morphiniques, est associée au développement du délire pendant le séjour aux urgences. Un contrôle adéquat de la douleur pendant le séjour à l'hôpital peut contribuer à une diminution des épisodes de délire.

Characterizing the Structural Integrity of Endotracheal Tube Taping Techniques: A Simulation Study.
Matchett G, Yang JH, Sripathi NR, Simpkins L, Ruikar K, Minhajuddin A, Whitten CW. | Anesth Analg. 2020 Aug;131(2):544-554
DOI: https://doi.org/10.1213/ane.0000000000004206
Keywords: Aucun

Article

Introduction : Endotracheal tubes (ETTs) are commonly secured with tape to prevent undesirable tube migration. Many methods of taping have been described, although little has been published comparing various methods of taping to one another. In this study, we evaluated several methods for securing ETTs with tape. We hypothesized a difference in mean peak forces between the methods studied during forced extubation.

Méthode : Five methods of securing an ETT with tape were studied in a variety of contexts including cadaver and simulation lab settings. Testing included measurement of peak force (Newton [N]) during forced extubation, durability of taping following mechanical stress, effects of tape length-width variation, and characterization of failure mechanisms.

Résultats : We found several significant differences in mean peak extubation forces between the 5 methods of taping, with mean peak forces during forced extubation ranging from 20 N to 156 N. In separate tests, we found an association between mean peak forces and total surface area as well as geometric configuration of tape on the face. Long thin strips of tape appeared to provide surprising durability against forced extubation, a phenomenon that was associated with minimization of the "peel angle" as tape was removed.

Conclusion : We found evidence of differential structural integrity between the 5 taping methods studied. More generally, we found that increased peak extubation forces were associated with increased total surface area of tape and that minimization of the "peel angle" by lateral application of tape is associated with surprisingly high relative peak extubation forces.

Conclusion (proposition de traduction) : Nous avons trouvé des preuves d'intégrité structurelle différente entre les 5 méthodes de fixation par sparadrap étudiées. Plus généralement, nous avons constaté que l'augmentation des forces d'extubation de pointe étaient associées à une augmentation de la surface totale du sparadrap et que la minimisation de « l'angle de décollement » par application latérale de bande est associée à des forces d'extubation de pointe relatives étonnamment élevées.

Commentaire :  Les types A – E sont cinq méthodes pour sécuriser une sonde endotrachéale avec du ruban adhésif. Le type O (panneau F) n'est pas garanti. Des bandes colorées ont été ajoutées à la bande avant l'enregistrement, pour montrer plus clairement chaque méthode d'enregistrement.
Voir les vidéos associées (Contenu numérique supplémentaire 1–5, Vidéos A – E, http://links.lww.com/AA/C813  , http://links.lww.com/AA/C814  , http://links.lww.com/AA/C815  , http://links.lww.com/AA/C816   et http://links.lww.com/AA/C817  ) pour une description complète de chaque méthode d'enregistrement.

Voir l'analyse de l'article sur le site JournalFeed : How to Tape an ETT - That Won't Come Out  . Rédigé par Aaron Lacy le 4 septembre 2020.

Prereduction Shoulder Radiographs should be Routine.
April MD, Koyfman A, Long B. | Ann Emerg Med. 2020 Aug;76(2):131-132
DOI: https://doi.org/10.1016/j.annemergmed.2020.03.021
Keywords: Aucun

Imaging

Editorial : Radiographic imaging provides an important means of assessing shoulders after blunt trauma, and can identify crucial injuries and fractures that require special care. However, the majority of patients have simple dislocations that do not require special care, and they receive little benefit from imaging. In this episode of Clinical Controversies, pro and con advocates discuss the risks and benefits of obtaining routine radiographic imaging of patients with shoulder injuries.

Conclusion : In accordance with the current literature, we recommend obtaining routine prereduction shoulder radiographs for patients older than 40 years; for those with first episode of dislocation, traumatic mechanism, and physical examination findings suggestive of trauma, including humeral ecchymosis; or in instances in which there is clinical uncertainty in regard to the diagnosis. We contend that most patients presenting to the ED with suspected anterior dislocation would likely be included in one of these categories. For increased efficiency at minimal additional cost, we propose that routine imaging of these patients be the default diagnostic pathway, with deferral ofimaging the exception. Beyond missing fractures, routine imaging may also maximize patient satisfaction and minimize the potential for malpractice claims through the provision of a definitive and objective diagnostic modality. Routine imaging will also rule out pseudo-subluxations. The downside ofordering these studies is minimal, and strategies exist to mitigate issues such as prolonged ED length of stay in particular. We believe that routinely ordering these studies will optimize the care of these patients.

Conclusion (proposition de traduction) : Conformément à la littérature actuelle, nous recommandons de réaliser des radiographies systématique de l'épaule avant la réduction pour les patients âgés de plus de 40 ans ; pour ceux qui présentent un premier épisode de luxation, un mécanisme traumatique et des résultats d'examen physique suggérant un traumatisme, y compris une ecchymose humérale ; ou dans les cas où il existe une incertitude clinique quant au diagnostic. Nous pensons que la plupart des patients se présentant au service des urgences pour une suspicion de luxation antérieure seraient probablement inclus dans l'une de ces catégories.
Pour une efficacité accrue à un coût supplémentaire minime, nous proposons que l'imagerie systématique pour ces patients soit la voie de diagnostic par défaut, avec le report de l'imagerie comme l'exception. Au-delà de l'absence de fracture, l'imagerie systématique peut également maximiser la satisfaction des patients et minimiser le potentiel de réclamations pour faute professionnelle grâce à la fourniture d'une modalité de diagnostic définitive et objective. L'imagerie systématique éliminera également les pseudo-subluxations. L'inconvénient de prescrire cette exploration est minime et des stratégies existent pour atténuer les problèmes tels que la durée prolongée du séjour aux urgences en particulier. Nous pensons que la prescription systématique de ces explorations radiologiques optimisera les soins de ces patients.

Commentaire : Voir le deuxième article de la controverse (Should Radiography Be Routine in Evaluating Shoulder Injuries?) :
Gottlieb M, Alerhand S. Prereduction radiographs are not routinely needed for anterior shoulder dislocations (Les radiographies avant réduction ne sont pas systématiquement nécessaires dans les luxations antérieures de l'épaule). Ann Emerg Med. 2020 Aug;76(2):132–3  .

Management of Acute Pain From Non-Low Back Musculoskeletal Injuries : A Systematic Review and Network Meta-analysis of Randomized Trials.
Busse JW, Sadeghirad B, Oparin Y, Chen E, Goshua A, May C, Hong PJ, Agarwal A, Chang Y, Ross SA, Emary P, Florez ID, Noor ST, Yao W, Lok A, Ali SH, Craigie S, Couban R, Morgan RL, Culig K, Brar S, Akbari-Kelachayeh K, Pozdnyakov A, Shergill Y, Sivananthan L, Zihayat B, Das A, Guyatt GH. | Ann Intern Med. 2020 Aug 18
DOI: https://doi.org/10.7326/m19-3601
Keywords: Aucun

Reviews

Introduction : Patients and clinicians can choose from several treatment options to address acute pain from non-low back musculoskeletal injuries.
Purpose: To assess the comparative effectiveness of outpatient treatments for acute pain from non-low back musculoskeletal injuries by performing a network meta-analysis of randomized clinical trials (RCTs).

Méthode : Data sources: MEDLINE, EMBASE, CINAHL, PEDro (Physiotherapy Evidence Database), and Cochrane Central Register of Controlled Trials to 2 January 2020.
Study selection: Pairs of reviewers independently identified interventional RCTs that enrolled patients presenting with pain of up to 4 weeks' duration from non-low back musculoskeletal injuries.
Data extraction: Pairs of reviewers independently extracted data. Certainty of evidence was evaluated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.Target audience and patient population: The target audience is all clinicians, and the target patient population is adults with acute pain from non-low back, musculoskeletal injuries.

Résultats : The 207 eligible studies included 32 959 participants and evaluated 45 therapies. Ninety-nine trials (48%) enrolled populations with diverse musculoskeletal injuries, 59 (29%) included patients with sprains, 13 (6%) with whiplash, and 11 (5%) with muscle strains; the remaining trials included various injuries ranging from nonsurgical fractures to contusions. Topical nonsteroidal anti-inflammatory agents (NSAIDs) proved to have the greatest net benefit, followed by oral NSAIDs and acetaminophen with or without diclofenac. Effects of these agents on pain were modest (around 1 cm on a 10-cm visual analogue scale, approximating the minimal important difference). Regarding opioids, compared with placebo, acetaminophen plus an opioid improved intermediate pain (1 to 7 days) but not immediate pain (≤2 hours), tramadol was ineffective, and opioids increased the risk for gastrointestinal and neurologic harms (all moderate-certainty evidence).
Limitations: Only English-language studies were included. The number of head-to-head comparisons was limited.

Conclusion : Topical NSAIDs, followed by oral NSAIDs and acetaminophen with or without diclofenac, showed the most convincing and attractive benefit-harm ratio for patients with acute pain from non-low back musculoskeletal injuries. No opioid achieved benefit greater than that of NSAIDs, and opioids caused the most harms.

Conclusion (proposition de traduction) : Les AINS topiques, suivis d'AINS per os et de paracétamol avec ou sans diclofénac, ont ont montré le rapport bénéfice/risque le plus convaincant et attrayant pour les patients souffrant de douleurs aiguës dues à des lésions musculo-squelettiques non lombaires. Aucun opioïde n'a obtenu de bénéfice supérieur à celui des AINS, et les opioïdes ont causé le plus d'effets secondaires.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Musculoskeletal Pain - New ACP|AAFP Guidelines  . Rédigé par Aaron Lacy, le 1^er septembre 2020.
Voir également l'article : Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians. Ann Intern Med. 2020 Aug 18  . doi: 10.7326/M19-3602. Online ahead of print.

Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians.
Qaseem A, McLean RM, O'Gurek D, Batur P, Lin K, Kansagara DL. | Ann Intern Med. 2020 Aug 18
DOI: https://doi.org/10.7326/m19-3602
Keywords: Aucun

Clinical Guideline

Introduction : The American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) developed this guideline to provide clinical recommendations on nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults in the outpatient setting. The guidance is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences. This guideline does not address noninvasive treatment of low back pain, which is covered by a separate ACP guideline that has also been endorsed by AAFP.

Méthode : This guideline is based on a systematic evidence review on the comparative efficacy and safety of nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults in the outpatient setting and a systematic review on the predictors of prolonged opioid use. We evaluated the following clinical outcomes using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system: pain (at ≤2 hours and at 1 to 7 days), physical function, symptom relief, treatment satisfaction, and adverse events.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Musculoskeletal Pain - New ACP|AAFP Guidelines  . Rédigé par Aaron Lacy, le 1^er septembre 2020.
Voir également l'article : Management of Acute Pain From Non-Low Back Musculoskeletal Injuries: A Systematic Review and Network Meta-analysis of Randomized Trials. Ann Intern Med. 2020 Aug 18  . doi: 10.7326/M19-3601. Online ahead of print.

Diagnostic accuracy of evaluation of suspected syncope in the emergency department: usual practice vs. ESC guidelines.
van Wijnen VK, Gans ROB, Wieling W, Ter Maaten JC, Harms MPM. | BMC Emerg Med. 2020 Aug 3;20(1):59
DOI: https://doi.org/10.1186/s12873-020-00344-9  | Télécharger l'article au format  
Keywords: Diagnostic accuracy; Emergency department; Guidelines; History taking; Syncope

Research article

Introduction : Syncope is a frequent reason for referral to the emergency department. After excluding a potentially life-threatening condition, the second objective is to find the cause of syncope. The objective of this study was to assess the diagnostic accuracy of the treating physician in usual practice and to compare this to the diagnostic accuracy of a standardised evaluation, consisting of thorough history taking and physical examination by a research physician.

Méthode : This prospective cohort study included suspected (pre) syncope patients without an identified serious underlying condition who were assessed in the emergency department. Patients were initially seen by the initial treating physician and the usual evaluation was performed. A research physician, blinded to the findings of the initial treating physician, then performed a standardised evaluation according to the ESC syncope guidelines. Diagnostic accuracy (proportion of correct diagnoses) was determined by expert consensus after long-term follow-up.

Résultats : One hundred and one suspected (pre) syncope patients were included (mean age 59 ± 20 years). The usual practice of the initial treating physicians did not in most cases follow ESC syncope guidelines, with orthostatic blood pressure measurements made in only 40% of the patients. Diagnostic accuracy by the initial treating physicians was 65% (95% CI 56-74%), while standardised evaluation resulted in a diagnostic accuracy of 80% (95% CI 71-87%; p = 0.009). No life-threatening causes were missed.

Conclusion : Usual practice of the initial treating physician resulted in a diagnostic accuracy of 65%, while standardised practice, with an emphasis on thorough history taking, increased diagnostic accuracy to 80%. Results suggest that the availability of additional resources does not result in a higher diagnostic accuracy than standardised evaluation, and that history taking is the most important diagnostic test in suspected syncope patients.

Conclusion (proposition de traduction) : Les habitudes de pratique du médecin traitant initial a abouti à une précision diagnostique de 65 %, tandis que la pratique standardisée, mettant l'accent sur une anamnèse approfondie, a augmenté la précision du diagnostic à 80 %. Les résultats suggèrent que la disponibilité de ressources supplémentaires n'entraîne pas une précision diagnostique plus élevée que l'évaluation standardisée, et que la recherche d'antécédents est le test de diagnostic le plus important chez les patients suspects de syncope.

Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury. .
Jones P, Lamdin R, Dalziel SR. | Cochrane Database Syst Rev. 2020 Aug 12;8(8):CD007789
DOI: https://doi.org/10.1002/14651858.cd007789.pub3
Keywords: Aucun

Review

Introduction : Acute soft tissue injuries are common and costly. The best drug treatment for such injuries is not certain, although non-steroidal anti-inflammatory drugs (NSAIDs) are often recommended. There is concern about the use of oral opioids for acute pain leading to dependence. This is an update of a Cochrane Review published in 2015.
To assess the benefits or harms of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries.

Méthode : We searched the CENTRAL, 2020 Issue 1, MEDLINE (from 1946), and Embase (from 1980) to January 2020; other databases were searched to February 2019.
Selection criteria: We included randomised or quasi-randomised controlled trials involving people with acute soft tissue injury (sprain, strain, or contusion of a joint, ligament, tendon, or muscle occurring within 48 hours of inclusion in the study), and comparing oral NSAIDs versus paracetamol (acetaminophen), opioid, paracetamol plus opioid, or complementary and alternative medicine. The outcomes were pain, swelling, function, adverse effects, and early re-injury.
Data collection and analysis: Two review authors independently assessed studies for eligibility, extracted data, and assessed risk of bias. We assessed the quality of the evidence using GRADE methodology.

Résultats : We included 20 studies, with 3305 participants. Three studies included children only. The others included predominantly young adults; approximately 60% were male. Seven studies recruited people with ankle sprains only. Most studies were at low or unclear risk of bias; however, two were at high risk of selection bias, three were at high risk of bias from lack of blinding, and five were at high risk of selective outcome reporting bias. Some evidence relating to pain relief was high certainty. Other evidence was either moderate, low or very low certainty, reflecting study limitations, indirectness, imprecision, or combinations of these. Thus, we are certain or moderately certain about some of the estimates, and uncertain or very uncertain of others. Eleven studies, involving 1853 participants compared NSAIDs with paracetamol. There were no differences between the two groups in pain at one to two hours (1178 participants, 6 studies; high-certainty evidence), at days one to three (1232 participants, 6 studies; high-certainty evidence), and at day seven or later (467 participants, 4 studies; low-certainty evidence). There was little difference between the groups in numbers of participants with minimal swelling at day seven or later (77 participants, 1 study; low-certainty evidence). Very low-certainty evidence from three studies (386 participants) means we are uncertain of the finding of little difference between the two groups in return to function at day seven or later. There was low-certainty evidence from 10 studies (1504 participants) that NSAIDs may slightly increase the risk of gastrointestinal adverse events compared with paracetamol. There was low-certainty evidence from nine studies (1679 participants) of little difference in neurological adverse events between the NSAID and paracetamol groups. Six studies, involving 1212 participants compared NSAIDs with opioids. There was moderate-certainty evidence of no difference between the groups in pain at one hour (1058 participants, 4 studies), and low-certainty evidence for no difference in pain at days four or seven (706 participants, 1 study). There was very low-certainty evidence of no important difference between the groups in swelling (84 participants, 1 study). Participants in the NSAIDs group were more likely to return to function in 7 to 10 days (542 participants, 2 studies; low-certainty evidence). There was moderate-certainty evidence (1143 participants, 5 studies) that NSAIDs were less likely to

Conclusion : Compared with paracetamol, NSAIDs make no difference to pain at one to two hours and at two to three days, and may make no difference at day seven or beyond. NSAIDs may result in a small increase in gastrointestinal adverse events and may make no difference in neurological adverse events compared with paracetamol. Compared with opioids, NSAIDs probably make no difference to pain at one hour, and may make no difference at days four or seven. NSAIDs probably result in fewer gastrointestinal and neurological adverse effects compared with opioids. The very low-certainly evidence for all outcomes for the NSAIDs versus paracetamol with opioid combination analgesics means we are uncertain of the findings of no differences in pain or adverse effects. The current evidence should not be extrapolated to adults older than 65 years, as this group was not well represented in the studies.

Conclusion (proposition de traduction) : Par rapport au paracétamol, les AINS ne font aucune différence dans la douleur à une à deux heures et à deux à trois jours, et peuvent ne faire aucune différence au septième jour ou au-delà. Les AINS peuvent entraîner une légère augmentation des événements indésirables gastro-intestinaux et peuvent ne faire aucune différence dans les événements indésirables neurologiques par rapport au paracétamol. Par rapport aux opioïdes, les AINS ne font probablement aucune différence pour la douleur à une heure et peuvent ne faire aucune différence aux jours quatre ou sept. Les AINS entraînent probablement moins d'effets indésirables gastro-intestinaux et neurologiques par rapport aux opioïdes. Les preuves de très faible certitude pour tous les résultats pour les AINS par rapport au paracétamol avec des analgésiques combinés d'opioïdes signifient que nous ne sommes pas certains des résultats de l'absence de différences dans la douleur ou les effets indésirables. Les preuves actuelles ne doivent pas être extrapolées aux adultes âgés de plus de 65 ans, car ce groupe n'était pas bien représenté dans les études.

Commentaire : Voir l'analyse de l'article sur : https://www.cochrane.org/fr/CD007789/MUSKINJ_anti-inflammatoires-non-steroidiens-oraux-compares-dautres-analgesiques-oraux-pour-les-entorses-les

Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis.
Li Y, Li H, Zhang D. | Crit Care. 2020 Aug 6;24(1):488
DOI: https://doi.org/10.1186/s13054-020-03204-x  | Télécharger l'article au format  
Keywords: Meta-analysis; Norepinephrine initiation; Septic shock; Systematic review; Timing.

Meta-Analysis

Introduction : The effect of the timing of norepinephrine initiation on clinical outcomes in patients with septic shock is uncertain. A systematic review and meta-analysis was performed to evaluate the impact of early and late start of norepinephrine support on clinical outcomes in patients with septic shock.

Méthode : We searched the PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) and cohort studies from inception to the 1st of March 2020. We included studies involving adult patients (> 18 years) with septic shock. All authors reported our primary outcome of short-term mortality and clearly comparing early versus late norepinephrine initiation with clinically relevant secondary outcomes (ICU length of stay, time to achieved target mean arterial pressure (≥ 65 mmHg), and volume of intravenous fluids within 6 h). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI).

Résultats : Five studies including 929 patients were included. The primary outcome of this meta-analysis showed that the short-term mortality of the early group was lower than that of the late group (odds ratio [OR] = 0.45; 95% CI, 0.34 to 0.61; P < 0.00001; χ2 = 3.74; I2 = 0%). Secondary outcomes demonstrated that the time to achieved target MAP of the early group was shorter than that of the late group (mean difference = - 1.39; 95% CI, - 1.81 to - 0.96; P < 0.00001; χ2 = 1.03; I2 = 0%). The volume of intravenous fluids within 6 h of the early group was less than that of the late group (mean difference = - 0.50; 95% CI, - 0.68 to - 0.32; P < 0.00001; χ2 = 33.76; I2 = 94%). There was no statistically significant difference in the ICU length of stay between the two groups (mean difference = - 0.11; 95% CI, - 1.27 to 1.05; P = 0.86; χ2 = 0.85; I2 = 0%).

Conclusion : Early initiation of norepinephrine in patients with septic shock was associated with decreased short-term mortality, shorter time to achieved target MAP, and less volume of intravenous fluids within 6 h. There was no significant difference in ICU length of stay between early and late groups. Further large-scale RCTs are still required to confirm these results.

Conclusion (proposition de traduction) : L’initiation précoce de norépinéphrine chez les patients présentant un choc septique a été associée à une diminution de la mortalité à court terme, à un délai plus court pour atteindre la pression artérielle moyenne cible et à une diminution du volume des liquides intraveineux en moins de 6 h. D’autres essais contrôlés randomisés à grande échelle sont encore nécessaires pour confirmer ces résultats.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Early Norepinephrine for Septic Shock  . Rédigé par Sam Parnell le 3 septembre 2020.

High-Flow Nasal Oxygen in Coronavirus Disease 2019 Patients With Acute Hypoxemic Respiratory Failure
A Multicenter, Retrospective Cohort Study.
Xia J, Zhang Y, Ni L, Chen L, Zhou C, Gao C, Wu X, Duan J, Xie J, Guo Q, Zhao J, Hu Y, Cheng Z, Zhan Q. | Crit Care Med. 2020 August 19;Volume Online First(Issue):xx
DOI: https://doi.org/10.1097/CCM.0000000000004558
Keywords: Aucun

ONLINE CLINICAL INVESTIGATION: PDF ONLY

Introduction : An ongoing outbreak of coronavirus disease 2019 is spreading globally. Acute hypoxemic respiratory failure is the most common complication of coronavirus disease 2019. However, the clinical effectiveness of early high-flow nasal oxygen treatment in patients with coronavirus disease 2019 with acute hypoxemic respiratory failure has not been explored. This study aimed to analyze the effectiveness of high-flow nasal oxygen treatment and to identify the variables predicting high-flow nasal oxygen treatment failure in coronavirus disease 2019 patients with acute hypoxemic respiratory failure.

Méthode : Design: A multicenter, retrospective cohort study.
Setting: Three tertiary hospitals in Wuhan, China.
Patients: Forty-three confirmed coronavirus disease 2019 adult patients with acute hypoxemic respiratory failure treated with high-flow nasal oxygen.
Interventions: None.

Résultats : Mean age of the enrolled patients was 63.0 ± 9.7 years; female patients accounted for 41.9%. High-flow nasal oxygen failure (defined as upgrading respiratory support to positive pressure ventilation or death) was observed in 20 patients (46.5%), of which 13 (30.2%) required endotracheal intubation. Patients with high-flow nasal oxygen success had a higher median oxygen saturation (96.0% vs 93.0%; p < 0.001) at admission than those with high-flow nasal oxygen failure. High-flow nasal oxygen failure was more likely in patients who were older (p = 0.030) and male (p = 0.037), had a significant increase in respiratory rate and a significant decrease in the ratio of oxygen saturation/FIO2 to respiratory rate index within 3 days of high-flow nasal oxygen treatment. In a multivariate logistic regression analysis model, male and lower oxygen saturation at admission remained independent predictors of high-flow nasal oxygen failure. The hospital mortality rate of the cohort was 32.5%; however, the hospital mortality rate in patients with high-flow nasal oxygen failure was 65%.

Conclusion : High-flow nasal oxygen may be effective for treating coronavirus disease 2019 patients with mild to moderate acute hypoxemic respiratory failure. However, high-flow nasal oxygen failure was associated with a poor prognosis. Male and lower oxygenation at admission were the two strong predictors of high-flow nasal oxygen failure.

Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit peut être efficace pour traiter les patients en insuffisance respiratoire hypoxémique aiguë légère à modérée atteints de coronavirus 2019 (et son utilisation peut réduire la nécessité d'une intubation trachéale). Cependant, l'échec de l'oxygénothérapie nasale à haut débit était associée à un mauvais pronostic. Être un homme et avoir une saturation plus basse (93 % vs 96 %) à l'entrée étaient les deux puissants prédicteurs d'un échec de l'oxygénothérapie nasale à haut débit.

Timing of Intubation and Mortality Among Critically Ill Coronavirus Disease 2019 Patients: A Single-Center Cohort Study.
Hernandez-Romieu AC, Adelman MW, Hockstein MA, Robichaux CJ, Edwards JA, Fazio JC, Blum JM, Jabaley CS, Caridi-Scheible M, Martin GS, Murphy DJ, Auld SC. | Crit Care Med. 2020 Aug 14
DOI: https://doi.org/10.1097/ccm.0000000000004600
Keywords: Aucun

ONLINE CLINICAL INVESTIGATION: PDF ONLY

Introduction : Increasing time to mechanical ventilation and high-flow nasal cannula use may be associated with mortality in coronavirus disease 2019. We examined the impact of time to intubation and use of high-flow nasal cannula on clinical outcomes in patients with coronavirus disease 2019.

Méthode : Design: Retrospective cohort study.
Setting: Six coronavirus disease 2019-specific ICUs across four university-affiliated hospitals in Atlanta, Georgia.
Patients: Adults with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection who received high-flow nasal cannula or mechanical ventilation.
Interventions: None.

Résultats : Among 231 patients admitted to the ICU, 109 (47.2%) were treated with high-flow nasal cannula and 97 (42.0%) were intubated without preceding high-flow nasal cannula use. Of those managed with high-flow nasal cannula, 78 (71.6%) ultimately received mechanical ventilation. In total, 175 patients received mechanical ventilation; 44.6% were female, 66.3% were Black, and the median age was 66 years (interquartile range, 56-75 yr). Seventy-six patients (43.4%) were intubated within 8 hours of ICU admission, 57 (32.6%) between 8 and 24 hours of admission, and 42 (24.0%) greater than or equal to 24 hours after admission. Patients intubated within 8 hours were more likely to have diabetes, chronic comorbidities, and higher admission Sequential Organ Failure Assessment scores. Mortality did not differ by time to intubation (≤ 8 hr: 38.2%; 8-24 hr: 31.6%; ≥ 24 hr: 38.1%; p = 0.7), and there was no association between time to intubation and mortality in adjusted analysis. Similarly, there was no difference in initial static compliance, duration of mechanical ventilation, or ICU length of stay by timing of intubation. High-flow nasal cannula use prior to intubation was not associated with mortality.

Conclusion : In this cohort of critically ill patients with coronavirus disease 2019, neither time from ICU admission to intubation nor high-flow nasal cannula use were associated with increased mortality. This study provides evidence that coronavirus disease 2019 respiratory failure can be managed similarly to hypoxic respiratory failure of other etiologies.

Conclusion (proposition de traduction) : Dans cette cohorte de patients en soins critiques atteints de maladie à coronavirus 2019, ni le temps écoulé entre l'admission aux soins intensifs et l'intubation ni l'utilisation de l'oxygénothérapie nasale à haut débit n'ont été associés à une augmentation de la mortalité. Cette étude fournit des preuves que l'insuffisance respiratoire de la maladie à coronavirus 2019 peut être gérée de la même manière que l'insuffisance respiratoire hypoxique d'autres étiologies.

Evaluation of stroke related risk factors in wake up and non-wake up stroke patients.
Sadeghi-Hokmabadi E, Vahdati SS, Rikhtegar R, Karzad N, Rezabakhsh A. | Emerg Care J. 2020;16(2):8834
DOI: https://doi.org/10.4081/ecj.2020.8834  | Télécharger l'article au format  
Keywords: Wake Up Stroke, Risk Factors, Familiar History, Hematologic Characteristics

Original Article

Editorial : Wake-Up Stroke (WUS) is defined as a stroke with the unclear onset of symptoms and subsequent neurological deficits which perceived upon awakening. WUS patients are often excluded from acute fibrinolytic and reperfusion therapy due to the unknown exact time of symptoms onset. This study aimed to evaluate patients with and without WUS characteristics and associated risk factors at two tertiary hospitals. First, we prospectively evaluated consecutive patients with stroke symptoms and determined stroke sub groups by using Computed Tomography (CT) scan. Next, demographic and clinical characteristics including past medical and drug consumption history as well as cardiac function index (ejection fraction), LDL (mg/dl) level and hematologic parameters: hemoglobin (Hb); hematocrit (Hct); platelet (Plt) were assessed. Results: 510 patients (56.1% men and 43.9% women) with averaged age of 70 and 72 years were studied, respectively. Of 510 patients, 405 (79.4%) had non-WUS stroke (known-onset stroke) and 105 (20.6%) had WUS strokes (unknown-onset stroke). The WUS occurrence most likely was observed in ischemic stroke compared to hemorrhagic one. No significant differences were found between patients from both groups regarding stroke risk factors. However, hypertension and family history were more common in patients with WUS (p>0.05). Moreover, individuals with a previous cerebrovascular accident in WUS group were almost similar to non-WUS counterparts. No differences also detected in case of hematologic characteristics, heart function index and LDL levels between study groups (p>0.05). Together, wake-up stroke occurs in approximately 20% of stroke subjects. In this study, patients with WUS had more hypertension and family history.

Conclusion : To date, clinical management of WUS is a controversial issue. As the importance of WUS, we aimed to study the prevalence of wake up stroke (20%) in patients who referred to the tertiary care hospitals. The results showed that there is an inconsiderable differ- ence between clinical findings and risk factors of both wake-up and known-onset strokes. However, according to our results, genetic history and hypertension categorized as two important wakes-up stroke associated risk factors.

Conclusion (proposition de traduction) : À ce jour, la prise en charge clinique de l'AVC de réveil est une question controversée. Au vue de l'importance de l'AVC au réveil, nous avons voulu étudier la prévalence de l'AVC au réveil (20 %) chez les patients qui ont été adressés dans des hôpitaux de soins tertiaires. Les résultats ont montré qu'il y a une différence négligeable entre les résultats cliniques et les facteurs de risque, tant pour le réveil que pour les accidents vasculaires cérébraux connus. Cependant, selon nos résultats, l'histoire génétique et l'hypertension ont été classées comme deux facteurs de risque importants associés à l'AVC du réveil.

Oxygen therapy practices in the acutely ill medical patients: A social media-based nationwide study of clinicians’ preferences and summary of current recommendations.
Karlis G, Barouxis D, Georgiopoulos G, Mitropoulou P, Mastora Z, Xanthos T. | Emerg Care J. 2020;16(2):8867
DOI: https://doi.org/10.4081/ecj.2020.8867  | Télécharger l'article au format  
Keywords: Oxygen therapy, Emergency medicine, Survey

Original Article

Editorial : Oxygen is the most commonly used drug in emergency medicine. The aim of this study was to identify healthcare professionals’ preferences regarding oxygen therapy in common medical emergencies. An online 9-part-questionnaire was distributed through Facebook to doctors and nurses working in Greek hospitals. The questionnaire included background information of the respondents and addressed individual preferences regarding best oxygenation parameter and oxygen targets in specific acute settings. We received 678 responses and we included 663 in our analysis. We found significant differences between doctors’ and nurses’ attitudes towards oxygenation targets in ARDS, sepsis, acute coronary syndrome, and post cardiac-arrest patients. Nurses preferred a more conservative oxygen strategy compared to doctors. Furthermore, nurses favor SaO2 as the best oxygenation parameter, while doctors prefer PaO2. In our survey, the type of hospital and department of the respondents did not affect the preferred oxygen strategy. Social media-based survey research is feasible and effective. In this single country study, doctors showed a tendency to liberally administer oxygen in acutely ill medical patients. On the other hand, Greek nurses preferred a more conservative approach.

Conclusion : We report a national survey on healthcare professionals’ self- reported preferences for targeting oxygenation in acute illness. Doctors overall favored higher SaO2 targets, thus a more liberal approach, despite the accumulating evidence of harm in the litera- ture. This might have implications in clinical training and future practice. On the other hand, nurses have chosen a more conserva- tive approach towards oxygen titration. Whether this is the effect of education and good clinical practice or a mere reflection of inde- cision in the absence of a specific medical order, remains unclear and warrants further evaluation. The current study confirmed again the feasibility and reliability of online survey research through social media platforms. Given the local distribution of the survey, our results need to be investigated in other healthcare systems.

Conclusion (proposition de traduction) : Nous faisons état d’une enquête nationale sur les préférences auto-déclarées des professionnels de santé en matière d’oxygénation dans les maladies aiguës. Dans l’ensemble, les médecins se sont prononcés en faveur d’objectifs de SaO₂ plus élevés, donc d’une approche plus libérale, malgré l’accumulation de preuves de dommages dans la littérature. Cela pourrait avoir des répercussions sur la formation clinique et la pratique future. Par contre, les infirmières ont opté pour une approche plus conservatrice de la titration de l’oxygène. La question de savoir s’il s’agit là d’un effet de l’éducation et des bonnes pratiques cliniques ou d’un simple reflet de l’indécision en l’absence d’un ordre médical spécifique demeure floue et mérite une évaluation plus approfondie. La présente étude a confirmé une fois de plus la faisabilité et la fiabilité des enquêtes en ligne sur les plateformes de réseaux sociaux. Compte tenu de la répartition locale de l’enquête, nos résultats doivent être étudiés dans d’autres systèmes de santé.

Assessment and management of recurrent abdominal pain in the emergency department.
Daniels J, Griffiths M, Fisher E. | Emerg Med J. 2020 Aug;37:515-521.
DOI: http://dx.doi.org/10.1136/emermed-2019-209113
Keywords: Aucun

Practice review

Editorial : Recurrent abdominal pain accounts for a significant proportion of attenders and high impact users in the emergency department. Due to the heterogeneity of presentation and the broad spectrum of possible causes, abdominal pain presents as a significant clinical challenge within the emergency department, particularly as distress and pain are commonly elevated. Patients in this group are routinely prescribed opiate-based interventions and repeated investigations in a ‘better safe than sorry’ culture which saturates the field of persistent physical symptoms. This approach is contributing to the growing problem, and fuelling a cycle of repeated attendance and failure to resolve. This article reviews the current clinical and psychophysiological understanding of recurrent abdominal pain, critiquing guidelines and approaches to diagnosis and management. We offer an alternative evidence-based biopsychosocial approach using the mnemonic ‘ERROR’, recommending five steps to assessment and clinical management of recurrent abdominal pain in the emergency department.

Conclusion : Here we have outlined recommendations for clinical practice to reduce the number of high-impact users using the ERROR mnemonic. These recommendations move towards addressing the unique and complex presentation of recurrent abdominal pain in the ED and serve to retain dignity and respect otoward the patient. Staff attitudes are crucial to engagement. Clinicians should exclude a medical emergency, review attendance and implement care plans. High-impact users who do not have care plans should have one developed through the high-impact user multidisciplinary with specialist coordination and appropriate onward referral; the evidence in favour is overwhelming. Finally, the patient’s pain should be openly recognised and distress validated: patients should be provided with a credible biopsychosocial explanation of their recurrent abdominal pain as part of a culture shift towards holistic high-quality care, affirmative diagnosis or otherwise.
Article Versions: Previous version (6 December 2019  ). You are viewing the most recent version of this article.

Conclusion (proposition de traduction) : Nous présentons ici des recommandations de pratique clinique afin de réduire le nombre des patients ayant un usage récurrent du service d'urgences en utilisant le moyen mnémotechnique ERROR. Ces recommandations visent à aborder la présentation unique et complexe des douleurs abdominales récidivantes au service des urgences tout en préservant la dignité et le respect du patient. L'attitude du personnel est cruciale dans l'engagement dans ces recommandations. Les cliniciens doivent exclure une urgence médicale, examiner le nombre de consultations précédentes et mettre en place des plans de soins. Les patients ayant un usage récurrent du services des urgences qui n'ont pas de plan de soins devraient en bénéficier, en collaboration avec l’utilisateur récurrent du service des urgences lui-même et avec une coordination spécialisée et une orientation ultérieure appropriée ; les preuves en faveur de cette solution sont accablantes. Enfin, la douleur du patient doit être ouvertement reconnue et la situation de détresse confirmée : les patients doivent recevoir une explication biopsychosociale crédible de leur douleur abdominale récurrente dans le cadre d'un changement de culture vers des soins holistiques de haute qualité, un diagnostic positif ou autre.

Commentaire : Le terme « high-impact users » (patients ayant un usage récurrent du service d'urgences) est utilisé pour décrire les patients qui ont plusieurs - au moins trois - hospitalisations aux urgences en un an. Voir l'article de Perdrix J, Bodenmann P. Patients à usage récurrent des services d’urgence : des mythes à la réalité. Revue Médicale Suisse 2010;6:939-939  .
Le modèle biopsychosocial, en médecine, est une approche théorique et pratique proposé par le médecin psychiatre Engel qui veut prendre en compte des facteurs psychologiques, sociaux et biologiques des pathologies.

I-FiBH trial: intravenous fluids in benign headaches-a randomised, single-blinded clinical trial.
Zitek T, Sigal T, Sun G, Martin Manuel C, Tran K. | Emerg Med J. 2020 Aug;37(8):469-473
DOI: https://doi.org/10.1136/emermed-2019-209389  | Télécharger l'article au format  
Keywords: headache

Neurology

Introduction : Many emergency physicians use an intravenous fluid bolus as part of a 'cocktail' of therapies for patients with headache, but it is unclear if this is beneficial. The objective of this study was to determine if an intravenous fluid bolus helps reduce pain or improve other outcomes in patients who present to the ED with a benign headache.

Méthode : This was a randomised, single-blinded, clinical trial performed on patients aged 10-65 years old with benign headaches who presented to a single ED in Las Vegas, Nevada, from May 2017 to February 2019. All patients received prochlorperazine and diphenhydramine, and they were randomised to also receive either 20 mL/kg up to 1000 mL of normal saline (the fluid bolus group) or 5 mL of normal saline (the control group). The primary outcome was the difference between groups in mean pain reduction 60 min after the initiation of treatment. Secondarily, we compared groups with regards to pain reduction at 30 min, nausea scores, the use of rescue medications and disposition.

Résultats : We screened 67 patients for enrolment, and 58 consented. Of those, 35 were randomised to the fluid bolus group and 23 to the control group. The mean pain score dropped by 48.3 mm over 60 min in the fluid bolus group, compared with 48.7 mm in the control group. The between groups difference of 0.4 mm (95% CI -16.5 to 17.3) was not statistically significant (p=0.96). Additionally, no statistically significant difference was found between groups for any secondary outcome.

Conclusion : Though our study lacked statistical power to detect small but clinically significant differences, ED patients who received an intravenous fluid bolus for their headache had similar improvements in pain and other outcomes compared with those who did not.

Conclusion (proposition de traduction) : Bien que notre étude n’ait pas de pouvoir statistique permettant de déceler de petites différences cliniquement significatives, les patients qui ont reçu un bolus de liquide intraveineux pour leur céphalée ont constaté des améliorations similaires de la douleur, et d’autres résultats (ndlr : score de nausée, recours à un médicament de secours…), comparativement à ceux qui n’en ont pas reçu.

Applications of artificial intelligence in the emergency department.
Moulik SK, Kotter N, Fishman EK. | Emerg Radiol. 2020 Aug;27(4):355-358
DOI: https://doi.org/10.1007/s10140-020-01794-1  | Télécharger l'article au format  
Keywords: Aucun

EDITORIAL

Editorial : Over the past 5 years, there has been an increasing number of applications of artificial intelligence and machine learning (AI/ML) throughout various sectors of the economy. This wide-reaching impact has fueled global venture capital invest- ments of around $83 billion since 2014 and nearly $26.6 bil- lion in 2019, of which the single largest sector was healthcare with $4 billion. These investments have yielded many impressive advances in varied fields ranging from autono- mous driving through novel drug discovery. As the technolo- gies continue to mature, the capabilities as well as the limita- tion of AI/ML are coming to the forefront and helping guide future development efforts.

Conclusion : The path towards true AI/ML implementation in the emergen- cy department is the same as for other medical and non- medical fields of study. Going to the marketplace today will provide access to systems that are clinically relevant though narrowly applicable. As the systems mature, some routine patient care tasks will become automated while decision- making in cognitive tasks will be augmented by AI/ML systems. It is important to keep the evolution of the AI/ML technology in context so as not to become overly enthusiastic about the current capabilities and simultaneously not to be- come overly pessimistic about future developments. Though the promised delivery date of fully self-driving cars has con- tinuously been pushed back for the past decade, it is undeni- able that drivers in semiautonomous vehicles are safer than unassisted drivers. Similarly, there are tangible patient care and cost benefits to be obtained through staged development of AL/ML systems even if fully autonomous MD systems are not on the horizon.

Conclusion (proposition de traduction) : Le chemin vers une véritable intelligence artificielle et la mise en œuvre de l'apprentissage automatique dans le service d'urgence est le même que pour d'autres domaines d'études médicaux et non médicaux. Le fait d'aller sur le marché aujourd'hui permettra d'accéder à des systèmes qui sont cliniquement pertinents bien qu'étroitement applicables. Au fur et à mesure que les systèmes mûriront, certaines tâches de soins de routine aux patients seront automatisées tandis que la prise de décision dans les tâches cognitives sera augmentée par l'intelligence artificielle et les systèmes d'apprentissage automatique. Il est important de garder l'évolution de l'intelligence artificielle et de la technologie d'apprentissage automatique dans son contexte afin de ne pas devenir trop enthousiasmé par les capacités actuelles et simultanément de ne pas devenir trop pessimiste quant aux développements futurs. Bien que la date de livraison promise des voitures entièrement autonomes ait été continuellement repoussée au cours de la dernière décennie, il est indéniable que les conducteurs de véhicules semi-autonomes sont plus sûrs que les conducteurs non assistés. De même, il y a des soins aux patients tangibles et des avantages en termes de coûts à obtenir grâce au développement par étapes d'intelligence artificielle et de systèmes d'apprentissage automatique, même si des systèmes de médecins entièrement autonomes ne sont pas à l'horizon.

The first use of artificial intelligence (AI) in the ER: triage not diagnosis.
Weisberg EM, Chu LC, Fishman EK. | Emerg Radiol. 2020 Aug;27(4):361-366
DOI: https://doi.org/10.1007/s10140-020-01773-6
Keywords: Artificial intelligence (AI); Intracranial bleed; Pneumothorax; Pulmonary embolism; Wrist fracture.

Review Article

Editorial : Predictions related to the impact of AI on radiology as a profession run the gamut from AI putting radiologists out of business to having no effect at all. The use of AI appears to show significant promise in ER triage in the present. We briefly discuss the emerging effectiveness of AI in the ER imaging setting by looking at some of the products approved by the FDA and finding their way into "practice." The FDA approval process to date has focused on applications that affect patient triage and not necessarily ones that have the computer serve as the only or final reader. We describe a select group of applications to provide the reader with a sense of the current state of AI use in the ER setting to assess neurologic, pulmonary, and musculoskeletal trauma indications. In the process, we highlight the benefits of triage staging using AI, such as accelerating diagnosis and optimizing workflow, with few downsides. The ability to triage patients and take care of acute processes such as intracranial bleed, pneumothorax, and pulmonary embolism will largely benefit the health system, improving patient care and reducing costs. These capabilities are all available now. This first wave of AI applications is not replacing radiologists. Rather, the innovative software is improving throughput, contributing to the timeliness in which radiologists can get to read abnormal scans, and possibly enhances radiologists' accuracy. As for what the future holds for the use of AI in radiology, only time will tell.

Conclusion : In the short term, AI has a small but expanding role in the ER in increasing efficiency. This is not inconsiderable, as it may directly be involved in saving lives by triaging patients with life-threatening emergencies.
The ability to triage patients and take care of acute processes such as intracranial bleed, pneumothorax, and pulmonary embolism will largely benefit the health system, improving patient care and reducing costs. In the end, our mission is the care of our patients, and if AI can improve it, we will need to adopt it with open arms. We acknowledge that we have not deeply broached the subject of cost. In a poor country or in other resource-poor conditions, computer-aided triage could decrease costs. Of course, obtaining such software would be an obstacle in such circumstances.
As we have maintained in another venue, though, radiologists will continue to be crucial in rendering complex ideas intelligible and interpreting the results of advancing technologies such as AI and machine learning. The first wave of AI applications is not replacing radiologists. Rather, the innovative software is improving throughput, contributing to the timeliness in which radiologists can get to read abnormal scans, and possibly enhances radiologists’ accuracy. As for what the future brings, time will tell.

Conclusion (proposition de traduction) : La capacité de trier les patients et de prendre en charge les processus aigus tels que les saignements intracrâniens, le pneumothorax et l'embolie pulmonaire profitera largement au système de santé, améliorant les soins aux patients et réduisant les coûts. En fin de compte, notre mission est le soin de nos patients, et si l'IA peut l'améliorer, nous devrons l'adopter à bras ouverts.
Nous reconnaissons que nous n’avons pas abordé en profondeur la question du coût. Dans un pays pauvre ou dans d'autres conditions de ressources limitées, le triage assisté par ordinateur pourrait réduire les coûts. Bien entendu, l'obtention d'un tel logiciel serait un obstacle dans de telles circonstances.
Cependant, comme nous l'avons présenté dans une autre publication, les radiologues continueront d'être essentiels pour rendre intelligibles des idées complexes et interpréter les résultats des technologies avancées telles que l'IA et l'apprentissage automatique. La première vague d'applications de l'IA n'a pas remplacé les radiologues. Au contraire, le logiciel innovant améliore le débit, contribuant à la rapidité avec laquelle les radiologues peuvent lire des scans anormaux, et peut-être améliore la précision des radiologues. Quant à ce que l'avenir nous réserve, le temps nous le dira.

Can AI outperform a junior resident? Comparison of deep neural network to first-year radiology residents for identification of pneumothorax.
Yi PH, Kim TK, Yu AC, Bennett B, Eng J, Lin CT. | Emerg Radiol. 2020 Aug;27(4):367-375
DOI: https://doi.org/10.1007/s10140-020-01767-4
Keywords: Artificial intelligence; Chest radiograph; Deep learning; Machine learning; Radiology residents.

Original Article

Introduction : To (1) develop a deep learning system (DLS) using a deep convolutional neural network (DCNN) for identification of pneumothorax, (2) compare its performance to first-year radiology residents, and (3) evaluate the ability of a DLS to augment radiology residents by detecting missed pneumothoraces.

Méthode : This was a retrospective study performed in September 2018. We obtained 112,120 chest radiographs (CXRs) from the NIH ChestXray14 database, of which 4360 cases (4%) were labeled as pneumothorax by natural language processing. We utilized 111,518 CXRs to train and validate the ResNet-152 DCNN pretrained on ImageNet to identify pneumothorax. DCNN testing was performed on a hold-out set of 602 CXRs, whose groundtruth was determined by a cardiothoracic radiologist. Two first-year radiology residents evaluated the test CXRs for presence of pneumothorax. Receiver operating characteristic (ROC) curves were generated for each evaluator with area under the curve (AUC) compared using the DeLong parametric method.

Résultats : The DCNN achieved AUC of 0.841 for identification of pneumothorax at a rate of 1980 images/min. In contrast, both first-year residents achieved significantly higher AUCs of 0.942 and 0.905 (p < 0.01 for both compared to DCNN), but at a slower rate of two images/min. The DCNN identified 3 of 31 (9.7%) additional pneumothoraces missed by at least one of the residents.

Conclusion : A DLS for pneumothorax identification had lower AUC than 1st-year radiology residents, but interpreted images > 1000× as fast and identified 3 additional pneumothoraces missed by the residents. Our findings suggest that DLS could augment radiologists-in-training to identify potential urgent findings.

Conclusion (proposition de traduction) : Un système d'apprentissage en profondeur pour l'identification du pneumothorax avait une zone sous la courbe inférieure à celle des résidents de première année en radiologie, mais a interprété les images > 1000 plus vite et identifié 3 pneumothorax supplémentaires manqués par les résidents. Nos résultats suggèrent que le système d'apprentissage en profondeur pourrait augmenter la formation des radiologues pour identifier les découvertes potentiellement urgentes.

Commentaire : L'apprentissage profond ou apprentissage en profondeur (en anglais : deep learning, deep structured learning, hierarchical learning) est un ensemble de méthodes d'apprentissage automatique tentant de modéliser avec un haut niveau d’abstraction des données grâce à des architectures articulées de différentes transformations non linéaires.
L'apprentissage automatique (en anglais : machine learning, litt. « apprentissage machine »), apprentissage artificiel ou apprentissage statistique est un champ d'étude de l'intelligence artificielle qui se fonde sur des approches mathématiques et statistiques pour donner aux ordinateurs la capacité d'« apprendre » à partir de données, c'est-à-dire d'améliorer leurs performances à résoudre des tâches sans être explicitement programmés pour chacune. Plus largement, il concerne la conception, l'analyse, l'optimisation, le développement et l'implémentation de telles méthodes.
Sources : https://fr.wikipedia.org/  .

Monteggia fracture: an easy fracture to miss.
Mathur N, Lau KK. | Emerg Radiol. 2020 Aug;27(4):377-381
DOI: https://doi.org/10.1007/s10140-020-01763-8
Keywords: Aucun

Original Article

Introduction : To assess the incidence of missed Monteggia fracture by radiologists and bedside clinicians (emergency and orthopaedic doctors) at a tertiary hospital.

Méthode : A comprehensive search was conducted on Picture Archiving and Communication System (PACS) and electronic medical records (EMR) between Jan 2010 and April 2019. All consecutive paediatric and adult patients who presented to the emergency department with the diagnosis of Monteggia fracture were included. The patient's emergency presentation medical notes and trauma film reports were compared. Most emergency presentations were discussed with orthopaedics; hence, this was combined as a single group (bedside clinician group). All images were blindly reviewed by a senior consultant radiologist. Results from the radiologist and bedside clinician groups were compared.

Résultats : Fifty-one patients were identified; 4 were excluded as they were not true Monteggia fracture on review. Forty-seven patients were included in the study (age range 3-70 years, mean age 15 years). Thirty-three patients (70%) were correctly diagnosed by both groups. Twelve patients (25.5%) had a missed diagnosis by the radiologist's group. Seven patients (14.9%) were missed by the bedside clinicians. Five patients (10.6%) were missed by both groups with fractures detected on re-presentations. The most commonly missed finding was a radial head dislocation/subluxation, followed by a subtle ulnar fracture (confirmed by periosteal reaction development on subsequent radiographs) and an ulnar plastic deformity.

Conclusion : The Monteggia fracture is an important diagnosis, but it is not infrequently missed by radiologists and clinicians. Special attention to the radiocapitellar joint alignment and ulnar periosteum, and looking for a subtle ulnar fracture or plastic deformity would ensure correct diagnosis.

Conclusion (proposition de traduction) : a fracture de Monteggia est un diagnostic important, mais il n'est pas rare qu'il soit manqué par les radiologues et les cliniciens. Une attention particulière à l'alignement de l'articulation capitalo-radiale et au périoste ulnaire, et la recherche d'une fracture ulnaire subtile ou d'une déformation plastique assurerait un diagnostic correct.

Commentaire : 
L'axe de la diaphyse radiale passe par le centre du noyau condylien en flexion et en extension.

Validation of the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria in patients undergoing percutaneous coronary intervention and comparison with contemporary bleeding risk scores.
Ueki Y, Bär S, Losdat S, Otsuka T, Zanchin C, Zanchin T, Gragnano F, Gargiulo G, Siontis GCM, Praz F, Lanz J, Hunziker L, Stortecky S, Pilgrim T, Heg D, Valgimigli M, Windecker S, Räber L. | EuroIntervention. 2020 Aug 28;16(5):371-379
DOI: https://doi.org/10.4244/eij-d-20-00052
Keywords: Aucun

CORONARY INTERVENTIONS

Introduction : The Academic Research Consortium for High Bleeding Risk (ARC-HBR) defined consensus-based criteria for patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI). We aimed to validate the ARC-HBR criteria for the bleeding outcomes using a large cohort of patients undergoing PCI.

Résultats : Between 2009 and 2016, patients undergoing PCI were prospectively included in the Bern PCI Registry. Patients were considered to be at HBR if at least one major criterion or two minor criteria were met. The primary endpoint was Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding at one year; ischaemic outcomes were assessed using the device-oriented composite endpoints (DOCE) of cardiac death, target vessel myocardial infarction, and target lesion revascularisation. Among 12,121 patients, those at HBR (n=4,781, 39.4%) had an increased risk of BARC 3 or 5 bleeding (6.4% vs 1.9%; p<0.001) and DOCE (12.5% vs 6.1%; p<0.001) compared with those without HBR. The degree of risk and prognostic value were related to the risk factors composing the criteria. The ARC-HBR criteria had higher sensitivity than the PRECISE-DAPT score and the PARIS bleeding risk score (63.8%, 53.1%, 31.9%), but lower specificity (62.7%, 71.3%, 86.5%) for BARC 3 or 5 bleeding.

Conclusion : Patients at HBR defined by the ARC-HBR criteria had a higher risk of BARC 3 or 5 bleeding as well as DOCE. The bleeding risk was related to its individual components. The ARC-HBR criteria were more sensitive for identifying patients with future bleedings than other contemporary risk scores at the cost of specificity.

Conclusion (proposition de traduction) : Les patients à haut risque hémorragique définis par les critères ARC-HBR présentaient un risque plus élevé de saignement BARC 3 ou 5 ainsi que des critères de jugement composites axés sur la procédure. Le risque de saignement était lié à ses composants individuels. Les critères ARC-HBR étaient plus sensibles pour identifier les patients présentant des saignements futurs que d'autres scores de risque contemporains au détriment de la spécificité.

Commentaire : Concernant les critères de jugements :
Garcia-Garcia HM, McFadden EP, Farb A and al; Academic Research Consortium. Standardized End Point Definitions for Coronary Intervention Trials: The Academic Research Consortium-2 Consensus Document. Circulation. 2018 Jun 12;137(24):2635-2650  .

Diagnosis of acute coronary syndrome in the emergency room: the dictatorship of high-sensitivity cardiac troponin and major adverse cardiac events.
Hausfater P, Velly L. | Eur J Emerg Med. 2020 Aug;27(4):239-240
DOI: https://doi.org/10.1097/mej.0000000000000733
Keywords: Aucun

Perspective Article

Editorial : Chest pain is one of the most frequent chief complaints encountered in the emergency department (ED) and emergency physicians should follow rigorous diagnostic strategies, mostly to rule out an acute coronary syndrome (ACS). Because of the potential life-threatening consequences of missing ACS [including non-ST-elevation myocardial infarction (NSTEMI)], very sensitive tools have been developed to help the emergency physician in triaging chest pain patient, among which cardiac troponins (cTn) play a pivotal, if not, dominant place. This is highlighted by the integration of the increase/decrease of high-sensitivity cTn (hsTn) concentration in the universal definition of myocardial infarction, sometimes over- looking the need for clinical symptoms of ischaemia or significant ST-wave changes on ECG to adjudicate the diagnosis.

Conclusion : There are therefore unmet needs to refine the diagnostic strategy of chest pain patients in ER by redefining what risk can be considered as acceptable. We must take into account the prevalence of ACS in our specific population (by using individual risk-scores such as GRACE or HEART), balance indications for cTn testing, consider the constraints of the real-life practice in the ED, and also probably use age-adapted cTn thresholds, while having in the line of fire the risk of MACE strictly linked to the emergency practice.

Conclusion (proposition de traduction) : Il existe donc des besoins non satisfaits pour affiner la stratégie diagnostique des patients souffrant de douleurs thoraciques en salle d'urgence en redéfinissant le risque qui peut être considéré comme acceptable. Il faut prendre en compte la prévalence du syndrome coronarien aigu dans notre population spécifique (en utilisant des scores de risque individuels tels que GRACE ou HEART), équilibrer les indications du test cTn, considérer les contraintes de la pratique réelle au service des urgences, et utiliser également probablement des seuils de troponine adaptés à l'âge, tout en ayant dans la ligne de mire le risque d'événements cardiaques indésirables majeurs strictement liés à la pratique de l'urgence.

Effect of target-controlled propofol infusion to reduce the incidence of adverse events for procedural sedation in the emergency department: a systematic review.
Burton FM, Lowe DJ, Millar JE, Corfield AR, Watson MJ, Shaw M, Sim MAB. | Eur J Emerg Med. 2020 Aug;27(4):253-259
DOI: https://doi.org/10.1097/mej.0000000000000655
Keywords: Aucun

Review Article

Editorial : The administration of propofol target-controlled infusion (TCI) for procedural sedation is standard in a range of hospital settings except for the Emergency Department (ED). Propofol TCI could be an alternative, safer way to provide procedural sedation in the ED compared with other methods of propofol administration. We compare the incidence of adverse events using propofol TCI compared with other methods of propofol administration. We conducted a systematic review of the literature from 1946 to January 2019 identifying studies that compared propofol TCI with other propofol regimens for procedural sedation in the adult population. Studies were assessed for risk of bias using the Cochrane Collaboration risk of bias tool. Seven articles were included. There was significant methodological heterogeneity in all aspects of study designs and definitions of adverse events which precluded a meta-analysis. A systematic review of the studies demonstrated fewer respiratory and cardiovascular adverse outcomes in three of the seven studies. It was not possible to determine if propofol TCI reduces the incidence of adverse events when compared with other sedating regimens using propofol using a descriptive systematic review of the relevant literature. Further research is required to compare the incidence of adverse events using propofol TCI for procedural sedation with other methods of administration in the ED. Future systematic reviews and meta-analysis comparisons would be aided by the use of standard adverse event reporting tools such as that of the Society of Intravenous Anaesthesia.

Conclusion : There were fewer respiratory adverse outcomes and hypotension with propofol TCI vs other methods of administering propofol for procedural sedation in three of the seven studies. There was significant methodological heterogeneity in all aspects of study designs and definitions of adverse events which precluded a meta-analysis. Only two of the studies had a measurable number of adverse events.
It was not possible to conclude that propofol TCI reduces the incidence of adverse events when compared with other sedating regimens using propofol using a systematic review.

Conclusion (proposition de traduction) : Il y avait moins de résultats indésirables respiratoires et d'hypotension avec le propofol en mode AIVOC par rapport aux autres méthodes d'administration de propofol pour la sédation procédurale dans trois des sept études. Il y avait une hétérogénéité méthodologique significative dans tous les aspects des design d'étude et des définitions des événements indésirables, ce qui a empêché une méta-analyse. Seules deux des études avaient un nombre mesurable d'événements indésirables.
Il n'a pas été possible de conclure que le propofol en mode AIVOC réduit l'incidence des événements indésirables par rapport à d'autres schémas sédatifs utilisant du propofol en utilisant une revue systématique.

Ring removal: an illustrated summary of the literature.
Asher CM, Fleet M, Bystrzonowski N. | Eur J Emerg Med. 2020 Aug;27(4):268-273
DOI: https://doi.org/10.1097/mej.0000000000000658
Keywords: Aucun

Review Article

Introduction : The inability to remove a ring from a finger is a common presentation to Emergency Departments in addition to Orthopaedic and Plastic Surgery Units. This is often complicated by factors including trauma and infection, leading to a superimposed tourniquet effect by the ring, strangulating the subcutaneous tissues. The threat of neurovascular compromise favours early removal of the ring to limit associated morbidity. This article illustrates the common methods within the literature. We offer assessing clinicians an illustrated summary of techniques for removing an incarcerated ring from an extremity and summarise notable considerations to be acknowledged at time of assessment and ring removal.

Méthode : A literature search using PubMed and Medline was performed to identify all articles written in English on ring removal.

Résultats : The 12 publications included in this illustrated review describing techniques for removal of an incarcerated ring were published between 1991 and 2018 and include modifications to overcome difficulties due to the composition of the ring or severity of the ring incarceration and penile/scrotal ring removal.

Conclusion : The ring removal techniques are ring preserving or destructive. The technique used depends on factors including the extent of associated trauma to the digit, evidence of strangulation, ring composition, patient preference and equipment availability. Before an attempt at ring removal, high arm elevation, indirect ice compression of the digit and adequate analgesia maximise chances of success. In cases of strangulation, emergent referral to a specialist is indicated for removal and further management.

Conclusion (proposition de traduction) : Les techniques de retrait des anneaux sont conservatrices ou destructives. La technique utilisée dépend de facteurs tels que l'étendue du traumatisme associé au doigt, l'effet de strangulation, la composition de l'anneau, les préférences du patient et la disponibilité de l'équipement. Avant une tentative de retrait d'un anneau, une sur-élévation du bras, une compression indirecte du doigt avec de la glace et une analgésie adéquate maximisent les chances de succès. En cas d'effet de strangulation, une référence urgente à un spécialiste est indiquée pour le retrait et la prise en charge ultérieure.

Commentaire : Une autre revue des techniques sur le thème :
• Kalkan A, Kose O, Tas M, Meric G. Review of techniques for the removal of trapped rings on fingers with a proposed new algorithm. Am J Emerg Med [Internet]. 2013;31(11):1605–11  .

Et d'autres articles, toujours sur le même thème :
• Cui C, Zhang RM. Using a rubber strip test to classify swollen fingers for ring removal. Am J Emerg Med [Internet]. 2018;36(8):1509–10  .
• Boe C, Kakar S. A Modified String Technique for Atraumatic Ring Removal. J Emerg Med [Internet]. 2018;55(2):240–3  .
• Kingston D, Bopf D, Dhanjee U, McLean A. Evaluation of a two rubber band technique for finger ring removal. Ann R Coll Surg Engl. 2016;98(5):300–2  .
• Chiu TF, Chu SJ, Chen SG, Chen SL, Chen TM. Use of a Penrose drain to remove an entrapped ring from a finger under emergent conditions. Am J Emerg Med. 2007;25(6):722–3  .
• St. Laurent C. The caterpillar technique for removal of a tight ring. Anesth Analg. 2006;103(4):1060–1  .

Ten things we learned about COVID-19.
Cecconi M, Forni G, Mantovani A. | Intensive Care Med. 2020 Aug;46(8):1590-1593
DOI: https://doi.org/10.1007/s00134-020-06140-0  | Télécharger l'article au format  
Keywords: Aucun

What's New in Intensive Care

Introduction : 1. The virus
SARS-CoV-2 contains over 30,000 RNA bases. A proof- reading mechanism keeps this large genome from accu- mulating frequent mutations. The large spike protein (S) forms a sort of crown on the surface of the viral particles. Its receptor-binding domain interacts with high affinity with angiotensin-converting enzyme 2 (ACE2) recep- tors on the surface of host cells. After the binding, two host cell proteases (Furin and TMPRLRS) cleave spike proteins and their exposed fusion peptides fuse the virus membrane with the membrane of the host cells. The virus RNA enters cells of the upper and lower respiratory tract, and it is translated into viral proteins. Other entry points are under investigation. The cell dies releasing millions of new viruses that infect other cells and other individuals…

Méthode : 2. The infection
3. Immunity
4. Inflammation
5. Thrombosis
6. Diagnostic tests
7. Clinical aspects
8. Therapy
9. Anti‐SARS‐CoV‐2 vaccines

Conclusion : 10. Preparedness and further research
If one thing is evident from the many deaths of this pan- demic, it is that the world was not ready from a struc- tural, political, clinical and research point of view…

Conclusion (proposition de traduction) : 10. Préparation et recherches complémentaires
Si une chose ressort des nombreux décès de cette pandémie, c'est que le monde n'était pas prêt d'un point de vue structurel, politique, clinique et de recherche…

Commentaire : 

New device and technique to protect intubation operators against COVID-19.
Chen C, Shen N, Li X, Zhang Q, Hei Z. | Intensive Care Med. 2020 Aug;46(8):1627-1629
DOI: https://doi.org/10.1007/s00134-020-06072-9  | Télécharger l'article au format  
Keywords: Aucun

Letter

Editorial : Over 200 countries have now reported more than 1.7 million laboratory-confirmed cases of novel coronavirus disease 2019 (COVID-19), and thousands of health- care workers have been infected as a result of shortages of personal protective equipment (PPE). Most severe or critical COVID-19 cases eventually require endotra- cheal intubation to improve ventilation. Given that intubation operators need to get close to the patient’s nose and mouth, and respiratory droplets containing the virus might land on their faces and clothes, it is urgently necessary to use practical devices to protect them from direct contact and also potential self-contami- nation when doffing PPE; such practical devices are espe- cially needed in countries which lack PPE.

Conclusion : We think that this protective sleeve may play a surprising role in protecting first-line doctors against COVID-19 infection, especially in developing countries and territories where there is an extreme dearth of PPE against COVID-19.

Conclusion (proposition de traduction) : Nous pensons que ce manchon protecteur peut jouer un rôle intéressant dans la protection des médecins de première ligne contre l'infection à la COVID-19, en particulier dans les pays et territoires en développement où il y a une pénurie extrême d'EPI contre le COVID-19.

Commentaire : 

Flowchart for non-invasive ventilation support in COVID-19 patients from a northern Italy Emergency Department.
Privitera D, Angaroni L, Capsoni N, Forni E, Pierotti F, Vincenti F, Bellone A. | Intern Emerg Med. 2020 Aug;15(5):767-771
DOI: https://doi.org/10.1007/s11739-020-02370-8  | Télécharger l'article au format  
Keywords: Continuous positive airways pressure, Non-invasive ventilation, COVID-19, Hypoxemic respiratory failure

IM-Point of view

Editorial : With the rapid pandemic spread of the novel coronavirus (SARS-CoV2), Emergency Departments of affected countries are facing an increasing number of patients presenting with hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). Providing mechanical support and endotracheal intubation can be challenging due to a number of patients larger than usual, often exceeding available resources. Considering the lack of recommendations available, we developed a flowchart to standardize the first approach to patients presenting to the Emergency Department with hypoxemic respiratory failure due to COVID-19.

Conclusion : Due to the lack of Randomized-Controlled Trials, no recommendations are offered on NIPPV use in these patients, but according to data from observational studies, a cautious NIPPV trial in selected patients in a protected environment and experienced centers can be tried. An NIPPV trial could be attempted for 60 min, being aware that a prolonged NIPPV treatment can be harmful delaying intubation and provoking large tidal volumes, injurious transpulmonary pressures, and increasing the risk of patient self-inflicted lung injury.

Conclusion (proposition de traduction) : En raison du manque d'essais contrôlés randomisés, aucune recommandation n'est proposée sur l'utilisation de la VNI chez ces patients, mais selon les données d'études observationnelles, un essai prudent du VNI chez des patients sélectionnés dans un environnement protégé et des centres expérimentés peut être tenté. Un essai de VNI pourrait être tenté pendant 60 minutes, sachant qu'un traitement prolongé par la VNI peut être nocif, retardant l'intubation et provoquant d'importants volumes courants, des pressions transpulmonaires préjudiciables et augmentant le risque d'atteinte pulmonaire auto-infligée par le patient.

Commentaire : 

Does this patient have COVID-19? A practical guide for the internist.
Bertolino L, Vitrone M, Durante-Mangoni E. | Intern Emerg Med. 2020 Aug;15(5):791-800
DOI: https://doi.org/10.1007/s11739-020-02377-1  | Télécharger l'article au format  
Keywords: Differential diagnosis; Influenza-like illness; Respiratory tract infection; Signs; Symptoms.

IM - REVIEW

Editorial : Coronavirus disease 2019 (COVID-19) is currently causing a pandemic and will likely persist in endemic form in the foreseeable future. Physicians need to correctly approach this new disease, often representing a challenge in terms of differential diagnosis. Although COVID-19 lacks specific signs and symptoms, we believe internists should develop specific skills to recognize the disease, learning its 'semeiotic'. In this review article, we summarize the key clinical features that may guide in differentiating a COVID-19 case, requiring specific testing, from upper respiratory and/or influenza-like illnesses of other aetiology. We consider two different clinical settings, where availability of the different diagnostic strategies differs widely: outpatient and inpatient. Our reasoning highlights how challenging a balanced approach to a patient with fever and flu-like symptoms can be. At present, clinical workup of COVID-19 remains a hard task to accomplish. However, knowledge of the natural history of the disease may aid the internist in putting common and unspecific symptoms into the correct clinical context.

Conclusion : COVID-19 is a new disease that will likely persist in the general population for a long time. Although changes in incidence and clinical presentation are possible and hard to be foreseen, we believe that all internal medicine physicians should develop clinical skills to adequately recognize COVID-19. This is true for both hospital-based physicians and those who practise in the community. A practical algorithm, valid for both clinical settings considered, that physicians could follow as a starting point, is presented in Fig. 1. We admit that, at the present time, clinical workup of COVID-19 remains a hard task to accomplish. To provide a landscape of the variable presentation of COVID-19, we have summarized the major features of four recent cases we dealt with in our hospital (Fig. 2). As shown, dissociation between clinical features, diagnostic test results and response to treatment may occur, making COVID-19 management challenging. However, we have shown evidence to support the fact that knowledge of the natural history of the disease may aid the internist in putting common and unspecific symptoms into the correct clinical context. Internists should refrain from indiscriminate application of diagnostic tests, and should be guided by clinical observation and reasoning towards the best management practice patterns. Such a correct approach will improve health care resource utilization, minimize psychologic distress, adequately protect the community and convey the optimal care to the subset of COVID-19 patients with a more severe clinical course.

Conclusion (proposition de traduction) : La COVID-19 est une nouvelle maladie qui persistera probablement dans la population générale pendant longtemps. Bien que des changements d'incidence et de présentation clinique soient possibles et difficiles à prévoir, nous pensons que tous les médecins en médecine interne devraient développer des compétences cliniques pour reconnaître correctement la COVID-19. Cela est vrai tant pour les médecins hospitaliers que pour ceux qui exercent dans en ville.
Un algorithme pratique, valable pour les deux paramètres cliniques considérés, que les médecins pourraient suivre comme point de départ, est présenté sur la figure 1 (ci-dessous).
Nous admettons qu'à l'heure actuelle, le bilan clinique de la COVID-19 reste une tâche difficile à accomplir. Pour fournir un paysage de la présentation variable de la COVID-19, nous avons résumé les principales caractéristiques de quatre cas récents que nous avons traités dans notre hôpital. Comme indiqué, une dissociation entre les caractéristiques cliniques, les résultats des tests diagnostiques et la réponse au traitement peut se produire, ce qui rend la gestion de la COVID-19 difficile. Cependant, nous avons montré des preuves pour soutenir le fait que la connaissance de l'histoire naturelle de la maladie peut aider l'interniste à mettre les symptômes communs et non spécifiques dans le contexte clinique correct. Les internistes devraient s'abstenir d'appliquer sans discernement des tests de diagnostic et devraient être guidés par l'observation clinique et le raisonnement vers les meilleures pratiques de gestion. Une telle approche correcte améliorera l'utilisation des ressources de soins de santé, minimisera la détresse psychologique, protégera adéquatement la communauté et apportera les soins optimaux au sous-ensemble de patients COVID-19 avec une évolution clinique plus sévère.

Commentaire : Fig. 1

Out-of-hospital cardiac arrest prognosis during the COVID-19 pandemic.
Pranata R, Lim MA, Yonas E, Siswanto BB, Meyer M. | Intern Emerg Med. 2020 Aug;15(5):875-877
DOI: https://doi.org/10.1007/s11739-020-02428-7  | Télécharger l'article au format  
Keywords: Aucun

CE-Research Letter to the Editor

Editorial : Since the outbreak of coronavirus disease 2019 (COVID-19), many health-care providers have urged patients to limit or delay non-urgent visits to minimize the risk of transmission. Despite these efforts, some health-care services have experienced an ever increasing volume of traffic. As health-care providers are prioritizing emergency and COVID-19 cases, the majority of elective procedures have been postponed indefinetly. During the COVID-19 pandemic, there has been up to 48% reduction in acute myocardial infarction-related hospitalization. A study by Hammad et al. in patients with ST-segment elevation myocardial infarction showed that 27% of patients avoided hospitals due to fear of COVID-19 transmission, 18% thought that the symptoms were related to COVID-19, and 9% did not want to burden the hospital. Patients that did not seek medical attention may experience higher out-of-hospital-related complications, including out-of-hospital cardiac arrest (OHCA). Cardiopulmonary resuscitation (CPR) hypothetically carries the risk of COVID-19 transmission and may reduce willingness to perform CPR without personal protective equipment. Bystanders with advanced age and comorbidities who are at risk for severe infection might be discouraged even more. We aimed to assess the effect of the COVID-19 pandemic on the characteristics, circumstances, and prognosis of OHCA.

Conclusion : In conclusion, the COVID-19 pandemic was associated with higher OHCA-related mortality. The numbers might be even higher in developing countries due to poor health-care and emergency medical service systems.

Conclusion (proposition de traduction) : En conclusion, la pandémie de COVID-19 était associée à une mortalité plus élevée de l'arrêt cardiaque extra-hospitalier. Les chiffres pourraient être encore plus élevés dans les pays en développement en raison de la faiblesse des systèmes de soins de santé et de services médicaux d'urgence.

Clinical and imaging profiles of pulmonary embolism: a single-institution experience.
Al Dandan O, Hassan A, AbuAlola H, Alzaki A, Alwaheed A, Alalwan M, Al Shammari M, AlShamlan N, Alsaif HS. | Int J Emerg Med. 2020 Aug 31;13(1):47
DOI: https://doi.org/10.1186/s12245-020-00303-y  | Télécharger l'article au format  
Keywords: Computed tomography angiography; Obesity; Pulmonary embolism; Sickle cell disease

Original Research

Introduction : Pulmonary embolism (PE) is a common life-threatening condition with non-specific clinical presentations. The diagnosis of PE depends highly on imaging studies, which may also provide prognostic information. This study aimed to describe the clinical and imaging profiles of patients with PE, emphasizing the differences between central and peripheral PE.

Méthode : After ethics review board approval, this retrospective observational study examined the non-negative results in adult patients who underwent computed tomography pulmonary angiography (CT-PA) at our hospital between May 2016 and December 2019. Demographic and clinical information and imaging findings were collected from the electronic medical records.

Résultats : The study included 85 cases that were identified after re-interpreting the 103 non-negative CT-PA scans. Six cases were excluded for incomplete data and 12 cases were false-positive. Central PE was found in 63.5% of the cases. Obesity was the most common risk factor seen in 37.6% of the cases. Furthermore, 9.4% of the patients had sickle cell disease, which tended to be associated with peripheral PE. There was no difference between the peripheral and central PE in most clinical and imaging parameters evaluated (P > 0.05). However, patients with isolated subsegmental PE were more likely to develop hemoptysis (P = 0.04).

Conclusion : This study suggests that patients with obesity and sickle cell disease constitute an important proportion of all PE cases. Furthermore, the clinical and imaging profiles in patients with peripheral PE are similar to those in patients with central PE. Future research should focus on the clinical value of peripheral PE in patients with sickle cell disease.

Conclusion (proposition de traduction) : Cette étude suggère que les patients souffrant d'obésité et de drépanocytose constituent une proportion importante de tous les cas d'embolie pulmonaire. De plus, les profils cliniques et d'imagerie des patients atteints d'embolie pulmonaire périphérique sont similaires à ceux des patients atteints d'embolie pulmonaire centrale. Les recherches futures devraient se concentrer sur la valeur clinique de l'embolie pulmonaire périphérique chez les patients atteints de drépanocytose.

Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series.
Alabdrabalnabi F, Alshahrani M, Ismail N. | Int J Emerg Med. 2020 Aug 20;13(1):45
DOI: https://doi.org/10.1186/s12245-020-00304-x  | Télécharger l'article au format  
Keywords: Anti-fibrinolytic agent; Hemoptysis; Pulmonary bleeding; Pulmonary hemorrhage; TXA; Tranexamic acid.

Case report

Introduction : Hemoptysis is a clinical condition encountered in the emergency department (ED) and must be managed and investigated urgently to maintain the patient's hemostasis. The management of hemoptysis depends on treating the underlying cause. Tranexamic acid (TXA) is an anti-fibrinolytic drug used to systemically control bleeding. There are a few studies available that investigate the use of nebulized tranexamic acid for hemoptysis with contradictory results. Our paper demonstrates three cases where patients presented with significant hemoptysis and had significant improvement in symptoms following the administration of nebulized tranexamic acid. The overall need for blood transfusion was reduced.

Résultats : Three patients presented to the emergency room for evaluation of hemoptysis. All three patients had different underlying pathologies resulting in their hemoptysis and were monitored in the ICU. Initial conventional medical therapies including the correction of coagulopathy and discontinuing offending agents were utilized for treatment. After persistent symptoms, nebulized TXA at a dose of 500 mg three times a day was administered. The patients were all discharged from the hospital with improvement in their symptoms.

Conclusion : ranexamic acid may be considered in the treatment of hemoptysis regardless of the underlying cause. This may be utilized pending further workup and investigation into the underlying source of the bleeding.

Conclusion (proposition de traduction) : L'acide tranexamique peut être envisagé dans le traitement de l'hémoptysie quelle qu'en soit la cause sous-jacente. Cela peut être utilisé en attendant un examen plus approfondi et une enquête sur la source sous-jacente du saignement.

Effects of hypertonic saline versus mannitol in patients with traumatic brain injury in prehospital, emergency department, and intensive care unit settings: a systematic review and meta-analysis.
Miyoshi Y, Kondo Y, Suzuki H, Fukuda T, Yasuda H, Yokobori S; Japan Resuscitation Council (JRC) Neuroresuscitation Task Force and the Guidelines Editorial Committee. | J Intensive Care. 2020 Aug 12;8:61
DOI: https://doi.org/10.1186/s40560-020-00476-x  | Télécharger l'article au format  
Keywords: Hypertonic saline; Mannitol; Prognosis; Trauma; Traumatic brain injury.

Research

Introduction : Intracranial pressure control has long been recognized as an important requirement for patients with severe traumatic brain injury. Hypertonic saline has drawn attention as an alternative to mannitol in this setting. The aim of this study was to assess the effects of hypertonic saline versus mannitol on clinical outcomes in patients with traumatic brain injury in prehospital, emergency department, and intensive care unit settings by systematically reviewing the literature and synthesizing the evidence from randomized controlled trials.

Méthode : We searched the MEDLINE database, the Cochrane Central Register of Controlled Trials, and the Igaku Chuo Zasshi (ICHUSHI) Web database with no date restrictions. We selected randomized controlled trials in which the clinical outcomes of adult patients with traumatic brain injury were compared between hypertonic saline and mannitol strategies. Two investigators independently screened the search results and conducted the data extraction. The primary outcome was all-cause mortality. The secondary outcomes were 90-day and 180-day mortality, good neurological outcomes, reduction in intracranial pressure, and serum sodium level. Random effects estimators with weights calculated by the inverse variance method were used to determine the pooled risk ratios.

Résultats : A total of 125 patients from four randomized trials were included, and all the studies were conducted in the intensive care unit. Among 105 patients from three trials that evaluated the primary outcome, 50 patients were assigned to the hypertonic saline group and 55 patients were assigned to the mannitol group. During the observation period, death was observed for 16 patients in the hypertonic saline group (32.0%) and 21 patients in the mannitol group (38.2%). The risks were not significant between the two infusion strategies (pooled risk ratio, 0.82; 95% confidence interval, 0.49-1.37). There were also no significant differences between the two groups in the other secondary outcomes. However, the certainty of the evidence was rated very low for all outcomes.

Conclusion : Our findings revealed no significant difference in the all-cause mortality rates between patients receiving hypertonic saline or mannitol to control intracranial pressure. Further investigation is warranted because we only included a limited number of studies.

Conclusion (proposition de traduction) : Nos résultats n'ont pas révélé de différence significative dans les taux de mortalité toutes causes confondues entre les patients recevant une solution saline hypertonique ou du mannitol pour contrôler la pression intracrânienne. Une enquête plus approfondie est justifiée car nous n'avons inclus qu'un nombre limité d'études.

2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Solution Set Oversight Committee.
Tomaselli GF, Mahaffey KW, Cuker A, Dobesh PP, Doherty JU, Eikelboom JW, Florido R, Gluckman TJ, Hucker WJ, Mehran R, Messé SR, Perino AC, Rodriguez F, Sarode R, Siegal DM, Wiggins BS. | J Am Coll Cardiol. 2020 Aug 4;76(5):594-622
DOI: https://doi.org/10.1016/j.jacc.2020.04.053
Keywords: ACC Expert Consensus Decision Pathway; apixaban; atrial fibrillation; betrixaban; Dabigatran; edoxaban; rivaroxaban; venous thromboembolism; warfarin

Expert Consensus Decision Pathway

Editorial : Anticoagulation is the cornerstone of treatment for thrombosis and thromboembolic complications of a variety of disorders. The incidence of the common indications for anticoagulation such as atrial fibrillation (AF) has continued to rise because of an aging population; rising age-adjusted incidence due to higher burdens of chronic illness; and advances in early detection, prevention, and treatment. It is estimated that over 6 million patients in the United States are treated with anticoagulants (5)and are thus at increased risk of bleeding, with substantially increased morbidity and mortality. Secular trends in anticoagulation use have demonstrated a relatively rapid adoption of direct-acting oral anticoagulants (DOACs) for the most common indications for anticoagulation. There has been particularly rapid adoption of DOACs in venous thromboembolism (VTE) and AF in the absence of mechanical valves or mitral stenosis. Systematic reviews have demonstrated favorable risk-benefit profiles for DOACs when compared with vitamin K antagonists (VKAs) in the management of AF and when compared with low-molecular-weight heparin followed by a VKA in the treatment and prevention of VTE. Additionally, the emergence of reversal agents may also further increase the proportionate use of DOACs and influence the management of bleeding that complicates anticoagulant use.

Conclusion : The primary objective of this ECDP is to provide a clinically applicable, easily referenced, conceptual framework to support clinical decision making while caring for patients with bleeding complications during OAC therapy. The writing committee considered patients taking anticoagulant therapy for any indication in order to broaden the potential clinical use and impact of the ECDP. Whenever possible, recommendations are based on quantitative evidence from clinical research. However, large gaps in knowledge exist, and therefore, somuch ofwhat clinicians do to care for these patients is based on limited information. It is anticipated that as the population continues to age, more people will be treated with OACs. As more evidence is generated from ongoing research and clinical practice, further refinement to this ECDP will be needed.

Conclusion (proposition de traduction) : L'objectif principal de ces chemins cliniques décisionnels par consensus d'experts est de fournir un cadre conceptuel cliniquement applicable et facilement référencé pour aider la prise de décision clinique tout en soignant les patients présentant des complications hémorragiques au cours d'un traitement anticoagulant oral. Le comité de rédaction a examiné les patients sous traitement anticoagulant pour toute indication afin d'élargir l'utilisation clinique potentielle et l'impact des chemins cliniques décisionnels par consensus d'experts. Dans la mesure du possible, les recommandations sont basées sur des preuves quantitatives issues de la recherche clinique. Cependant, de grandes lacunes dans les connaissances existent et, par conséquent, une grande partie de ce que font les cliniciens pour soigner ces patients repose sur des preuves limitées. On prévoit qu'à mesure que la population vieillit, davantage de personnes seront traitées avec des anticoagulants oraux. Au fur et à mesure que de plus en plus de preuves sont générées à partir de la recherche et de la pratique clinique en cours, il sera nécessaire d'affiner davantage ces chemins cliniques décisionnels par consensus d'experts.

Commentaire : Le chemin clinique (CC) décrit, pour une pathologie donnée, tous les éléments du processus de prise en charge constituant le parcours du patient. Cette méthode vise à planifier, rationaliser et standardiser la prise en charge multidisciplinaire et/ou pluriprofessionnelle de patients présentant un problème de santé comparable afin de réaliser une prise en charge optimale et efficiente respectant les règles de bonnes pratiques (HAS 2017  ).

Optimum Blood Pressure in Patients With Shock After Acute Myocardial Infarction and Cardiac Arrest.
Ameloot K, Jakkula P, Hästbacka J, Reinikainen M, Pettilä V, Loisa P, Tiainen M, Bendel S, Birkelund T, Belmans A, Palmers PJ, Bogaerts E, Lemmens R, De Deyne C, Ferdinande B, Dupont M, Janssens S, Dens J, Skrifvars MB. | J Am Coll Cardiol. 2020 Aug 18;76(7):812-824
DOI: https://doi.org/10.1016/j.jacc.2020.06.043
Keywords: acute myocardial infarction; cardiac arrest; cardiogenic shock.

Original Investigation

Introduction : In patients with shock after acute myocardial infarction (AMI), the optimal level of pharmacologic support is unknown. Whereas higher doses may increase myocardial oxygen consumption and induce arrhythmias, diastolic hypotension may reduce coronary perfusion and increase infarct size.
Objectives: This study aimed to determine the optimal mean arterial pressure (MAP) in patients with AMI and shock after cardiac arrest.

Méthode : This study used patient-level pooled analysis of post-cardiac arrest patients with shock after AMI randomized in the Neuroprotect (Neuroprotective Goal Directed Hemodynamic Optimization in Post-cardiac Arrest Patients; NCT02541591) and COMACARE (Carbon Dioxide, Oxygen and Mean Arterial Pressure After Cardiac Arrest and Resuscitation; NCT02698917) trials who were randomized to MAP 65 mm Hg or MAP 80/85 to 100 mm Hg targets during the first 36 h after admission. The primary endpoint was the area under the 72-h high-sensitivity troponin-T curve.

Résultats : Of 235 patients originally randomized, 120 patients had AMI with shock. Patients assigned to the higher MAP target (n = 58) received higher doses of norepinephrine (p = 0.004) and dobutamine (p = 0.01) and reached higher MAPs (86 ± 9 mm Hg vs. 72 ± 10 mm Hg, p < 0.001). Whereas admission hemodynamics and angiographic findings were all well-balanced and revascularization was performed equally effective, the area under the 72-h high-sensitivity troponin-T curve was lower in patients assigned to the higher MAP target (median: 1.14 μg.72 h/l [interquartile range: 0.35 to 2.31 μg.72 h/l] vs. median: 1.56 μg.72 h/l [interquartile range: 0.61 to 4.72 μg. 72 h/l]; p = 0.04). Additional pharmacologic support did not increase the risk of a new cardiac arrest (p = 0.88) or atrial fibrillation (p = 0.94). Survival with good neurologic outcome at 180 days was not different between both groups (64% vs. 53%, odds ratio: 1.55; 95% confidence interval: 0.74 to 3.22).

Conclusion : In post-cardiac arrest patients with shock after AMI, targeting MAP between 80/85 and 100 mm Hg with additional use of inotropes and vasopressors was associated with smaller myocardial injury.

Conclusion (proposition de traduction) : Chez les patients en post-arrêt cardiaque en état de choc après un infarctus aigu du myocarde, une pression artérielle moyenne cible entre 80/85 et 100 mmHg, grâce à l'utilisation d'inotropes et de vasopresseurs en complément, a été associée à une diminution de la taille de l'infarctus du myocarde.

Sex Differences in All-Cause Mortality in the Decade Following Complex Coronary Revascularization.
Hara H, Takahashi K, van Klaveren D, Wang R, Garg S, Ono M, Kawashima H, Gao C, Mack M, Holmes DR, Morice MC, Head SJ, Kappetein AP, Thuijs DJFM, Onuma Y, Noack T, Mohr FW, Davierwala PM, Serruys PW; SYNTAX Extended Survival Investigators. | J Am Coll Cardiol. 2020 Aug 25;76(8):889-899
DOI: https://doi.org/10.1016/j.jacc.2020.06.066
Keywords: CABG; PCI; SYNTAX; sex; survival

Original Investigation

Introduction : The poorer prognosis of coronary artery disease in females compared with males is related mainly to differences in baseline characteristics. In the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial, the effect of treatment with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting surgery (CABG) on mortality at 5 years differed significantly between females and males; however, the optimal revascularization beyond 5 years according to sex has not been evaluated. Objectives: The aim of this study was to investigate the impact of sex on mortality and sex-treatment interaction at 10 years.

Méthode : The SYNTAXES (SYNTAX Extended Survival) study evaluated vital status up to 10 years in 1,800 patients with de novo 3-vessel and/or left main coronary artery disease randomized to treatment with PCI or CABG in the SYNTAX trial. All-cause death at 10 years was separately evaluated in female and male patients with complex coronary artery disease.

Résultats : Of 1,800 patients, 402 (22.3%) were female and 1,398 (77.7%) were males. Females had a higher 10-year mortality rate compared with males (32.8% vs. 24.7%; log-rank p = 0.002), but female sex was not an independent predictor of mortality (adjusted hazard ratio: 1.02; 95% confidence interval: 0.76 to 1.36). Mortality at 10 years tended to be lower after CABG than after PCI, with a similar treatment effect for female and male patients (adjusted hazard ratio for females: 0.90 [95% confidence interval: 0.54 to 1.51]; adjusted hazard ratio for males: 0.76 [95% confidence interval: 0.56 to 1.02]; p for interaction = 0.952).

Conclusion : Female sex was not an independent predictor of mortality at 10 years in patients with complex coronary artery disease. The interaction between sex and treatment with PCI or CABG that was observed at 5 years was no longer present at 10 years. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).

Conclusion (proposition de traduction) : Le sexe féminin n'était pas un prédicteur indépendant de la mortalité à 10 ans chez les patients atteints de coronaropathie complexe. L'interaction entre le sexe et le traitement avec PCI ou PAC qui était observée à 5 ans n'était plus présente à 10 ns.

Potentially survivable fatal vascular access hemorrhage with tourniquet use: A post-mortem analysis.
Goolsby C, Rojas LE, Andersen M, Charlton N, Tilley L, Pasley J, Rasmussen TE, Levy MJ. | J Am Coll Emerg Physicians Open. 2020 Aug 17;1(6):1224-1229
DOI: https://doi.org/10.1002/emp2.12201  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL RESEARCH

Introduction : The US military has prioritized battlefield hemorrhage control. Researchers credit tourniquet use, and a novel trauma care training program, with saving 1000-2000 lives in Iraq and Afghanistan. The Stop the Bleed campaign translates these lessons learned to the public. This is the first analysis of the potential impact of this newfound knowledge about tourniquet use for extremity fatal vascular access hemorrhage in a civilian population. Fatal vascular access hemorrhage includes bleeding from arteriovenous fistulas and grafts used for hemodialysis and central venous catheters.

Méthode : This is a retrospective study of decedent records. We selected Maryland death records from 2002-2017 using the following search terms: "graft," "shunt," "fistula," "dialysis," and "central venous catheter." The records were analyzed for potential survivability with a checklist of military criteria modified for a civilian population. Suicides were excluded. Two reviewers independently classified the deaths as either potentially survivable or non-survivable, and a third reviewer broke ties.

Résultats : There were 111 deaths included in the final analysis. Ninety-two of the 111 decedents had potentially survivable extremity fatal vascular access hemorrhage. The remaining 19 records were excluded, because they did not have extremity hemorrhage. Zero decedents had hemorrhage deemed to be non-survivable with prompt tourniquet application.

Conclusion : This study identified 92 Maryland extremity fatal vascular access hemorrhage decedents who potentially could have survived with tourniquet use-an average of 6 per year. These results suggest the need for further epidemiology investigation, as well as exploration of the risks and benefits of teaching and equipping vascular access patients and their caregivers to use tourniquets for life-threatening bleeding.

Conclusion (proposition de traduction) : Cette étude a identifié 92 personnes décédées d'hémorragie vasculaire mortelle aux extrémités du Maryland qui auraient pu survivre avec l'utilisation d'un garrot - une moyenne de 6 par an. Ces résultats suggèrent la nécessité d'une enquête épidémiologique plus approfondie, ainsi que l'exploration des risques et des avantages d'enseigner et d'équiper les patients ayant un accès vasculaire et leurs soignants à utiliser des garrots pour les saignements potentiellement mortels.

Variation in the Presentation of Intussusception by Age.
Kimia AA, Hadar PN, Williams S, Landschaft A, Monuteaux MC, Bachur RG. | Pediatr Emerg Care. 2020 Aug;36(8):372-377
DOI: https://doi.org/10.1097/pec.0000000000002179
Keywords: Aucun

Original article

Introduction : To compare the clinical presentation of intussusception among children younger and older than 24 months of age.

Méthode : We performed a retrospective cross-sectional cohort study of children treated in the emergency department, aged 1 month to 6 years, who had an abdominal ultrasound to evaluate for intussusception over a 5-year period. After stratifying by an age cut-point of 24 months, univariate and multivariate analyses were performed.

Résultats : One thousand two hundred fifty-eight cases of suspected intussusception were studied; median age was 1.7 years (interquartile range, 0.8, 2.9 years), and 37% were female. Intussusception was identified in 176 children (14%); 153 (87%) were ileocolic, and 23 were ileoileal. Abdominal pain (odds ratio, 4.0; 95% confidence interval [CI], 1.5-10.5), emesis (OR, 3.5; 95% CI, 1.8-6.7), bilious emesis (OR, 2.9; 95% CI, 1.5-5.7), lethargy (OR, 2.3; 95% CI, 1.3-5.7), rectal bleeding (OR, 2.8; 95% CI, 1.4-5.7), and irritability (OR, 0.4; 95% CI, 0.2-0.8) were found to be predictors in those younger than 24 months. In children older than 24 months, male sex was the only predictor identified (OR, 2.0; 95% CI, 1.1-3.7). In cases where abdominal radiographs were obtained (n = 1212), any abnormality on abdominal radiograph was found to be predictive in both age groups (OR, 7.8; 95% CI, 3.8-25.7; and OR, 3.1; 95% CI, 1.8-5.2, respectively).

Conclusion : Intussusception presents differently in children younger than 24 months compared with older children. "Traditional" clinical predictors of intussusception should be interpreted with caution when assessing children older than 2 years.

Conclusion (proposition de traduction) : L'invagination se présente différemment chez les enfants de moins de 24 mois par rapport aux enfants plus âgés. Les prédicteurs cliniques traditionnels de l'invagination doivent être interprétés avec prudence lors de l’évaluation des enfants de plus de 2 ans.

Use of Ondansetron for Vomiting After Head Trauma: Does It Mask Clinically Significant Traumatic Brain Injury?.
Green-Hopkins I, Monuteaux MC, Lee LK, Nigrovic LE, Mannix R, Schutzman SA. | Pediatr Emerg Care. 2020 Aug;36(8):e433-e437
DOI: https://doi.org/10.1097/pec.0000000000001315
Keywords: Aucun

Original contribution

Introduction : We describe ondansetron use in children with head injury evaluated in pediatric emergency departments and its association with return visits and late diagnoses of intracranial injuries requiring intervention.

Méthode : Children ages 6 months to 18 years discharged without neuroimaging from 35 pediatric emergency departments with a diagnosis of head injury from 2009 to 2013 were identified retrospectively from the Pediatric Health Information System. We evaluated the rates of ondansetron use during the study period and of the association of ondansetron treatment with the diagnosis of intracranial injury, skull fracture, and return visits within 72 hours requiring admission or operative intervention.

Résultats : We identified 218,904 encounters during the study period. Of these, 5894 patients (2.8%) were given ondansetron. There was significant variation in the use of ondansetron during the index visit between hospitals (0.1%-5.7%), and ondansetron use significantly increased over the study period. Return visits within 72 hours were more likely for patients treated with ondansetron during the index visit (3.7% vs 1.9%; adjusted odds ratio, 1.99; 95% confidence interval, 1.7-2.4). These patients were more likely to be admitted than those not treated initially with ondansetron (7% vs 4%; adjusted odds ratio, 1.97; 95% confidence interval, 1.09-3.55). There were no significant differences in rates of skull fractures, intracranial injury, intensive care unit admission, or operative intervention between groups.

Conclusion : Ondansetron use during an initial emergency department visit for head trauma in children not requiring neuroimaging is associated with a higher likelihood of return within 72 hours and subsequent admission. There were no differences in rates of missed skull fractures, intracranial injury, intensive care admission, or operative intervention for groups who were and were not treated with ondansetron; however, this study was underpowered to detect significant differences in these categories. Future investigations with greater numbers would be required to confidently assess these critical differences.

Conclusion (proposition de traduction) : L'utilisation d'ondansétron lors d'une première visite aux urgences pour un traumatisme crânien chez des enfants ne nécessitant pas de neuroimagerie est associée à une plus grande probabilité de re-consultation dans les 72 heures et d'admission ultérieure. Il n'y a pas eu de différences dans les taux de fractures du crâne manquées, de lésions intracrâniennes, d'admission en soins intensifs ou d'intervention chirurgicale pour les groupes qui ont été et n'ont pas été traités avec l'ondansétron ; cependant, cette étude n'a pas permis de détecter de différences significatives dans ces catégories. Des enquêtes plus nombreuses seraient nécessaires à l'avenir pour évaluer avec confiance ces différences critiques.

Intranasal Ketamine for Treatment of Acute Pain in Pediatrics: A Systematic Review.
Ferguson CL, Beckett RD. | Pediatr Emerg Care. 2020 Aug;36(8):e476-e481
DOI: https://doi.org/10.1097/pec.0000000000002181
Keywords: Intranasal ketamine was safe and effective in the 6 clinical studies included in this systematic review.

Review Article

Introduction : Intranasal ketamine has not been well studied in acute pain treatment and does not have a recognized place in therapy in current practice guidelines for pediatric patients. Ketamine has a unique mechanism of action with a favorable side effect profile that may provide benefit to the pediatric population for acute pain. The purpose of this review is to summarize the evidence evaluating intranasal ketamine versus any other comparator for children who require acute pain treatment.

Méthode : A systematic review was performed to include clinical studies of intranasal ketamine for acute pain that reported any pain-related outcome and adverse events in children 0 to 17 years old. Trials were identified through PubMed, Google Scholar, clinical trial registries, research registries, and key journals through April 2018. The Jadad scoring system was used to assess the methodological quality of the included randomized controlled trials.

Résultats : Six studies consisting of 261 patients were reviewed. Intranasal ketamine demonstrated pain relief in all included clinical studies; however, there was inconsistency in dosing, comparators, scales, and indications. Two of the randomized controlled trials were rated as high quality, and 1 randomized controlled trial was rated as poor quality on the Jadad scale.

Conclusion : Six studies consisting of 261 patients were reviewed. Intranasal ketamine demonstrated pain relief in all included clinical studies; however, there was inconsistency in dosing, comparators, scales, and indications. Two of the randomized controlled trials were rated as high quality, and 1 randomized controlled trial was rated as poor quality on the Jadad scale.

Conclusion (proposition de traduction) : Six études portant sur 261 patients ont été examinées. La kétamine intranasale a permis le soulagement de la douleur dans toutes les études cliniques incluses ; cependant, il y avait une incohérence dans la posologie, les groupes de comparaison, les échelles et les indications. Deux des essais contrôlés randomisés ont été évalués comme étant de haute qualité et 1 essai contrôlé randomisé a été évalué comme étant de mauvaise qualité sur l'échelle de Jadad.

Impact of Dispatcher-Assisted Bystander Cardiopulmonary Resuscitation with Out-of-Hospital Cardiac Arrest: A Systemic Review and Meta-Analysis.
Wang J, Zhang H, Zhao Z, Wen K, Xu Y, Wang D, Ma Q. | Prehosp Disaster Med. 2020 Aug;35(4):372-381
DOI: https://doi.org/10.1017/s1049023x20000588
Keywords: bystander; cardiopulmonary resuscitation; emergency medical dispatcher; out-of-hospital cardiac arrest; outcome assessment.

Original Research

Introduction : This systemic review and meta-analysis was conducted to explore the impact of dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) on bystander cardiopulmonary resuscitation (BCPR) probability, survival, and neurological outcomes with out-of-hospital cardiac arrest (OHCA).

Méthode : Electronically searching of PubMed, Embase, and Cochrane Library, along with manual retrieval, were done for clinical trials about the impact of DA-BCPR which were published from the date of inception to December 2018. The literature was screened according to inclusion and exclusion criteria, the baseline information, and interested outcomes were extracted. Two reviewers assessed the methodological quality of the included studies. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated by STATA version 13.1.

Résultats : n 13 studies, 235,550 patients were enrolled. Compared with no dispatcher instruction, DA-BCPR tended to be effective in improving BCPR rate (I2 = 98.2%; OR = 5.84; 95% CI, 4.58-7.46; P <.01), return of spontaneous circulation (ROSC) before admission (I2 = 36.0%; OR = 1.17; 95% CI, 1.06-1.29; P <.01), discharge or 30-day survival rate (I2 = 47.7%; OR = 1.25; 95% CI, 1.06-1.46; P <.01), and good neurological outcome (I2 = 30.9%; OR = 1.24; 95% CI, 1.04-1.48; P = .01). However, no significant difference in hospital admission was found (I2 = 29.0%; OR = 1.09; 95% CI, 0.91-1.30; P = .36).

Conclusion : This review shows DA-BPCR plays a positive role for OHCA as a critical section in the life chain. It is effective in improving the probability of BCPR, survival, ROSC before admission, and neurological outcome.

Conclusion (proposition de traduction) : Cette revue montre que la réanimation cardio-pulmonaire assistée par un régulateur joue un rôle positif dans l'arrêt cardiaque pré-hospitalier en tant que partie critique de la chaîne de survie. Le régulateur est efficace pour améliorer la probabilité de réalisation d'une réanimation cardio-pulmonaire par le témoin, la survie, la RASC avant l'admission et le résultat neurologique.

Remaining Cervical Spine Movement Under Different Immobilization Techniques.
Uzun DD, Jung MK, Weerts J, Münzberg M, Grützner PA, Häske D, Kreinest M. | Prehosp Disaster Med. 2020 Aug;35(4):382-387
DOI: https://doi.org/10.1017/s1049023x2000059x
Keywords: Emergency Medical Service; cervical collar; cervical spine; immobilization; spine board.

Original Research

Introduction : Immobilization of the cervical spine by Emergency Medical Services (EMS) personnel is a standard procedure. In most EMS, multiple immobilization tools are available.The aim of this study is the analysis of residual spine motion under different types of cervical spine immobilization.

Méthode : In this explorative biomechanical study, different immobilization techniques were performed on three healthy subjects. The test subjects' heads were then passively moved to cause standardized spinal motion. The primary endpoints were the remaining range of motion for flexion, extension, bending, and rotation measured with a wireless human motion detector.

Résultats : In the case of immobilization of the test person (TP) on a straight (0°) vacuum mattress, the remaining rotation of the cervical spine could be reduced from 7° to 3° by additional headblocks. Also, the remaining flexion and extension were reduced from 14° to 3° and from 15° to 6°, respectively. The subjects' immobilization was best on a spine board using a headlock system and the Spider Strap belt system (MIH-Medical; Georgsmarienhütte, Germany). However, the remaining cervical spine extension increased from 1° to 9° if a Speedclip belt system was used (Laerdal; Stavanger, Norway). The additional use of a cervical collar was not advantageous in reducing cervical spine movement with a spine board or vacuum mattress.

Conclusion : The remaining movement of the cervical spine is minimal when the patient is immobilized on a spine board with a headlock system and a Spider Strap harness system or on a vacuum mattress with additional headblocks. The remaining movement of the cervical spine could not be reduced by the additional use of a cervical collar.

Conclusion (proposition de traduction) : Le mouvement possible de la colonne cervicale est minime lorsque le patient est immobilisé sur une planche dorsale avec un système de serre-tête et un système de harnais Spider Strap ou sur un matelas à dépression (ndlr : appelle matelas coquille) avec des blocs de tête supplémentaires. Le mouvement possible de la colonne cervicale n'a pas pu être réduit par l'utilisation supplémentaire d'un collier cervical.

Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient: A Joint Position Statement.
Morgan MM, Perina DG, Acquisto NM, Fallat ME, Gallagher JM, Brown KM, Ho J, Burnett A, Lairet J, Rowe D, Gestring ML. | Prehosp Emerg Care. 2020 Aug 10:1-8
DOI: https://doi.org/10.1080/10903127.2020.1801920
Keywords: Aucun

Article

Editorial : The American College of Surgeons Committee on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), the National Association of State EMS Officials (NASEMSO), the National Association of EMS Physicians (NAEMSP) and the National Association of EMTs (NAEMT) have previously offered varied guidance on the use of ketamine in trauma patients. The following consensus statement represents the collective positions of the ACS-COT, ACEP, NASEMSO, NAEMSP and NAEMT. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, nurses and pharmacists in their treatment of the trauma patient in both the prehospital and hospital setting.

Conclusion : This consensus document outlines the role of ketamine in the management of trauma patients in both the prehospital and hospital setting. Low-dose also called sub-dissociative dose ketamine is a safe and effective analgesic that can be used for adult and pediatric trauma patients as an alternative to opioids, with opioids for synergistic effect; or for patients taking buprenorphine products with minimal effects on hemodynamic stability. Ketamine dissociative doses are safe and effective in adult and pediatric trauma patients and at higher doses is an excellent agent for induction of RSI, post-intubation sedation/analgesia and procedural sedation in the hypotensive trauma patient. Ketamine has a wide therapeutic window and thus can also be used for acute agitation and excited delirium. Ketamine analgesic dose policies and procedures should follow those of other analgesic agents administered by nursing staff in the emergency department. Ketamine use in the prehospital environment should be governed by local EMS policies and medical director oversight. Further study on the use of ketamine in the adult and pediatric trauma patient population is warranted.

Conclusion (proposition de traduction) : Ce document consensuel décrit la place de la kétamine dans la prise en charge des patients traumatisés en milieu préhospitalier et hospitalier. La kétamine à faible dose, également appelée dose sous-dissociative, est un analgésique sûr et efficace qui peut être utilisé chez les adultes et les enfants traumatisés comme alternative aux opioïdes, avec des opioïdes pour un effet synergique, ou pour les patients prenant des produits à base de buprénorphine avec un effet minime sur la stabilité hémodynamique. Les doses dissociatives (ndlr : pour la sédation) de kétamine sont sûres et efficaces chez les patients adultes et pédiatriques ayant subi un traumatisme et, à des doses plus élevées, elles sont un excellent agent d’induction de l'intubation en séquence rapide, de sédation/analgésie post-intubation et de sédation procédurale chez le patient traumatisé hypotendu. La kétamine a une fenêtre thérapeutique large et peut donc aussi être utilisée pour l’agitation aiguë et le délire avec agitation. Les politiques et les procédures relatives aux doses analgésiques de kétamine devraient suivre celles des autres analgésiques administrés par le personnel infirmier du service d’urgence. L'utilisation de kétamine en milieu préhospitalier devrait être régie par les protocoles locaux des service de médecine d'urgence et sur la supervision du directeur médical. Une étude plus approfondie sur l'utilisation de la kétamine dans la population traumatisé adulte et pédiatrique est justifiée.

Using Red Lights and Sirens for Emergency Ambulance Response: How Often Are Potentially Life-Saving Interventions Performed?.
Jarvis JL, Hamilton V, Taigman M, Brown LH. | Prehosp Emerg Care. 2020 Aug 7:1-7
DOI: https://doi.org/10.1080/10903127.2020.1797963
Keywords: emergency medical service; interventions; prehospital; red lights and sirens; safety.

Article

Introduction : Emergency Medical Services (EMS) often respond to 911 calls using red lights and sirens (RLS). RLS is associated with increased collisions and increased injuries to EMS personnel. While some patients might benefit from time savings, there is little evidence to guide targeted RLS response strategies.
Objective: To describe the frequency and nature of 911 calls that result in potentially life-saving interventions (PLSI) during the call.

Méthode : Using data from ESO (Austin, Texas, USA), a national provider of EMS electronic health records, we analyzed all 911 calls in 2018. We abstracted the use of RLS, call nature, and interventions performed. A liberal definition of PLSI was developed a priori through a consensus process and included both interventions, medications, and critical hospital notifications. We calculated the proportion of calls with RLS response and with PLSI performed, both overall and stratified by call nature.

Résultats : There were 5,977,612 calls from 1,187 agencies included in the analysis. The majority (85.8%) of calls utilized RLS, yet few (6.9%) resulted in PLSI. When stratified by call nature, cardiac arrest calls had the highest frequency PLSI (45.0%); followed by diabetic problems (37.0%). Glucose was the most frequently given PLSI, n = 69,036. When including multiple administrations to the same patient, epinephrine was given most commonly PLSI, n = 157,282 administrations).

Conclusion : In this large national dataset, RLS responses were very common (86%) yet potentially life-saving interventions were infrequent (6.9%). These data suggest a methodology to help EMS leaders craft targeted RLS response strategies.

Conclusion (proposition de traduction) : Dans ce vaste ensemble de données nationales, les interventions avec gyrophare et deux tons étaient très courantes (86 %), mais les interventions potentiellement vitales étaient peu fréquentes (6,9 %). Ces données suggèrent une méthodologie pour aider les responsables des services médicaux d'urgence à élaborer des stratégies d'intervention ciblées sur l'utilisation du gyrophare et du deux tons.

ETCO2 values during CPR: Your ventilation tempo matters.
Noordergraaf GJG, Vormer AJMA. | Resuscitation. 2020 Aug 28:S0300-9572(20)30433-0
DOI: https://doi.org/10.1016/j.resuscitation.2020.08.119
Keywords: Aucun

Editorial

Editorial : Monitoring end-tidal carbon dioxide (ETCO2 or capnography) as a feedback tool during cardiopulmonary resuscitation (CPR) has been discussed since the early 1980s. Many authors have suggested that it is a sensitive indicator for compression depth, a prognosticator for outcome during CPR,1,2 as well as an indicator for return of spontaneous circulation (ROSC).3 Clinically, a stable level of ETCO2 is seen as an indicator of a life supporting cardiac output when compressions are paused, particularly where pulse palpation is ambivalent. Both the American Heart Association and the European Resuscitation Council have advocated ETCO2 monitoring as a level 1 recommendation in their Standards and Guidelines 2010.4,5 But ca using waveform ETCO2, in the complexity of CPR settings, really be so straight forward?

Conclusion : The use of physiological feedback during CPR, and in particular waveform ETCO2, is associated with better outcomes. Ruiz de Gauna and coworkers contribute to our understanding of a fundamental aspect in CPR: how can we interpret waveform ETCO2 values and apply this to monitor the quality of our care. Their manuscript should be a “must-read” for the forward thinkers and those wanting to understand how CPR works. In 2016 Sandroni and Ristagno, writing in this Journal, suggested that we are not ready yet for ETCO2 as a major feedback instrument; we would now suggest, with the non-linear relationship in ventilation frequency and ETCO2 described by Ruiz de Guana c.s., that we have made a large step forward in being ready.

Conclusion (proposition de traduction) : L'utilisation de la rétroaction physiologique pendant la RCP, et en particulier le monitorage de l'ETCO₂, est associée à de meilleurs résultats. Ruiz de Gauna et ses collègues améliore notre compréhension d'un aspect fondamental de la RCP : comment pouvons-nous interpréter les valeurs de l'ETCO₂ et les appliquer pour surveiller la qualité de notre prise en charge. Leur article doit être une « lecture incontournable » pour les précurseurs et ceux qui souhaitent comprendre le fonctionnement de la RCP. En 2016, Sandroni et Ristagno, écrivant dans ce Journal, ont suggéré que nous ne sommes pas encore prêts pour le monitorage de l'ETCO₂ en tant qu'instrument majeur de rétroaction; nous suggérons maintenant, avec la relation non linéaire entre la fréquence de ventilation et l'ETCO₂ décrite par Ruiz de Guana c.s., que nous avons fait un grand pas en avant pour être prêt.

Commentaire : Voir l'article de Ruiz de Gauna S. :
Ruiz de Gauna S, Gutiérrez JJ, Ruiz J, Leturiondo M, Azcarate I, González-Otero DM, Corcuera C, Russell JK, Daya MR. The impact of ventilation rate on end-tidal carbon dioxide level during manual cardiopulmonary resuscitation. Resuscitation. 2020 Jul 1:S0300-9572(20)30243-4  .

No ST-segment elevation after return of spontaneous circulation and non-shockable initial rhythm of cardiac arrest. To cath or not to cath?.
Nikolaou NI | Resuscitation. 2020 Aug 19:S0300-9572(20)30316-6
DOI: https://doi.org/10.1016/j.resuscitation.2020.07.033
Keywords: Aucun

Online ahead of print

Editorial : Acute coronary syndromes (ACS) represent the commonest cause of out-of-hospital cardiac arrest (OHCA) in adults. Immediate coronary angiography (CAG) and myocardial reperfusion using percutaneous coronary intervention (PCI) has long been established as treatment of patients experiencing return of spontaneous circulation (ROSC) after cardiac arrest (CA). It remains uncertain, however, which subgroups of these patients will have a favourable risk to benefit ratio with this management strategy.

Conclusion : The certainty in evidence supporting decisions about emergent CAG in patients with ROSC without STE and non-shockable initial rhythm is mainly limited by the observational nature of existing studies. All the ongoing randomised trials include patients with these characteristics. The randomized design of these studies may help overcome some of the methodological limitations of the observational studies. Completion of these trials will, hopefully, provide some further evidence to inform decisions for these patients.

Conclusion (proposition de traduction) : La certitude des preuves étayant les décisions relatives à l'indication de l'angiographie coronarienne en urgence chez les patients présentant une récupération d'activité cardiaque spontanée (RACS) sans élévation du segment ST et avec un rythme initial non choquable est principalement limitée par la nature observationnelle des études existantes. Tous les essais randomisés en cours incluent des patients présentant ces caractéristiques. La conception randomisée de ces études peut aider à surmonter certaines des limites méthodologiques des études d'observation. L'achèvement de ces essais fournira, espérons-le, d'autres preuves pour éclairer les décisions concernant ces patients.

Rate of intra-arrest epinephrine administration and early post-arrest organ failure after in-hospital cardiac arrest.
Baird A, Coppler PJ, Callaway CW, Dezfulian C, Flickinger KL, Elmer J; University of Pittsburgh Post-Cardiac Arrest Service. | Resuscitation. 2020 Aug 24:S0300-9572(20)30323-3
DOI: https://doi.org/10.1016/j.resuscitation.2020.08.012
Keywords: Cardiac arrest; cardiopulmonary resuscitation; epinephrine; resuscitation.

Short paper

Introduction : Data supporting epinephrine administration during resuscitation of in-hospital cardiac arrest (IHCA) are limited. We hypothesized that more frequent epinephrine administration would predict greater early end-organ dysfunction and worse outcomes after IHCA.

Méthode : We performed a retrospective cohort study including patients resuscitated from IHCA at one of 67 hospitals between 2010 and 2019 who were ultimately cared for at a single tertiary care hospital. Our primary exposure of interest was rate of intra-arrest epinephrine bolus administration (mg/min). We considered several outcomes, including severity of early cardiovascular failure (modeled using Sequential Organ Failure Assessment (SOFA) cardiovascular subscore), early neurological and early global illness severity injury (modeled as Pittsburgh Cardiac Arrest Category (PCAC)). We used generalized linear models to test for independent associations between rate of epinephrine administration and outcomes.

Résultats : We included 695 eligible patients. Mean age was 62 ± 15 years, 416 (60%) were male and 172 (26%) had an initial shockable rhythm. Median arrest duration was 16 [IQR 9-25] min, and median rate of epinephrine administration was 0.2 [IQR 0.1-0.3] mg/min. Higher rate of epinephrine predicted worse PCAC, and lower survival in patients with initial shockable rhythms. There was no association between rate of epinephrine and other outcomes.

Conclusion : Higher rates of epinephrine administration during IHCA are associated with more severe early global illness severity.

Conclusion (proposition de traduction) : Des nombres plus élevés d'administration d'adrénaline pendant un arrêt cardiaque intra-hospitalier sont associés à une plus grande sévérité de la maladie globale précoce.

Airway management during in-hospital cardiac arrest: An international, multicentre, retrospective, observational cohort study.
Penketh JA, Nolan JP, Skrifvars MB, Rylander C, Frenell I, Tirkkonen J, Reynolds EC, Parr MJA, Aneman A. | Resuscitation. 2020 Aug;153:143-148
DOI: https://doi.org/10.1016/j.resuscitation.2020.05.028
Keywords: Airway management, In-hospital cardiac arrest, Resuscitation

Clinical paper

Introduction : To determine the type of airway devices used during in-hospital cardiac arrest (IHCA) resuscitation attempts.

Méthode : International multicentre retrospective observational study of in-patients aged over 18 years who received chest compressions for cardiac arrest from April 2016 to September 2018. Patients were identified from resuscitation registries and rapid response system databases. Data were collected through review of resuscitation records and hospital notes. Airway devices used during cardiac arrest were recorded as basic (adjuncts or bag
mask), or advanced, including supraglottic airway devices, tracheal tubes or tracheostomies. Descriptive statistics and multivariable regression modelling were used for data analysis.

Résultats : The final analysis included 598 patients. No airway management occurred in 36 (6%), basic airway device use occurred at any time in 562 (94%), basic airway device use without an advanced airway device in 182 (30%), tracheal intubation in 301 (50%), supraglottic airway in 102 (17%), and tracheostomy in 1 (0.2%). There was significant variation in airway device use between centres. The intubation rate ranged between 21% and 90% while supraglottic airway use varied between 1% and 45%. The choice of tracheal intubation vs. supraglottic airway as the second advanced airway device was not associated with immediate survival from the resuscitation attempt (odds ratio 0.81; 95% confidence interval 0.35
1.8).

Conclusion : There is wide variation in airway device use during resuscitation after IHCA. Only half of patients are intubated before return of spontaneous circulation and many are managed without an advanced airway. Further investigation is needed to determine optimal airway device management strategies during resuscitation following IHCA.

Conclusion (proposition de traduction) : Il existe une grande variation dans l'utilisation des dispositifs de gestion des voies aériennes supérieures pendant la réanimation d'un arrêt cardiaque à l'hôpital. La moitié seulement des patients sont intubés avant le retour à une circulation spontanée et beaucoup sont pris en charge sans gestion des voies aériennes spécialisée. Une étude plus approfondie est nécessaire pour déterminer les stratégies optimales de gestion des dispositifs de gestion des voies aériennes pendant la réanimation d'un arrêt cardiaque intra-hospitalier.

Chest compressions induce errors in end-tidal carbon dioxide measurement.
Leturiondo M, Ruiz de Gauna S, Gutiérrez JJ, Alonso D, Corcuera C, Urtusagasti JF, González-Otero DM, Russell JK, Daya MR, Ruiz JM. | Resuscitation. 2020 Aug;153:195-201
DOI: https://doi.org/10.1016/j.resuscitation.2020.05.029
Keywords: Advanced life support; Capnometry; Cardiopulmonary resuscitation; Chest compressions; End-tidal CO2; Ventilations; Waveform capnography.

Clinical paper

Introduction : Real-time measurement of end-tidal carbon dioxide (ETCO2) is used as a non-invasive estimate of cardiac output and perfusion during cardiopulmonary resuscitation (CPR). However, capnograms are often distorted by chest compressions (CCs) and this may affect ETCO2 measurement. The aim of the study was to quantify the effect of CC-artefact on the accuracy of ETCO2 measurements obtained during out-of-hospital manual CPR.

Méthode : We retrospectively analysed monitor-defibrillator recordings collected by two advanced life support agencies during out-of-hospital cardiac arrest. These two agencies, represented as A and B used different side-stream capnometers and monitor-defibrillators. One-minute capnogram segments were reviewed. Each ventilation within each segment was identified using the transthoracic impedance signal and the capnogram. ETCO2 values per ventilation were manually annotated and compared to the corresponding capnometry values stored in the monitor-defibrillator. Ventilations were classified as distorted or non-distorted by CC-artefact.

Résultats : A total of 407 1-min capnogram segments from 65 patients were analysed. Overall, 4095 ventilations were annotated, 2170 (32.4% distorted) and 1925 (31.8% distorted) for agency A and B, respectively. Median (IQR) unsigned error in ETCO2 measurement increased from 1.5 (0.6-3.1)% for non-distorted to 5.5 (1.8-14.1)% for distorted ventilations; from 0.7 (0.3-1.2)% to 3.7 (1.0-9.9)% in agency A and from 2.3 (1.2-3.9)% to 8.3 (3.9-19.5)% in agency B (p < 0.001). Errors were higher than 10 mmHg in 9% and higher than 15 mmHg in 5% of the distorted ventilations.

Conclusion : CC-artefact causes ETCO2 measurement errors in the two studied devices. This suggests that capnometer algorithms may need to be adapted to reliably perform in the presence of CC-artefact during CPR.

Conclusion (proposition de traduction) : L'artéfact occasionné par les compressions thoraciques provoque des erreurs de mesure de l'ETCO2 avec les deux appareils étudiés. Cela suggère que les algorithmes du capnomètre doivent peut-être être adaptés pour fonctionner de manière fiable en présence d'un artéfact de compression thoracique pendant la RCP.

Association between rapid weather changes and incidence of chiefly cardiovascular complaints in the emergency department.
Ostendorf T, Bernhard M, Hartwig T, Voigt M, Keller T, Stumvoll M, Gries A. | Am J Emerg Med. 2020 August;38(8):1604-1610
DOI: https://doi.org/10.1016/j.ajem.2019.158440
Keywords: Capacity; Cardiovascular disease; Case-crossover; Emergency department; Temperature; Weather

Original Contribution

Introduction : Studies suggest that there is an association between weather and cardiovascular disease (CVD) related visits in emergency departments (ED).

Méthode : We used a case-crossover study design to investigate the association between ED visits for CVD and changes in temperature, atmospheric pressure, and relative humidity. Patient and weather data from the years 2014 and 2015 were used to investigate relevance of changes associated with weather in the frequency of CVD-related ED visits. They were correlated to overall variability of the visits adjusted to day of the week.

Résultats : In the study period 20,558 ED visits were related to CVD (mean per day: 28.3). Significant associations were identified for all three variables (temperature, atmospheric pressure, and relative humidity). Significant odds ratio (OR) was found for a large decrease in temperature 1.29 (95%-CI, 1.1–1.52). However, the related effects, although significant, were small compared to overall variability of visits.

Conclusion : We found an association between rapid weather changes on the day before ED admission and ED visits due to CVD. In conclusion, a drop in temperature and an increase or decrease in atmospheric pressure and relative humidity are associated with a slight increase in CVD admissions. However, the observed significant effects seem to be too small to draw any conclusions in terms of ED capacity due to weather changes.

Conclusion (proposition de traduction) : Nous avons trouvé une association entre les changements climatiques rapides la veille de l'admission aux urgences et les visites aux urgences en raison d'une maladie cardiovasculaire. En conclusion, une baisse de température et une augmentation ou une diminution de la pression atmosphérique et de l'humidité relative sont associées à une légère augmentation des admissions pour maladies cardiovasculaires. Cependant, les effets significatifs observés semblent trop faibles pour tirer des conclusions en termes de capacité des services d'urgence en raison des changements climatiques.

Factors Associated with Survival After Emergency Department Thoracotomy for Adult Trauma Patients in the United States.
Elhajj A, Dakessian A, Bachir R, El Sayed M. | J Emerg Med. 2020 Aug;59(2):169-177
DOI: https://doi.org/10.1016/j.jemermed.2020.05.005
Keywords: factors associated; outcome; survival; thoracotomy; trauma.

Original Contribution

Introduction : Emergency department thoracotomy (EDT) is done to control life threatening hemorrhage and injuries. Literature examining this topic is limited to relatively small studies from single trauma centers.
Objective : This study identifies factors associated with survival to hospital discharge of patients undergoing EDT using the largest U.S. national trauma database.

Méthode : This retrospective cohort study used the U.S. National Trauma Data Bank 2015. We conducted univariate and bivariate analyses followed by a multivariate analysis that adjusted for confounders to identify factors associated with survival.

Résultats : Two thousand four hundred eighty-six patients who underwent EDT were included. Most patients were 16 to 64 years of age (92.3%) with a male predominance (84.9%) and without any previous comorbidities (62.8%). Penetrating injury was most common (60.2%), mainly as a result of assault (51.0%) by firearm (45.1%). Overall survival to hospital discharge was 38.2%. After adjusting for confounders, factors associated with increased survival were cut/piece injuries, presenting with signs of life, Glasgow Coma Scale score ≥8, systolic blood pressure >90 mm Hg, and transportation to the ED through helicopter/fixed-wing ambulance or public/private vehicle (reference, ground ambulance).

Conclusion : Factors associated with survival in patients undergoing EDT were identified. The clinical indication of presence of appropriate resources to continue and repair EDT was validated, along with the contraindications of lack of signs of life and presence of major nonsurvivable injuries. Future studies should focus on validation of all criteria of EDT, namely hemodynamic instability despite appropriate fluid resuscitation, duration of time of cardiopulmonary resuscitation and pulselessness, cardiac rhythm on arrival, and the presence of pericardial tamponade.

Conclusion (proposition de traduction) : Les facteurs associés à la survie des patients bénéficiant d'une thoracotomie au service des urgences ont été identifiés. L'indication clinique de la présence de ressources appropriées pour poursuivre et réparer la thoracotomie au service des urgences a été validée, de même que les contre-indications comme l'absence de signes de vie et la présence de blessures majeures non viables. Les études futures devraient se concentrer sur la validation de tous les critères de thoracotomie au service des urgences, à savoir l'instabilité hémodynamique malgré une réanimation liquidienne appropriée, la durée de la réanimation cardio-pulmonaire et l'absence de pouls, le rythme cardiaque à l'arrivée et la présence de tamponnade cardiaque.

BRASH Syndrome: Bradycardia, Renal Failure, AV Blockade, Shock, and Hyperkalemia.
Farkas JD, Long B, Koyfman A, Menson K. | J Emerg Med. 2020 Aug;59(2):216-223
DOI: https://doi.org/10.1016/j.jemermed.2020.05.001  | Télécharger l'article au format  
Keywords: AV blockade; BRASH syndrome; bradycardia; hyperkalemia; renal failure; shock.

original contribution

Introduction : BRASH syndrome, or Bradycardia, Renal Failure, AV blockade, Shock, and Hyperkalemia, has recently become recognized as a collection of objective findings in a specific clinical context pertaining to emergency medicine and critical care. However, there is little emergency medicine and critical care literature specifically evaluating this condition.

Méthode : We sought to define and review BRASH syndrome and identify specific management techniques that differ from the syndromes as they present individually.

Discussion : BRASH syndrome is initiated by synergistic bradycardia due to the combination of hyperkalemia and medications that block the atrioventricular (AV) node. The most common precipitant is hypovolemia or medications promoting hyperkalemia or renal injury. Left untreated, this may result in deteriorating renal function, worsening hyperkalemia, and hemodynamic instability. Patients can present with a variety of symptoms ranging from asymptomatic bradycardia to multiorgan failure. BRASH syndrome should be differentiated from isolated hyperkalemia and overdose of AV-nodal blocking medications. Treatment includes fluid resuscitation, hyperkalemia therapies (intravenous calcium, insulin/glucose, beta agonists, diuresis), management of bradycardia (which may necessitate epinephrine infusion), and more advanced therapies if needed (lipid emulsion, glucagon, or high-dose insulin infusion). Understanding and recognizing the pathophysiology of BRASH syndrome as a distinct entity may improve patient outcomes.

Conclusion : BRASH syndrome can be a difficult diagnosis and is due to a combination of hyperkalemia and medications that block the AV node. Knowledge of this condition may assist emergency and critical care providers.

Conclusion (proposition de traduction) : Le syndrome BRASH peut être un diagnostic difficile et est dû à une combinaison d'hyperkaliémie et de médicaments qui bloquent le nœud AV. La connaissance de cette situation peut aider les urgentistes et les réanimateurs.

Perfusion Index Measurement in Predicting Hypovolemic Shock in Trauma Patients.
Ozakin E, Yazlamaz NO, Kaya FB, Karakilic EM, Bilgin M. | J Emerg Med. 2020 Aug;59(2):238-245
DOI: https://doi.org/10.1016/j.jemermed.2020.04.010
Keywords: blood transfusion; multitrauma; outcome; perfusion index.

Original contribution

Introduction : Perfusion index (PI) derived from pulse oximeter shows the ratio of the pulsatile blood flow to the nonpulsatile blood flow or static blood in peripheral tissue.
Objectives : The aim of this study was to investigate the relationship between PI and blood transfusion necessity in 24 h and stage of hemorrhagic shock, as well as the utility of PI according to laboratory and clinical parameters, and determining the major risk of hemorrhage.

Méthode : PI was measured with a pulse oximeter in 338 patients (235 males, average age 41.8 ± 17.94 years). Laboratory parameters (hemoglobin, hematocrit, lactate, base deficits, pH) and clinical parameters (pulse rate, respiratory rate, SpO2, systolic blood pressure [SBP] and diastolic blood pressure [DBP]), shock index (SI) and revised trauma score (RTS) were recorded. Univariate analysis was used to determine major risk for bleeding, and the receiver operating characteristic curves were performed to compare parameters.

Résultats : PI was < 1 in 39 (11.5%) patients. Positive correlation between PI and hemoglobin (p < 0.001; r: 0.320), hematocrit (p < 0.001; r: 0.294), base deficit (p < 0.001; r: 0.315), pH (p < 0.05; r: 0.235), SBP (p < 0.001; r: 0.146), DBP (p < 0.001; r: 0.259), SpO2 (p < 0.001; r: 0.197), RTS (p < 0.001; r: 0.344), and negative correlation with lactate (p < 0.05; r: -0.117), pulse (p < 0.001; r: -0.326), respiratory rate (p < 0.001; r: -0.231), and SI (p < 0.001; r: -0.257) were detected. A difference was detected between class 1 and 2, and class 1 and 3 (both p < 0.05) in hemorrhagic shock. Thirty-one with PI < 1 had blood transfusion within 24 h (p < 0.001; odds ratio 111.98, sensitivity 75.6%, specificity 97.3, positive predictive value 79.5%, negative predictive value 96.7%). The main risk factors of the need for blood transfusions were PI, pulse rate, and SpO2. PI was more significant than lactate, base deficit, RTS, and SI measurements.

Conclusion : PI might be beneficial in the detection and exclusion of critical patients and blood transfusion needs in the emergency department. PI can be used with vital signs and shock parameters in the early diagnosis of hemorrhage.

Conclusion (proposition de traduction) : L'indice de perfusion peut être bénéfique pour la détection et l'exclusion des patients critiques et des besoins de transfusion sanguine au service des urgences. L'indice de perfusion peut être utilisé avec les signes vitaux et les paramètres de choc dans le diagnostic précoce de l'hémorragie.

Endotracheal Tube Placement Confirmation by Ultrasonography: A Systematic Review and Meta-Analysis of more than 2500 Patients.
Sahu AK, Bhoi S, Aggarwal P, Mathew R, Nayer J, T AV, Mishra PR, Sinha TP. | J Emerg Med. 2020 Aug;59(2):254-264
DOI: https://doi.org/10.1016/j.jemermed.2020.04.040
Keywords: airway; cardiac arrest; effectiveness; intubation; meta-analysis; resuscitation; ultrasonography; ultrasound.

Ultrasound in Emergency Medicine

Introduction : The integration of point-of-care ultrasound in endotracheal tube placement confirmation has been focus of many recent studies.
Objectives : We sought to determine the diagnostic accuracy of ultrasonography in confirmation of endotracheal intubation compared with standard confirmatory methods.

Méthode : We completed an extensive search of PubMed, EMBASE, Cochrane Central, Web of Science, and bibliographies of the selected articles from inception to October 2019. The search was limited to prospective studies conducted in human adults that compared the accuracy of ultrasonography in confirming the endotracheal tube position with a reference standard. The methodologic quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A bivariate random-effects model summarized diagnostic accuracy statistics. Subgroup analyses by ultrasonographic signs, study location, the operator's specialty, types of transducer, the technique of ultrasound confirmation, and clinical setting (cardiac arrest vs. non-cardiac arrest) were performed.

Résultats : Thirty studies involving 2534 patients were selected for this meta-analysis. The estimated pooled sensitivity and specificity for ultrasonography were 0.982 (95% confidence interval [CI] 0.971-0.988) and 0.957 (95% CI 0.901-0.982), respectively. Subgroup analyses did not reveal significant difference by ultrasonographic sign used, location, the sonographer's specialty, transducer type, or ultrasound technique used. Ultrasound was also found to be a useful adjunct in confirming endotracheal tube position in the subgroup of patients with cardiac arrest, with sensitivity of 0.99 (95% CI 0.98-1.00) and specificity of 0.84 (95% CI 0.67-1.00), respectively.

Conclusion : Ultrasonography is a valuable and reliable adjunct for endotracheal tube confirmation, including during cardiac arrest resuscitation.

Conclusion (proposition de traduction) : L'échographie est un complément précieux et fiable pour la confirmation de la position du tube endotrachéal, y compris pendant la réanimation d'un arrêt cardiaque.

Osborn J-Wave in a Patient with Hypercalcemic Crisis.
Manzur-Sandoval D, Dueñas-Pérez G, Ortiz-Brizuela E, Valdez-Hernández P, Oseguera-Moguel J, Briseño-de la Cruz JL. | J Emerg Med. 2020 Aug;59(2):298-299
DOI: https://doi.org/10.1016/j.jemermed.2020.04.032
Keywords: Aucun

Visual Diagnosis in Emergency Medicine

Editorial : The cardiac action potential is generated by the movement of ions inside and outside the cell; consequently, alterations in their serum concentrations result in characteristic electrocardiographic findings. The most common finding in hypercalcemia is QT interval shortening; however, other findings have been reported. That is the case of the Osborn J-wave, which has been linked to an increased risk of malignant ventricular dysrhythmias. We describe a patient with a hypercalcemic crisis in whom a J-wave was recorded.

Conclusion : This patient suffered a hypercalcemic crisis that conditioned the appearance of the J-wave, an altered level of consciousness, and severe acute pancreatitis. The other electrolyte disturbances (hypokalemia and hypomagnesemia) are caused by gastrointestinal losses within the context of severe acute pancreatitis.

Conclusion (proposition de traduction) : Ce patient a présenté une hypercalcémique aigüe qui a conditionné l'apparition de l'onde J, une altération du niveau de conscience et une pancréatite aiguë sévère. Les autres perturbations électrolytiques (hypokaliémie et hypomagnésémie) sont causées par des pertes gastro-intestinales dans le cadre d'une pancréatite aigüe sévère.

Commentaire :  Électrocardiogramme à l'arrivée. Notez la dépression du segment ST convexe diffus et l'onde J en V3.

NDLR : AIGU, AIGUË ◇ adjectif. Peut s'écrire aigu, aigüe, selon les rectifications orthographiques de 1990. [règle §3] Les accents et le tréma. in:Les rectifications de l’orthographe : principes et règles. Dictionnaire de l'Académie française  .

Pediatric Case of Successful Point-of-Care Ultrasound-Guided Nasogastric Tube Placement.
Mori T, Takei H, Nomura O, Ihara T, Hagiwara Y. | J Emerg Med. 2020 Aug;59(2):e57-e60
DOI: https://doi.org/10.1016/j.jemermed.2020.04.029
Keywords: Aucun

Ultrasound in Emergency Medicine

Editorial : Nasogastric tube (NGT) place- ment is commonly performed in pediatric emergency care and is classically confirmed by any one of several methods, among which auscultation or aspiration and radiography comprise the currently recognized as the reference stan- dard. Point-of-care ultrasound (POCUS) is used to confirm NGT insertion, especially in adults or prehospital patients, but reports of its use in the pediatric emergency department (ED) are still scarce. We report a case of successful POCUS- guided NGT placement in a pediatric ED. Case report: A 3- year-old male undergoing remission therapy for acute lym- phocytic leukemia presented to our ED with fever and decreased appetite. Tumor lysis syndrome was diagnosed, and endotracheal intubation was required because of the need for emergency hemodialysis for hypercalcemia. Because of difficulty in guiding the tube through the nose, ultrasound-guided placement was attempted. In the trans- verse view over the neck below the level of the cricoid carti- lage, the 10-Fr NGT was visualized under ultrasound guidance as it passed through the esophagus. Subsequently, the entry of the NGT tip into the gastric cardia was confirmed on the subxiphoid longitudinal view. A chest radiograph confirmed the presence of the NGT in the stom- ach. Why Should an Emergency Physician Be Aware of This?: Although the utility of POCUS for NGT placement was reported in adult patients, reports of its use in pediatric cases are still few. POCUS is a real-time, noninvasive, time- saving procedure that can be a useful alternative to radiog- raphy for confirming correct NGT placement.

Conclusion : POCUS is a real-time, noninvasive, nonradioactive procedure that can help lessen children’s lifetime risk of malignancies caused by radiation exposure; therefore, the procedure is highly beneficial because of its rapidity especially in cases where other confirmation methods are not immediately available, such as patients requiring resuscitation or those in a prehospital setting. Although further investigation is needed to determine the optimal manner and length of training needed to perform the procedure, the current report demonstrated that a pediatric emergency physician was able to perform POCUS to confirm NGT placement.

Conclusion (proposition de traduction) : L'échographie au point d'intervention est une procédure en temps réel, non invasive et non irradiante qui peut contribuer à réduire le risque carcinologique causé par l'exposition aux radiations notamment chez les enfants. Cette procédure est donc très bénéfique en raison de sa rapidité, surtout dans les cas où d'autres méthodes de confirmation ne sont pas immédiatement disponibles, chez les patients nécessitant une réanimation ou ceux qui se trouvent dans un cadre préhospitalier.
Bien qu'une enquête plus approfondie soit nécessaire pour déterminer la manière optimale et la durée de la formation nécessaire pour effectuer la procédure, le rapport actuel a démontré qu'un médecin urgentiste pédiatrique a pu effectuer une échographie au point d'intervention pour confirmer le placement de la sonde nasogastrique.

Commentaire :  Protocole d'échographie au point de service. Le face antérieure du cou est d'abord examinée, puis la région sub-xiphoïde. Résultats de l'échographie au point d'intervention (vue antérieure du cou). L'échographie montre que la sonde nasogastrique de 10-Fr est une structure hyperéchogène (flèche blanche) avec un artefact de réverbération dans l'œsophage situé à gauche de la trachée. CCA = artère carotide commune ; IJV = veine jugulaire interne. Résultats de l'échographie au point d'intervention (vue sous-xiphoïde). L'échographie montre que la pointe du tube naso-gastrique est une structure hyperéchogène (flèche blanche) pénétrant à travers le cardia gastrique en arrière du foie et en avant de l'aorte abdominale.