Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department.
Musey PI Jr, Bellolio F, Upadhye S, Chang AM, Diercks DB, Gottlieb M, Hess EP, Kontos MC, Mumma BE, Probst MA, Stahl JH, Stopyra JP, Kline JA, Carpenter CR. | Acad Emerg Med. 2021 Jul;28(7):718-744
DOI: https://doi.org/10.1111/acem.14296
Keywords: acute coronary syndrome; chest pain; low risk; recurrent.

EDITOR'S PICK

Editorial : This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.

Conclusion : These guidelines outline and summarize the evidence and strength of GRACE recommendations regarding eight priority questions of interest to emergency clinicians, other healthcare professionals, patients, and policymakers with regard to the evaluation and management management of patients with recurrent, low-risk chest pain seen in the emergency department. Direct evidence for the selected priority questions in this population is lacking, which highlights areas which will benefit from further robust prospective investigation in this specific population.

Conclusion (proposition de traduction) : Ces recommandations décrivent et résument les preuves et la force des recommandations selon la classification GRACE concernant huit questions d'intérêt prioritaires pour les urgentistes, les autres professionnels de la santé, les patients et les décideurs en ce qui concerne l'évaluation et la gestion des patients souffrant de douleurs thoraciques récurrentes à faible risque observées dans le service des urgences. Il manque des preuves directes pour les questions prioritaires sélectionnées dans cette population, ce qui met en évidence les domaines qui bénéficieront d'une étude prospective plus approfondie dans cette population spécifique.

Using a Simulated Model and Mastery Learning Approach to Teach the Ultrasound-guided Serratus Anterior Plane Block to Emergency Medicine Residents: A Pilot Study.
Rider AC, Miller DT, Ashenburg N, Duanmu Y, Lobo V, Schertzer K, Sebok-Syer SS. | AEM Educ Train. 2020 Sep 27;5(3):e10525
DOI: https://doi.org/10.1002/aet2.10525
Keywords: Aucun

Original Contribution

Introduction : The serratus anterior plane block (SAPB) is a safe, single-injection alternative for pain control in patients with rib fractures. This pilot study aims to teach the ultrasound-guided SAPB to emergency medicine (EM) residents using a mastery learning approach.

Méthode : A 19-item checklist was created and mastery was determined to be 17 of 19 items correct. This pass score was established using a Mastery Angoff standard-setting exercise with a group of EM experts. Learners participated in baseline testing on a simulated model and performance was assessed by two raters. Learners then watched an instructional video and participated in an individualized teaching session. Learners underwent deliberate practice followed by posttesting until mastery was achieved. Score differences in baseline testing and posttesting were analyzed using a paired t-test. Pre- and posttesting surveys were also completed by participants.

Résultats : Twenty-eight PGY-1 to -4 residents volunteered to participate in the study. The range of reported SAPBs seen previously was 0 to 5. The mean (±SD) number of items correct on the checklist for initial testing was 8.5 of 19 (±2.7), while the mean (±SD) final score was 18 of 19 (±0.6; p < 0.001). All participants met mastery standards after the curriculum intervention. Median self-reported procedural confidence was 2 out of 5 on a 5-point Likert scale before the session and 5 out of 5 after the session (Z = -4.681, p < 0.001).

Conclusion : Using a mastery learning approach and simulated model, we were able to successfully train EM residents to perform the SAPB at a level of mastery and increase their overall confidence in executing this procedure.

Conclusion (proposition de traduction) : À l’aide d’une approche par compétence et d’un modèle simulé, nous avons réussi à former des résidents en médecine d’urgence à effectuer le bloc du plan antérieur du serratus à un bon niveau de maîtrise et à accroître leur confiance générale dans l’exécution de cette procédure.

Commentaire : L’anesthésique local est injecté en regard de la 5ème côte au niveau de la ligne axillaire moyenne, entre le muscle serratus et le muscle grand dorsal. Ce bloc a été nommé le Serratus Plane Block. Il s’agit là encore d’injecter l’AL en superficie du serratus mais sur la face latérale de ce dernier.
Donc pour bloquer les nerfs intercostaux, il faut injecter l’AL en superficie du serratus, soit par voie antérieure (entre les muscles serratus et petit pectoral), soit par voie latérale au niveau de la ligne axillaire moyenne, revient à injecter l’AL dans un même plan de diffusion (mais en utilisant des points d’entrée différents) et permet de bloquer les branches cutanées latérales des nerfs intercostaux. Il convient donc d’éviter de parler de Pecs blocs (notion à réserver au bloc interpectoral) dans ce cas mais plutôt de bloc superficiel du serratus.
Régis Fuzier, Philippe Izard, Sébastien Pierre. Serratus superficiel et profond, blocs associés (thoracique long et thoraco-dorsal). MAPAR 2019  .

L’Approche Par Compétences (APC) place au premier plan une démarche fondée sur les résultats d’apprentissage, quel que soit le lieu et la forme d’acquisition ; par opposition à l’approche traditionnelle, basée sur les contenus de formation, les programmes et leur durée. Elle consiste essentiellement à définir les compétences inhérentes à l’exercice d’un métier et à les transposer dans le cadre de l’élaboration d’un référentiel de formation ou programme d’études.

Vasopressors in Trauma: A Never Event?.
Richards JE, Harris T, Dünser MW, Bouzat P, Gauss T. | Anesth Analg. 2021 Jul 1;133(1):68-79
DOI: https://doi.org/10.1213/ane.0000000000005552
Keywords: Aucun

Narrative Review Article

Editorial : Vasopressor use in severely injured trauma patients is discouraged due to concerns that vasoconstriction will worsen organ perfusion and result in increased mortality and organ failure in hypotensive trauma patients. Hypotensive resuscitation is advocated based on limited data that lower systolic blood pressure and mean arterial pressure will result in improved mortality. It is classically taught that hypotension and hypovolemia in trauma are associated with peripheral vasoconstriction. However, the pathophysiology of traumatic shock is complex and involves multiple neurohormonal interactions that are ultimately manifested by an initial sympathoexcitatory phase that attempts to compensate for acute blood loss and is characterized by vasoconstriction, tachycardia, and preserved mean arterial blood pressure. The subsequent hypotension observed in hemorrhagic shock reflects a sympathoinhibitory vasodilation phase. The objectives of hemodynamic resuscitation in hypotensive trauma patients are restoring adequate intravascular volume with a balanced ratio of blood products, correcting pathologic coagulopathy, and maintaining organ perfusion. Persistent hypotension and hypoperfusion are associated with worse coagulopathy and organ function. The practice of hypotensive resuscitation would appear counterintuitive to the goals of traumatic shock resuscitation and is not supported by consistent clinical data. In addition, excessive volume resuscitation is associated with adverse clinical outcomes. Therefore, in the resuscitation of traumatic shock, it is necessary to target an appropriate balance with intravascular volume and vascular tone. It would appear logical that vasopressors may be useful in traumatic shock resuscitation to counteract vasodilation in hemorrhage as well as other clinical conditions such as traumatic brain injury, spinal cord injury, multiple organ dysfunction syndrome, and vasodilation of general anesthetics. The purpose of this article is to discuss the controversy of vasopressors in hypotensive trauma patients and advocate for a nuanced approach to vasopressor administration in the resuscitation of traumatic shock.

Conclusion : The use of vasopressors is traditionally cautioned against in the management of traumatic hemorrhagic shock. However, the pathophysiology of shock in trauma patients is complex. Multiple clinical scenarios exist, which may warrant early administration of AVP or NOREPI, along with appropriately titrated volume administration and resuscitation. Further scientific work is necessary to better define specific vasopressor medications, optimal arterial blood pressure goals, and resuscitation strategies that are most beneficial to the critically injured trauma patient. Based on the current literature, we conclude that clinical equipoise exists and will only be solved by adequately powered, multicenter, prospectively randomized trials.

Conclusion (proposition de traduction) : L'utilisation de vasopresseurs est traditionnellement déconseillée dans la prise en charge du choc hémorragique traumatique. Cependant, la physiopathologie du choc chez les patients traumatisés est complexe. De multiples scénarios cliniques existent, qui peuvent justifier l'administration précoce d'arginine vasopressine ou de norépinéphrine, ainsi qu'une administration de volume et une réanimation adéquatement titrés. Des travaux scientifiques supplémentaires sont nécessaires pour mieux définir les médicaments vasopresseurs spécifiques, les objectifs de pression artérielle optimale et les stratégies de réanimation les plus bénéfiques pour le patient traumatisé gravement blessé. Sur la base de la littérature actuelle, nous concluons que l'équilibre clinique existe et ne sera résolu que par des essais multicentriques prospectivement randomisés de puissance adéquate.

Association of Obstructive Sleep Apnea With Difficult Intubation: Prospective Multicenter Observational Cohort Study.
Seet E, Chung F, Wang CY, Tam S, Kumar CM, Ubeynarayana CU, Yim CC, Chew EFF, Lam CKM, Cheng BCP, Chan MTV. | Anesth Analg. 2021 Jul 1;133(1):196-204
DOI: https://doi.org/10.1213/ane.0000000000005479
Keywords: Aucun

Original Clinical Research Report

Introduction : Obstructive sleep apnea (OSA) has been found to be associated with difficult airway, although there is a paucity of prospective studies investigating thresholds of OSA severity with difficult airway outcomes. The aim of this study was to examine the association between OSA and difficult intubation or difficult mask ventilation. We also explored the utility of the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender (STOP-Bang) score for difficult airway prediction.

Méthode : The Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) trial was an international prospective cohort study of surgical patients 45 years or older with one or more cardiac risk factor presenting for noncardiac surgery, with planned secondary analyses of difficult airway outcomes. Multivariable logistic regression analyses tested associations between OSA severity and predictors of difficult airway with difficult intubation or difficult mask ventilation. Overall, 869 patients without prior diagnosis of OSA were screened for OSA risk with the STOP-Bang tool, underwent preoperative sleep study, and had routine perioperative care, including general anesthesia with tracheal intubation. The primary outcome analyzed was difficult intubation, and the secondary outcome was difficult mask ventilation.

Résultats : Based on the sleep studies, 287 (33%), 324 (37%), 169 (20%), and 89 (10%) of the 869 patients had no, mild, moderate, and severe OSA, respectively. One hundred and seventy-two (20%) had a STOP-Bang score of 0-2 (low risk), 483 (55%) had a STOP-Bang score of 3-4 (intermediate risk), and 214 (25%) had a STOP-Bang score 5-8 (high risk). The incidence of difficult intubation was 6.7% (58 of 869), and difficult mask ventilation was 3.7% (32 of 869). Multivariable logistic regression demonstrated that moderate OSA (odds ratio [OR] = 3.26 [95% confidence interval {CI}, 1.37-8.38], adjusted P = .010) and severe OSA (OR = 4.05 [95% CI, 1.51-11.36], adjusted P = .006) but not mild OSA were independently associated with difficult intubation compared to patients without OSA. Relative to scores of 0-2, STOP-Bang scores of 3-4 and 5-8 were associated with increased odds of difficult intubation (OR = 3.01 [95% CI, 1.13-10.40, adjusted P = .046] and 4.38 [95% CI, 1.46-16.36, adjusted P = .014]), respectively. OSA was not associated with difficult mask ventilation, and only increasing neck circumference was found to be associated (adjusted P = .002).

Conclusion : Moderate and severe OSA were associated with difficult intubation, and increasing neck circumference was associated with difficult mask ventilation. A higher STOP-Bang score of 3 or more may be associated with difficult intubation versus STOP-Bang score of 0-2. Anesthesiologists should be vigilant for difficult intubation when managing patients suspected or diagnosed with OSA.

Conclusion (proposition de traduction) : L'apnée obstructive du sommeil modérée et sévère était associée à une intubation difficile, et l'augmentation de la circonférence du cou était associée à une ventilation difficile au masque. Un score STOP-Bang supérieur ou égal à 3 ou peut être associé à une intubation difficile par rapport à un score STOP-Bang de 0-2. Les anesthésistes doivent être vigilants en cas d'intubation difficile lors de la prise en charge de patients suspectés ou diagnostiqués d'apnée obstructive du sommeil.

Commentaire : Le score STOP-BANG   (Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender)

Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report.
Yealy DM, Mohr NM, Shapiro NI, Venkatesh A, Jones AE, Self WH. | Ann Emerg Med. 2021 Jul;78(1):1-19
DOI: https://doi.org/10.1016/j.annemergmed.2021.02.006  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Editorial : Sepsis is a major cause of hospital death in the United States (US) and is associated with over 850,000 annual emergency department visits. Despite advances in care, patients with serious infection continue to have a high inpatient mortality rate, reaching 20% or more in some settings. This makes sepsis and septic shock one of the highest mortality conditions treated in the ED. Additionally, many survivors never fully recover, and instead, long-term morbidities, chronic critical illness, or post-intensive care syndrome develops in them.

Conclusion : In conclusion, our multidisciplinary task force identified opportunities to improve recommendations, guidance, and quality metrics for early sepsis care. The points reviewed and suggested within this document seek to foster the next set of improvements for a leading cause of mortality. We identified many specific content and process opportunities in which research and collaboration could advance care, health, and outcomes. These include clear opportunities to guide fluid, vasopressor, and antibiotic therapy and thoughts on ancillary care and future guideline development. Optimal future sepsis recommendations will rely on a collaborative multiple stakeholder engagement approach to evaluating current processes, designing iterative improvements, and discovering new knowledge in the quest to conquer sepsis.

Conclusion (proposition de traduction) : En conclusion, notre groupe de travail multidisciplinaire a identifié des opportunités d'améliorer les recommandations, les conseils et les mesures de qualité pour les soins précoces du sepsis. Les points examinés et suggérés dans ce document visent à favoriser la prochaine série d'améliorations pour l'une des principales causes de mortalité. Nous avons identifié de nombreuses opportunités de contenu et de processus spécifiques dans lesquelles la recherche et la collaboration pourraient faire progresser les soins, la santé et les résultats. Il s'agit notamment d'opportunités claires pour guider le traitement par le remplissage, les vasopresseurs et les antibiotiques et des réflexions sur les soins auxiliaires et l'élaboration future de lignes directrices. Les futures recommandations optimales sur le sepsis reposeront sur une approche collaborative d'engagement de multiples parties prenantes pour évaluer les processus actuels, concevoir des améliorations itératives et découvrir de nouvelles connaissances dans la quête pour vaincre le sepsis.

Managing a Cutaneous Abscess in the Emergency Department.
Schmitz GR, Gottlieb M. | Ann Emerg Med. 2021 Jul;78(1):44-48
DOI: https://doi.org/10.1016/j.annemergmed.2020.12.003
Keywords: Aucun

Infectious Disease

Editorial : Cutaneous abscesses are a common type of skin and soft tissue infection observed in the emergency department (ED). Patients typically present with painful, erythematous nodules, which are often indurated and surrounded by an erythematous and edematous border. The overlying skin may have palpable fluctuance, surrounding cellulitis, and signs of spontaneous drainage.

Conclusion : In this article, we will focus on the management of uncomplicated cutaneous abscesses (ie, purulent lesions, requiring incision and drainage, that can be managed in an ED or outpatient setting). Our recommendations may not apply to complicated abscesses in immunocompromised patients or in special locations (ie, perirectal, hand, and those from bite wounds or surgical site infections; or in patients with suspected disseminated infection). These complicated abscesses may require operative management, debridement, intravenous antimicrobial therapy, or hospitalization. Abscesses in patients with diabetes or a remote history of intravenous drug use are not necessarily complicated, assuming the patients do not have a fever or signs of systemic illness.

Conclusion (proposition de traduction) : Dans cet article, nous nous concentrerons sur la prise en charge des abcès cutanés non compliqués (c'est-à-dire des lésions purulentes, nécessitant une incision et un drainage, qui peuvent être prises en charge en urgence ou en ambulatoire). Nos recommandations peuvent ne pas s'appliquer aux abcès compliqués chez les patients immunodéprimés ou dans des localisations particulières (c'est-à-dire, périrectale, de la main et ceux provenant de morsures ou d'infections du site opératoire ; ou chez les patients suspectés d'infection disséminée). Ces abcès compliqués peuvent nécessiter une prise en charge chirurgicale, un débridement, un traitement antimicrobien intraveineux ou une hospitalisation. Les abcès chez les patients diabétiques ou ayant des antécédents éloignés d'utilisation de drogues par voie intraveineuse ne sont pas nécessairement compliqués, en supposant que les patients n'ont pas de fièvre ou de signes de maladie systémique.

Out-of-Hospital Ketamine: Indications for Use, Patient Outcomes, and Associated Mortality.
Fernandez AR, Bourn SS, Crowe RP, Bronsky ES, Scheppke KA, Antevy P, Myers JB. | Ann Emerg Med. 2021 Jul;78(1):123-131
DOI: https://doi.org/10.1016/j.annemergmed.2021.02.020
Keywords: Aucun

Emergency Medical Services

Introduction : To describe out-of-hospital ketamine use, patient outcomes, and the potential contribution of ketamine to patient death.

Méthode : We retrospectively evaluated consecutive occurrences of out-of-hospital ketamine administration from January 1, 2019 to December 31, 2019 reported to the national ESO Data Collaborative (Austin, TX), a consortium of 1,322 emergency medical service agencies distributed throughout the United States. We descriptively assessed indications for ketamine administration, dosing, route, transport disposition, hypoxia, hypercapnia, and mortality. We reviewed cases involving patient death to determine whether ketamine could be excluded as a potential contributing factor.

Résultats : Indications for out-of-hospital ketamine administrations in our 11,291 patients were trauma/pain (49%; n=5,575), altered mental status/behavioral indications (34%; n=3,795), cardiovascular/pulmonary indications (13%; n=1,454), seizure (2%; n=248), and other (2%; n=219). The highest median dose was for altered mental status/behavioral indications at 3.7 mg/kg (interquartile range, 2.2 to 4.4 mg/kg). Over 99% of patients (n=11,274) were transported to a hospital. Following ketamine administration, hypoxia and hypercapnia were documented in 8.4% (n=897) and 17.2% (n=1,311) of patients, respectively. Eight on-scene and 120 in-hospital deaths were reviewed. Ketamine could not be excluded as a contributing factor in 2 on-scene deaths, representing 0.02% (95% confidence interval 0.00% to 0.07%) of those who received out-of-hospital ketamine. Among those with in-hospital data, ketamine could not be excluded as a contributing factor in 6 deaths (0.3%; 95% confidence interval 0.1% to 0.7%).

Conclusion : In this large sample, out-of-hospital ketamine was administered for a variety of indications. Patient mortality was rare. Ketamine could not be ruled out as a contributing factor in 8 deaths, representing 0.07% of those who received ketamine.

Conclusion (proposition de traduction) : Dans ce grand échantillon, la kétamine a été administrée en extra-hospitalier pour diverses indications. La mortalité des patients était faible. La kétamine n'a pas pu être exclue comme facteur contributif dans 8 décès, représentant 0,07 % des patients qui ont reçu de la kétamine.

Commentaire : Les principales indications de l'utilisation de la kétamine dans cette étude était le traitement de la douleur ou d'une agitation aigüe. Une désaturation et une hypercapnie n'était pas rare chez ces patients.
Les auteurs concluent qu'une surveillance plus étroite des utilisations de kétamine en pré-hospitalier permettrait de définir le meilleur profil d'utilisation de la kétamine par rapport à d'autres médicaments dans une population de patients similaires.

Is Chest Ultrasonography Superior to Supine Chest Radiography in Identifying Pneumothorax in Emergency Department Trauma Patients?.
Bridwell RE, Long B, Gottlieb M. | Ann Emerg Med. 2021 Jun;77(6):646-648
DOI: https://doi.org/10.1016/j.annemergmed.2020.09.437
Keywords: Aucun

General Medicine

Introduction : Two authors searched the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, EMBASE, Web of Science Core Collection, MEDLINE, Cumulative Index of Nursing and Allied Health Literature Plus, Database of Abstracts of Reviews of Effects, and ClinicalTrials.gov up to April 10, 2020, using a combination of terms including “chest radiography,” “ultrasound,” and “pneumothorax.” The authors also evaluated reference lists of identified publications and performed forward-citation searching of relevant articles in Google Scholar and PubMed. There were no language restrictions.

Méthode : Authors included prospective, paired, comparative accuracy studies for trauma patients with suspected pneumothorax irrespective of age or sex. Patients must have received chest ultrasonography by a frontline, nonradiologist physician and chest radiography as index tests, both in the supine position, with computed omography (CT) of the chest or tube thoracostomy for the criterion standard. Two authors independently assessed studies for relevance and resolved disagreements through discussion, arbitrated by a third author.

Résultats : Two investigators independently extracted data from included studies, with discrepancies resolved by a third author. The primary outcome was the diagnostic accuracy of chest ultrasonography versus chest radiography for the diagnosis of pneumothorax in ED trauma patients. Subgroup analyses were stratified by type of trauma (blunt versus blunt and penetrating), type of chest ultrasonographic operator, and type of transducer. The authors also performed a sensitivity analysis assessing only studies that blinded outcome assessors evaluating the results of chest ultrasonography to the results of chest radiography and vice versa. Investigators performed this meta-analysis on binary data, using a bivariate meta-regression to estimate sensitivity and specificity. Investigators assessed heterogeneity with forest plots and summary receiver operating characteristic plots. Two investigators assessed risk of bias and applicability of each study according to the Quality Assessment of Diagnostic Accuracy Studies–2 tool.

Conclusion : Chest ultrasonography performed by trained emergency physicians is more sensitive than supine chest radiography in assessing emergency department trauma patients for pneumothorax.

Conclusion (proposition de traduction) : L'échographie thoracique réalisée par des urgentistes qualifiés est plus sensible que la radiographie du thorax en décubitus dorsal dans l'évaluation des patients traumatisés au service des urgences pour pneumothorax.

Noninvasive ventilation vs. high-flow nasal cannula oxygen for preoxygenation before intubation in patients with obesity: a post hoc analysis of a randomized controlled trial.
Rodriguez M, Ragot S, Coudroy R, Quenot JP, Vignon P, Forel JM, Demoule A, Mira JP, Ricard JD, Nseir S, Colin G, Pons B, Danin PE, Devaquet J, Prat G, Merdji H, Petitpas F, Vivier E, Mekontso-Dessap A, Nay MA, Asfar P, Dellamonica J, Argaud L, Ehrmann S, Fartoukh M, Girault C, Robert R, Thille AW, Frat JP; REVA Network. | Ann Intensive Care. 2021 Jul 22;11(1):114
DOI: https://doi.org/10.1186/s13613-021-00892-8  | Télécharger l'article au format  
Keywords: High-flow oxygen; Hypoxemia; Intubation; Non-invasive ventilation; Obesity; Preoxygenation; Respiratory failure.

Research

Introduction : Critically ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. We hypothesized that pre-oxygenation with noninvasive ventilation before intubation as compared with high-flow nasal cannula oxygen may decrease the risk of severe hypoxemia in patients with obesity.

Méthode : Post hoc subgroup analysis of critically ill patients with obesity (body mass index ≥ 30 kg·m-2) from a multicenter randomized controlled trial comparing preoxygenation with noninvasive ventilation and high-flow nasal oxygen before intubation of patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mm Hg). The primary outcome was the occurrence of severe hypoxemia (pulse oximetry < 80%) during the intubation procedure.

Résultats : Among the 313 patients included in the original trial, 91 (29%) had obesity with a mean body mass index of 35 ± 5 kg·m-2. Patients with obesity were more likely to experience an episode of severe hypoxemia during intubation procedure than patients without obesity: 34% (31/91) vs. 22% (49/222); difference, 12%; 95% CI 1 to 23%; P = 0.03. Among patients with obesity, 40 received preoxygenation with noninvasive ventilation and 51 with high-flow nasal oxygen. Severe hypoxemia occurred in 15 patients (37%) with noninvasive ventilation and 16 patients (31%) with high-flow nasal oxygen (difference, 6%; 95% CI - 13 to 25%; P = 0.54). The lowest pulse oximetry values during intubation procedure were 87% [interquartile range, 77-93] with noninvasive ventilation and 86% [78-92] with high-flow nasal oxygen (P = 0.98). After multivariable analysis, factors independently associated with severe hypoxemia in patients with obesity were intubation difficulty scale > 5 points and respiratory primary failure as reason for admission.

Conclusion : Patients with obesity and acute hypoxemic respiratory failure had an increased risk of severe hypoxemia during intubation procedure as compared to patients without obesity. However, preoxygenation with noninvasive ventilation may not reduce this risk compared with high-flow nasal oxygen.

Conclusion (proposition de traduction) : Les patients obèse en insuffisance respiratoire aiguë hypoxémique présentaient un risque accru d'hypoxémie sévère pendant la procédure d'intubation par rapport aux patients sans obésité. Cependant, la préoxygénation avec la ventilation non invasive (VNI) peut ne pas réduire ce risque par rapport à l'oxygénothérapie nasale à haut débit (OHD).

Comparison of Emergency Echocardiographic Results between Cardiologists and an Emergency Medicine Resident in Acute Coronary Syndrome.
Rasooli F, Bagheri F, Sadatnaseri A, Ashraf H, Bahreini M. | Arch Acad Emerg Med. 2021 Jul 22;9(1):e53
DOI: https://doi.org/10.22037/aaem.v9i1.1247  | Télécharger l'article au format  
Keywords: Cardiologists; Emergency medicine; Patient Discharge; Point-of-Care Systems; Ultrasonography.

Original/Research Article

Introduction : Early detection of regional wall motion abnormality (RWMA) can be a reliable tool for rapid disposition of patients with acute coronary syndrome (ACS) in the emergency department. In this study, the diagnostic accuracy of point-of-care echocardiography performed by a trained emergency medicine resident was evaluated in comparison with board-certified cardiologists.

Méthode : A prospective, cross-sectional study was implemented on adult patients with ACS. A trained emergency medicine (EM) PGY-3 resident performed point-of-care echocardiography under the supervision of two cardiologists and the reports were compared with cardiologists as a reference test.

Résultats : 100 patients with the mean age of 54.1 ± 11.5 years were recruited (65% male). Based on Thrombolysis in Myocardial Infarction (TIMI) and History, EKG, Age, Risk factors, and troponin (HEART) scores, 43.0% and 25.0% of patients were categorized as low-risk for ACS, respectively. The absolute measure of agreement between cardiologists to determine ejection fraction (EF) was 0.829 (95% CI: 0.74-0.89) based on intraclass correlation coefficient (ICC) estimation. The measurements of agreement between specialists and the EM resident based on the analysis of Kappa coefficient were 0.677 and 0.884 for RWMA and pericardial effusion, respectively. Moreover, 25 patients were in the-low risk group according to the HEART score with an agreement rate of 92% for the lack of RWMA between the EM resident and cardiologists.

Conclusion : This study found acceptable agreement between the EM resident and cardiologists in assessing RWMA in different ACS risk groups. In addition, there was acceptable agreement between the EM resident and cardiologists in determining left ventricular ejection fraction (LVEF) and pericardial effusion.

Conclusion (proposition de traduction) : Cette étude a trouvé un accord acceptable entre le résident de médecine d'urgence et les cardiologues dans l'évaluation de l'anomalie du mouvement de la paroi régionale dans différents groupes à risque de syndrome coronarien aigu. De plus, il y avait un accord acceptable entre le résident de médecine d'urgence et les cardiologues pour déterminer la fraction d'éjection ventriculaire gauche (FEVG) et l'épanchement péricardique.

Comparison of the novel VieScope with conventional and video laryngoscope in a difficult airway scenario - a randomized, controlled simulation trial.
Ecker H, Kolvenbach S, Stranz S, Herff H, Wetsch WA. | BMC Emerg Med. 2021 Jul 30;21(1):90
DOI: https://doi.org/10.1186/s12873-021-00484-6  | Télécharger l'article au format  
Keywords: Difficult airway; Difficult airway management; Endotracheal intubation; Video-laryngoscopy; VieScope

Research

Introduction : Endotracheal intubation continues to be the gold standard for securing the airway in emergency situations. Difficult intubation is still a dreadful situation when securing the airway.
Objective: To compare VieScope with Glidescope and conventional Macintosh laryngoscopy (MAC) in a simulated difficult airway situation.

Méthode : In this randomized controlled simulation trial, 35 anesthesiologists performed endotracheal intubation using VieScope, GlideScope and MAC in a randomized order on a certified airway manikin with difficult airway.

Résultats : For the primary endpoint of correct tube position, no statistical difference was found (p = 0.137). Time until intubation for GlideScope (27.5 ± 20.3 s) and MAC (20.8 ± 8.1 s) were shorter compared to the VieScope (36.3 ± 10.1 s). Time to first ventilation, GlideScope (39.3 ± 21.6 s) and MAC (31.9 ± 9.5 s) were also shorter compared to the VieScope (46.5 ± 12.4 s). There was no difference shown between handling time for VieScope (20.7 ± 7.0 s) and time until intubation with GlideScope or MAC. Participants stated a better Cormack & Lehane Score with VieScope, compared to direct laryngoscopy.

Conclusion : Rate of correct tracheal tube position was comparable between the three devices. Time to intubation and ventilation were shorter with MAC and Glidescope compared to VieScope. It did however show a comparable handling time to video laryngoscopy and MAC. It also did show a better visualization of the airway in the Cormack & Lehane Score compared to MAC.

Conclusion (proposition de traduction) : Le taux de position correcte de la sonde trachéale était comparable entre les trois dispositifs.
Le temps d'intubation et de ventilation était plus court avec le McGRATH® MAC et le Glidescope par rapport au VieScope. Le VieScope a cependant montré un temps de traitement comparable à la vidéo-laryngoscopie et au McGRATH® MAC. Il a également montré une meilleure visualisation des voies respiratoires dans le score de Cormack et Lehane par rapport au McGRATH® MAC.

Commentaire :  Intubation à l'aide du VieScope.
a : Le VieScope est doté d'une lame de laryngoscope droite en forme de Miller, transparente et éclairée, pour permettre une visualisation directe des cordes vocales.
b : VieScope en place, avec visualisation des cordes vocales.
c : Insertion de la bougie dans la trachée ; après une insertion réussie, le VieScope peut être retiré, laissant la bougie en place.
d : Insertion de la sonde trachéale en utilisant la bougie comme guide.

A first-aid fast track channel for rescuing critically ill children with airway foreign bodies: our clinical experience.
Chen YC, Xian ZX, Han SH, Li L, Teng YS. | BMC Emerg Med. 2021 Jul 21;21(1):85
DOI: https://doi.org/10.1186/s12873-021-00482-8  | Télécharger l'article au format  
Keywords: Child; First-aid fast Track Channel; Foreign bodies; Trachea.

Research

Introduction : To explore the role of a first-aid fast track channel in rescuing children with airway foreign bodies and to analyse and summarize the experience and lessons of the first-aid fast track channel in rescuing airway foreign bodies from patients in critical condition.

Méthode : We retrospectively reviewed the medical records of children with airway foreign bodies rescued by first-aid fast track channels admitted to our hospital from January 2017 to December 2020. The corresponding clinical features, treatments, and prognoses were summarized.

Résultats : Clinical data from 21 cases of first-aid fast track channel patients were retrospectively collected, including 12 males and 9 females aged 9-18 months. Cough was the most frequently exhibited symptom (100.0%), followed by III inspiratory dyspnoea (71.4%). Regarding the location of foreign bodies, 5 cases (23.8%) had glottic foreign bodies, 10 cases (47.6%) had tracheal foreign bodies, and 6 cases (28.6%) had bilateral bronchial foreign bodies. The most common type of FB was organic. FB removal was performed by rigid bronchoscopy in every case, and there were no complications of laryngeal oedema, subcutaneous emphysema, or pneumothorax. No tracheotomy was performed in any of the children.

Conclusion : The first-aid fast track channel for airway foreign bodies saves a valuable time for rescue, highlights the purpose of rescue, improves the success rate of rescue and the quality of life of children, and is of great value for the treatment of critical tracheal foreign bodies. It is necessary to regularly summarize the experience of the first-aid fast track channel of airway foreign bodies and further optimize the setting of the first-aid fast track channel.

Conclusion (proposition de traduction) : Les premiers soins d’urgence pour les corps étrangers des voies aériennes permet de gagner un temps précieux pour le sauvetage, de mettre en évidence l’objectif du sauvetage, d’améliorer le taux de réussite du sauvetage et la qualité de vie des enfants, et d’être très utile pour le traitement des corps étrangers trachéaux critiques. Il est nécessaire de faire régulièrement le bilan de l’expérience des premiers soins d’urgence pour les corps étrangers et d’optimiser davantage le réglage des premiers soins d’urgence.

Prehospital time and mortality in polytrauma patients: a retrospective analysis.
Berkeveld E, Popal Z, Schober P, Zuidema WP, Bloemers FW, Giannakopoulos GF.. | BMC Emerg Med. 2021 Jul 6;21(1):78
DOI: https://doi.org/10.1186/s12873-021-00476-6  | Télécharger l'article au format  
Keywords: Mortality; Polytrauma patients; Prehospital time.

Research

Introduction : The time from injury to treatment is considered as one of the major determinants for patient outcome after trauma. Previous studies already attempted to investigate the correlation between prehospital time and trauma patient outcome. However, the outcome for severely injured patients is not clear yet, as little data is available from prehospital systems with both Emergency Medical Services (EMS) and physician staffed Helicopter Emergency Medical Services (HEMS). Therefore, the aim was to investigate the association between prehospital time and mortality in polytrauma patients in a Dutch level I trauma center.

Méthode : A retrospective study was performed using data derived from the Dutch trauma registry of the National Network for Acute Care from Amsterdam UMC location VUmc over a 2-year period. Severely injured polytrauma patients (Injury Severity Score (ISS) ≥ 16), who were treated on-scene by EMS or both EMS and HEMS and transported to our level I trauma center, were included. Patient characteristics, prehospital time, comorbidity, mechanism of injury, type of injury, HEMS assistance, prehospital Glasgow Coma Score and ISS were analyzed using logistic regression analysis. The outcome measure was in-hospital mortality.

Résultats : In total, 342 polytrauma patients were included in the analysis. The total mortality rate was 25.7% (n = 88). Similar mean prehospital times were found between the surviving and non-surviving patient groups, 45.3 min (SD 14.4) and 44.9 min (SD 13.2) respectively (p = 0.819). The confounder-adjusted analysis revealed no significant association between prehospital time and mortality (p = 0.156).

Conclusion : This analysis found no association between prehospital time and mortality in polytrauma patients. Future research is recommended to explore factors of influence on prehospital time and mortality.

Conclusion (proposition de traduction) : Cette analyse n'a trouvé aucune association entre la durée de prise en charge préhospitalière et la mortalité chez les patients polytraumatisés. Des recherches futures sont recommandées pour explorer les facteurs d'influence sur a durée de prise en charge préhospitalière et la mortalité.

Factors associated with survival in adult patients with traumatic arrest: a retrospective cohort study from US trauma centers.
Ariss AB, Bachir R, El Sayed M. | BMC Emerg Med. 2021 Jul 5;21(1):77
DOI: https://doi.org/10.1186/s12873-021-00473-9  | Télécharger l'article au format  
Keywords: Injury; Outcome; Resuscitation; Survival; Traumatic arrest.

Research

Introduction : Traumatic arrests increasingly affect young adults worldwide with low reported survival rates. This study examines factors associated with survival (to hospital discharge) in traumatic arrests transported to US trauma centers.

Méthode : This retrospective cohort study used the US National Trauma Databank 2015 dataset and included patients who presented to trauma centers with "no signs of life". Univariate and bivariate analyses were done. Factors associated with survival were identified using multivariate regression analyses.

Résultats : The study included 5980 patients with traumatic arrests. Only 664 patients (11.1%) survived to hospital discharge. Patients were predominantly in age group 16-64 (84.6%), were mostly males (77.8%) and white (55.1%). Most were admitted to Level I (55.5%) or Level II trauma centers (31.6%). Injuries were mostly blunt (56.7%) or penetrating (39.3%). The median of the injury severity score (ISS) was 19 (interquartile range [IQR]: 9-30). Factors associated with decreased survival included: Age group ≥ 65 (Ref: 16-24), male gender, self-inflicted and other or undetermined types of injuries (Ref: assault), injuries to head and neck, injuries to torso and ISS ≥ 16 (Ref: < 16) and ED thoracotomy. While factors associated with increased survival included: All injury mechanisms (with the exception of motor vehicle transportation) (Ref: firearm), injuries to extremities or spine and back and all methods of coverage (Ref: self-pay).

Conclusion : Patients with traumatic arrests have poor outcomes with only 11.1% surviving to hospital discharge. Factors associated with survival in traumatic arrests were identified. These findings are important for devising injury prevention strategies and help guide trauma management protocols to improve outcomes in traumatic arrests.

Conclusion (proposition de traduction) : Les patients en arrêt cardiaque traumatique ont des résultats médiocres avec seulement 11,1 % survivant à la sortie de l'hôpital. Les facteurs associés à la survie dans les arrêts cardiaques traumatiques ont été identifiés. Ces résultats sont importants pour concevoir des stratégies de prévention des blessures et aident à orienter les protocoles de gestion des traumatismes afin d'améliorer les résultats des arrêts cardiaques traumatiques.

Commentaire : La survie est plus élevée dans le groupe d'âge plus jeune, le sexe féminin et avec tout type de couverture assurantielle (par rapport à ceux non assurés), contrairement à d'autres études.
Les patients en arrêt cardiaque traumatique par armes à feu ont une faible survie.

Ultrasonography indicators for predicting difficult intubation: a systematic review and meta-analysis.
Sotoodehnia M, Rafiemanesh H, Mirfazaelian H, Safaie A, Baratloo A. | BMC Emerg Med. 2021 Jul 3;21(1):76
DOI: https://doi.org/10.1186/s12873-021-00472-w  | Télécharger l'article au format  
Keywords: Airway management; Difficult airway; Intratracheal intubation; Prediction; Ultrasonography.

Research article

Introduction : Ultrasonography (US) is recently used frequently as a tool for airway assessment prior to intubation (endotracheal tube (ETT) placement), and several indicators have been proposed in studies with different reported performances in this regard. This systematic review and meta-analysis reviewed the performance of US in difficult airway assessment.

Méthode : This systematic review and meta-analysis was conducted according to the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane book. All the studies that had carried out difficult airway assessments using US, had compared the indicators in difficult and easy groups, and had published the results in English by the time we conducted our search in April 28, 2020, were included.

Résultats : In the initial search, 17,156 articles were retrieved. After deleting the duplicate articles retrieved from multiple databases, 7578 articles remained for screening based on the abstracts and titles. Finally, the full text of 371 articles were assessed and the data from 26 articles were extracted, which had examined a total of 45 US indicators for predicting difficult intubation. The most common US index was the "thickness of anterior neck soft tissue at the vocal cords level". Also, "skin to epiglottis" and "anterior neck soft tissue at the hyoid bone level" were among the most common indicators examined in this area.

Conclusion : This systematic review showed that US can be used for predicting difficult airway. Of note, "skin thickness at the epiglottis and hyoid levels", "the hyomental distance", and "the hyomental distance ratio" were correlated with difficult laryngoscopy in the meta-analysis. Many other indicators, including some ratios, have also been proposed for accurately predicting difficult intubation, although there have been no external validation studies on them.

Conclusion (proposition de traduction) : Cette revue systématique a montré que l'échographie peut être utilisée pour prédire une intubation difficile. Il est à noter que « l'épaisseur de la peau au niveau de l'épiglotte et de l'hyoïde », « la distance hyomentale » et « le rapport de la distance hyomentale » étaient corrélées à une laryngoscopie difficile dans la méta-analyse. De nombreux autres indicateurs, y compris certains ratios, ont également été proposés pour prédire avec précision une intubation difficile, bien qu'il n'y ait eu aucune étude de validation externe sur eux.

Use of cast immobilisation versus removable brace in adults with an ankle fracture: multicentre randomised controlled trial.
Kearney R, McKeown R, Parsons H, Haque A, Parsons N, Nwankwo H, Mason J, Underwood M, Redmond AC, Brown J, Kefford S, Costa M; AIR trial collaborators. | BMJ. 2021 Jul 5;374:n1506
DOI: https://doi.org/10.1136/bmj.n1506  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : To assess function, quality of life, resource use, and complications in adults treated with plaster cast immobilisation versus a removable brace for ankle fracture.
Design: Multicentre randomised controlled trial.

Méthode : 20 trauma units in the UK National Health Service.
Participants : 669 adults aged 18 years and older with an acute ankle fracture suitable for cast immobilisation: 334 were randomised to a plaster cast and 335 to a removable brace.
Interventions : A below the knee cast was applied and ankle range of movement exercises started on cast removal. The removable brace was fitted, and ankle range of movement exercises were started immediately.
Main outcome measures: Primary outcome was the Olerud Molander ankle score at 16 weeks, analysed by intention to treat. Secondary outcomes were Manchester-Oxford foot questionnaire, disability rating index, quality of life, and complications at 6, 10, and 16 weeks.

Résultats : The mean age of participants was 46 years (SD 17 years) and 381 (57%) were women. 502 (75%) participants completed the study. No statistically significant difference was found in the Olerud Molander ankle score between the cast and removable brace groups at 16 weeks (favours brace: 1.8, 95% confidence interval -2.0 to 5.6). No clinically significant differences were found in the Olerud Molander ankle scores at other time points, in the secondary unadjusted, imputed, or per protocol analyses.

Conclusion : Traditional plaster casting was not found to be superior to functional bracing in adults with an ankle fracture. No statistically difference was found in the Olerud Molander ankle score between the trial arms at 16 weeks.

Conclusion (proposition de traduction) : Le moulage en plâtre traditionnel ne s'est pas avéré supérieur à l'attelle fonctionnelle chez les adultes présentant une fracture de la cheville. Aucune différence statistique n'a été trouvée dans le score de cheville d'Olerud Molander entre les bras de l'essai à 16 semaines.

Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: systematic review and meta-analysis.
Cashin AG, Folly T, Bagg MK, Wewege MA, Jones MD, Ferraro MC, Leake HB, Rizzo RRN, Schabrun SM, Gustin SM, Day R, Williams CM, McAuley JH. | BMJ. 2021 Jul 7;374:n1446
DOI: https://doi.org/10.1136/bmj.n1446  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : To investigate the efficacy, acceptability, and safety of muscle relaxants for low back pain.
Design

Méthode : Medline, Embase, CINAHL, CENTRAL, ClinicalTrials.gov, clinicialtrialsregister.eu, and WHO ICTRP from inception to 23 February 2021.
Eligibility criteria for study selection: Randomised controlled trials of muscle relaxants compared with placebo, usual care, waiting list, or no treatment in adults (≥18 years) reporting non-specific low back pain.
Data extraction and synthesis: Two reviewers independently identified studies, extracted data, and assessed the risk of bias and certainty of the evidence using the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development and Evaluations, respectively. Random effects meta-analytical models through restricted maximum likelihood estimation were used to estimate pooled effects and corresponding 95% confidence intervals. Outcomes included pain intensity (measured on a 0-100 point scale), disability (0-100 point scale), acceptability (discontinuation of the drug for any reason during treatment), and safety (adverse events, serious adverse events, and number of participants who withdrew from the trial because of an adverse event).

Résultats : 49 trials were included in the review, of which 31, sampling 6505 participants, were quantitatively analysed. For acute low back pain, very low certainty evidence showed that at two weeks or less non-benzodiazepine antispasmodics were associated with a reduction in pain intensity compared with control (mean difference -7.7, 95% confidence interval-12.1 to-3.3) but not a reduction in disability (-3.3, -7.3 to 0.7). Low and very low certainty evidence showed that non-benzodiazepine antispasmodics might increase the risk of an adverse event (relative risk 1.6, 1.2 to 2.0) and might have little to no effect on acceptability (0.8, 0.6 to 1.1) compared with control for acute low back pain, respectively. The number of trials investigating other muscle relaxants and different durations of low back pain were small and the certainty of evidence was reduced because most trials were at high risk of bias.

Conclusion : Considerable uncertainty exists about the clinical efficacy and safety of muscle relaxants. Very low and low certainty evidence shows that non-benzodiazepine antispasmodics might provide small but not clinically important reductions in pain intensity at or before two weeks and might increase the risk of an adverse event in acute low back pain, respectively. Large, high quality, placebo controlled trials are urgently needed to resolve uncertainty.

Conclusion (proposition de traduction) : Il existe une incertitude considérable quant à l'efficacité clinique et à l'innocuité des myorelaxants. Des preuves de très faible et faible certitude montrent que les antispasmodiques autres que les benzodiazépines pourraient entraîner des réductions faibles mais non cliniquement importantes de l'intensité de la douleur au bout de deux semaines ou avant et pourraient augmenter le risque d'événement indésirable dans la lombalgie aiguë, respectivement. Des essais contrôlés par placebo à grande échelle, de haute qualité sont nécessaires de toute urgence pour résoudre l'incertitude.

Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence.
Blom AW, Donovan RL, Beswick AD, Whitehouse MR, Kunutsor SK. | BMJ. 2021 Jul 7;374:n1511
DOI: https://doi.org/10.1136/bmj.n1511  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : To determine the clinical effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care and assess the impact on clinical guidelines.
Design: Umbrella review of meta-analyses of randomised controlled trials or other study designs in the absence of meta-analyses of randomised controlled trials.

Méthode : Ten of the most common elective orthopaedic procedures-arthroscopic anterior cruciate ligament reconstruction, arthroscopic meniscal repair of the knee, arthroscopic partial meniscectomy of the knee, arthroscopic rotator cuff repair, arthroscopic subacromial decompression, carpal tunnel decompression, lumbar spine decompression, lumbar spine fusion, total hip replacement, and total knee replacement-were studied. Medline, Embase, Cochrane Library, and bibliographies were searched until September 2020.
Eligibility criteria for selecting studies: Meta-analyses of randomised controlled trials (or in the absence of meta-analysis other study designs) that compared the clinical effectiveness of any of the 10 orthopaedic procedures with no treatment, placebo, or non-operative care.
Data extraction and synthesis: Summary data were extracted by two independent investigators, and a consensus was reached with the involvement of a third. The methodological quality of each meta-analysis was assessed using the Assessment of Multiple Systematic Reviews instrument. The Jadad decision algorithm was used to ascertain which meta-analysis represented the best evidence. The National Institute for Health and Care Excellence Evidence search was used to check whether recommendations for each procedure reflected the body of evidence.
Main outcome measures: Quality and quantity of evidence behind common elective orthopaedic interventions and comparisons with the strength of recommendations in relevant national clinical guidelines.

Résultats : Randomised controlled trial evidence supports the superiority of carpal tunnel decompression and total knee replacement over non-operative care. No randomised controlled trials specifically compared total hip replacement or meniscal repair with non-operative care. Trial evidence for the other six procedures showed no benefit over non-operative care.

Conclusion : Although they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.

Conclusion (proposition de traduction) : Bien qu'elles puissent être efficaces dans l'ensemble ou dans certains sous-groupes, aucune base de preuves solides et de haute qualité ne montre que de nombreuses procédures orthopédiques électives couramment pratiquées sont plus efficaces que les alternatives non chirurgicales. Malgré le manque de preuves solides, certaines de ces procédures sont toujours recommandées par les directives nationales dans certaines situations.

Associations between statins and adverse events in primary prevention of cardiovascular disease: systematic review with pairwise, network, and dose-response meta-analyses.
Cai T, Abel L, Langford O, Monaghan G, Aronson JK, Stevens RJ, Lay-Flurrie S, Koshiaris C, McManus RJ, Hobbs FDR, Sheppard JP. | BMJ. 2021 Jul 14;374:n1537
DOI: https://doi.org/10.1136/bmj.n1537  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : To assess the associations between statins and adverse events in primary prevention of cardiovascular disease and to examine how the associations vary by type and dosage of statins.
Design: Systematic review and meta-analysis.

Méthode : Studies were identified from previous systematic reviews and searched in Medline, Embase, and the Cochrane Central Register of Controlled Trials, up to August 2020.
Review methods: Randomised controlled trials in adults without a history of cardiovascular disease that compared statins with non-statin controls or compared different types or dosages of statins were included.
Main outcome measures: Primary outcomes were common adverse events: self-reported muscle symptoms, clinically confirmed muscle disorders, liver dysfunction, renal insufficiency, diabetes, and eye conditions. Secondary outcomes included myocardial infarction, stroke, and death from cardiovascular disease as measures of efficacy.
Data synthesis: A pairwise meta-analysis was conducted to calculate odds ratios and 95% confidence intervals for each outcome between statins and non-statin controls, and the absolute risk difference in the number of events per 10 000 patients treated for a year was estimated. A network meta-analysis was performed to compare the adverse effects of different types of statins. An E_max model based meta-analysis was used to examine the dose-response relationships of the adverse effects of each statin.

Résultats : 62 trials were included, with 120 456 participants followed up for an average of 3.9 years. Statins were associated with an increased risk of self-reported muscle symptoms (21 trials, odds ratio 1.06 (95% confidence interval 1.01 to 1.13); absolute risk difference 15 (95% confidence interval 1 to 29)), liver dysfunction (21 trials, odds ratio 1.33 (1.12 to 1.58); absolute risk difference 8 (3 to 14)), renal insufficiency (eight trials, odds ratio 1.14 (1.01 to 1.28); absolute risk difference 12 (1 to 24)), and eye conditions (six trials, odds ratio 1.23 (1.04 to 1.47); absolute risk difference 14 (2 to 29)) but were not associated with clinically confirmed muscle disorders or diabetes. The increased risks did not outweigh the reduction in the risk of major cardiovascular events. Atorvastatin, lovastatin, and rosuvastatin were individually associated with some adverse events, but few significant differences were found between types of statins. An E_max dose-response relationship was identified for the effect of atorvastatin on liver dysfunction, but the dose-response relationships for the other statins and adverse effects were inconclusive.

Conclusion : For primary prevention of cardiovascular disease, the risk of adverse events attributable to statins was low and did not outweigh their efficacy in preventing cardiovascular disease, suggesting that the benefit-to-harm balance of statins is generally favourable. Evidence to support tailoring the type or dosage of statins to account for safety concerns before starting treatment was limited.

Conclusion (proposition de traduction) : Pour la prévention primaire des maladies cardiovasculaires, le risque d'événements indésirables attribuables aux statines était faible et ne l'emportait pas sur leur efficacité dans la prévention des maladies cardiovasculaires, ce qui suggère que le rapport bénéfice-risque des statines est généralement favorable. Les preuves à l'appui de l'adaptation du type ou de la posologie des statines pour tenir compte des problèmes de sécurité avant le début du traitement étaient limitées.

Association of ultra-processed food intake with risk of inflammatory bowel disease: prospective cohort study.
Narula N, Wong ECL, Dehghan M, Mente A, Rangarajan S, Lanas F, Lopez-Jaramillo P, Rohatgi P, Lakshmi PVM, Varma RP, Orlandini A, Avezum A, Wielgosz A, Poirier P, Almadi MA, Altuntas Y, Ng KK, Chifamba J, Yeates K, Puoane T, Khatib R, Yusuf R, Boström KB, Zatonska K, Iqbal R, Weida L, Yibing Z, Sidong L, Dans A, Yusufali A, Mohammadifard N, Marshall JK, Moayyedi P, Reinisch W, Yusuf S. | BMJ. 2021 Jul 14;374:n1554
DOI: https://doi.org/10.1136/bmj.n1554  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : To evaluate the relation between intake of ultra-processed food and risk of inflammatory bowel disease (IBD).
Design : Prospective cohort study.

Méthode : 21 low, middle, and high income countries across seven geographical regions (Europe and North America, South America, Africa, Middle East, south Asia, South East Asia, and China).
Participants : 116 087 adults aged 35-70 years with at least one cycle of follow-up and complete baseline food frequency questionnaire (FFQ) data (country specific validated FFQs were used to document baseline dietary intake). Participants were followed prospectively at least every three years.
Main outcome measures: The main outcome was development of IBD, including Crohn's disease or ulcerative colitis. Associations between ultra-processed food intake and risk of IBD were assessed using Cox proportional hazard multivariable models. Results are presented as hazard ratios with 95% confidence intervals.

Résultats : Participants were enrolled in the study between 2003 and 2016. During the median follow-up of 9.7 years (interquartile range 8.9-11.2 years), 467 participants developed incident IBD (90 with Crohn's disease and 377 with ulcerative colitis). After adjustment for potential confounding factors, higher intake of ultra-processed food was associated with a higher risk of incident IBD (hazard ratio 1.82, 95% confidence interval 1.22 to 2.72 for ≥5 servings/day and 1.67, 1.18 to 2.37 for 1-4 servings/day compared with <1 serving/day, P=0.006 for trend). Different subgroups of ultra-processed food, including soft drinks, refined sweetened foods, salty snacks, and processed meat, each were associated with higher hazard ratios for IBD. Results were consistent for Crohn's disease and ulcerative colitis with low heterogeneity. Intakes of white meat, red meat, dairy, starch, and fruit, vegetables, and legumes were not associated with incident IBD.

Conclusion : Higher intake of ultra-processed food was positively associated with risk of IBD. Further studies are needed to identify the contributory factors within ultra-processed foods.

Conclusion (proposition de traduction) : Une consommation plus élevée d'aliments ultra-transformés était positivement associée au risque de maladie inflammatoire de l'intestin. D'autres études sont nécessaires pour identifier les facteurs contributifs dans les aliments ultra-transformés.

Recommended Approaches to Minimize Aerosol Dispersion of SARS-CoV-2 During Noninvasive Ventilatory Support Can Cause Ventilator Performance Deterioration: A Benchmark Comparative Study.
Patout M, Fresnel E, Lujan M, Rabec C, Carlucci A, Razakamanantsoa L, Kerfourn A, Nunes H, Tandjaoui-Lambiotte Y, Cuvelier A, Muir JF, Lalmoda C, Langevin B, Sayas J, Gonzalez-Bermejo J, Janssens JP; SomnoNIV Group. | Chest. 2021 Jul;160(1):175-186
DOI: https://doi.org/10.1016/j.chest.2021.02.047  | Télécharger l'article au format  
Keywords: COVID-19; CPAP; aerosolization; filter; noninvasive ventilation.

CRITICAL CARE - Original Research

Introduction : SARS-CoV-2 aerosolization during noninvasive positive-pressure ventilation may endanger health care professionals. Various circuit setups have been described to reduce virus aerosolization. However, these setups may alter ventilator performance.
Research question: What are the consequences of the various suggested circuit setups on ventilator efficacy during CPAP and noninvasive ventilation (NIV)?

Méthode : Eight circuit setups were evaluated on a bench test model that consisted of a three-dimensional printed head and an artificial lung. Setups included a dual-limb circuit with an oronasal mask, a dual-limb circuit with a helmet interface, a single-limb circuit with a passive exhalation valve, three single-limb circuits with custom-made additional leaks, and two single-limb circuits with active exhalation valves. All setups were evaluated during NIV and CPAP. The following variables were recorded: the inspiratory flow preceding triggering of the ventilator, the inspiratory effort required to trigger the ventilator, the triggering delay, the maximal inspiratory pressure delivered by the ventilator, the tidal volume generated to the artificial lung, the total work of breathing, and the pressure-time product needed to trigger the ventilator.

Résultats : With NIV, the type of circuit setup had a significant impact on inspiratory flow preceding triggering of the ventilator (P < .0001), the inspiratory effort required to trigger the ventilator (P < .0001), the triggering delay (P < .0001), the maximal inspiratory pressure (P < .0001), the tidal volume (P = .0008), the work of breathing (P < .0001), and the pressure-time product needed to trigger the ventilator (P < .0001). Similar differences and consequences were seen with CPAP as well as with the addition of bacterial filters. Best performance was achieved with a dual-limb circuit with an oronasal mask. Worst performance was achieved with a dual-limb circuit with a helmet interface.

Conclusion : Ventilator performance is significantly impacted by the circuit setup. A dual-limb circuit with oronasal mask should be used preferentially.

Conclusion (proposition de traduction) : Les performances du respirateur sont considérablement affectées par la configuration du circuit. Un circuit à connecteurs parallèles avec masque facial doit être utilisé de préférence.

Association between the use of balanced fluids and outcomes in critically ill children: a before and after study.
Barhight MF, Nelson D, Moran T, Christiano J, Sanchez-Pinto LN. | Crit Care. 2021 Jul 29;25(1):266
DOI: https://doi.org/10.1186/s13054-021-03705-3  | Télécharger l'article au format  
Keywords: Acute kidney injury; Balanced fluids; Mortality; Pediatric critical care.

Research

Introduction : Hyperchloremia and chloride load have been associated with worse clinical outcomes in critically ill patients. We sought to evaluate the electrolyte profile and clinical outcomes associated with a unit-wide transition from saline to balanced fluids for resuscitation and maintenance fluids in a pediatric intensive care unit (PICU).

Méthode : A before and after analysis of all patients admitted to the PICU in a large, urban, academic hospital between August 2018 and March 2020. The transition from the use of saline to the use of balanced fluids for both resuscitation and maintenance fluid as standard care occurred in June 2019. The primary outcome was day 3 acute kidney injury (AKI). The secondary outcomes included mortality, ventilator-free days (VFDs), need for renal replacement therapy (RRT), hospital length of stay (LOS), and electrolyte abnormalities.

Résultats : Overall, 2863 patients (47% female) with a day 3 AKI rate of 12.9% (n = 130) and a mortality rate of 2.8% (n = 79) were included. After adjusting for confounders (age, PRISM III, mechanical ventilation, and immunocompromised state, septic shock), there were no significant differences in the odds of day 3 AKI (pre 13%, post 12.5%; adjusted odds ratio [aOR] 0.96, 95%CI 0.65-1.42). There were no differences in the secondary outcomes. The post-intervention period had fewer patients with hyperchloremia (pre 15.5% vs. post 10.4%, p = < 0.0001) and hyperkalemia (pre 3.2% vs. post 1.4%, p = 0.02) and more patients with hypochloremia (pre 9.5% vs. post 14.4%, p = < 0.0001) and hypokalemia (pre 38.2% vs. post 47.2%, p = < 0.0001). In reference to the normochloremic cohort, the hypochloremic cohort had an increase in day 3 AKI, need for RRT, hyperchloremia, and hyperkalemia, and a decrease in hypokalemia; and the hyperchloremic cohort had an increase in VFD and a decrease in hospital LOS.

Conclusion : Following a unit-wide implementation of balanced fluids as standard care, there were no differences in rates of day 3 AKI or other clinical outcomes. However, there were lower rates of hyperkalemia and hyperchloremia and higher rates of hypokalemia and hypochloremia. Further evaluation of the effect of balanced fluids and the clinical significance of electrolyte abnormalities in critically ill children is needed.

Conclusion (proposition de traduction) : À la suite d'une mise en œuvre à l'échelle de l'unité de cristalloïdes balancés comme soins standard, il n'y avait aucune différence dans les taux de lésions rénales au 3° jour ou d'autres résultats cliniques. Cependant, il y avait des taux plus faibles d'hyperkaliémie et d'hyperchlorémie et des taux plus élevés d'hypokaliémie et d'hypochlorémie. Une évaluation plus approfondie de l'effet des cristalloïdes balancés et de la signification clinique des anomalies électrolytiques chez les enfants gravement malades est nécessaire.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Balanced Fluids in Critically Ill Children  . Rédigé par Clay Smith, le 13 September 2021.

Exhalation Spreading During Nasal High-Flow Therapy at Different Flow Rates.
Dellweg D, Kerl J, Gena AW, Alsaad H, Voelker C. | Crit Care Med. 2021 Jul 1;49(7):e693-e700
DOI: https://doi.org/10.1097/ccm.0000000000005009  | Télécharger l'article au format  
Keywords: Aucun

Online Clinical Investigation

Introduction : Severe acute respiratory syndrome coronavirus 2 is transmitted through aerosols and droplets. Nasal high-flow therapy could possibly increase the spreading of exhalates from patients. The aim of this study is to investigate whether nasal high-flow therapy affects the range of the expiratory plume compared with spontaneous breathing.
Design : Interventional experiment on single breaths of a healthy volunteer.

Méthode : Research laboratory at the Bauhaus-University Weimar.
Subjects : A male subject.
Interventions: Videos and images from a schlieren optical system were analyzed during spontaneous breathing and different nasal high-flow rates.

Résultats : The maximal exhalation spread was 0.99, 2.18, 2.92, and 4.1 m during spontaneous breathing, nasal high-flow of 20 L/min, nasal high-flow of 40 L/min, and nasal high-flow of 60 L/min, respectively. Spreading of the expiratory plume in the sagittal plane can completely be blocked with a surgical mask.

Conclusion : Nasal high-flow therapy increases the range of the expiratory air up to more than 4 meters. The risk to pick up infectious particles could be increased within this range. Attachment of a surgical mask over the nasal high-flow cannula blocks the expiratory airstream.

Conclusion (proposition de traduction) : La thérapeutique par nasale à haut débit augmente la portée de l'air expiratoire jusqu'à plus de 4 mètres. Le risque de contracter des particules infectieuses pourrait être accru dans cette plage. L'utilisation d'un masque chirurgical sur la canule nasale à haut débit bloque le flux d'air expiratoire.

Inter-regional transfers for pandemic surges were associated with reduced mortality rates.
Guillon A, Laurent E, Godillon L, Kimmoun A, Grammatico-Guillon L. | Intensive Care Med. 2021 Jul;47(7):798-800
DOI: https://doi.org/10.1007/s00134-021-06412-3  | Télécharger l'article au format  
Keywords: Aucun

Letter

Editorial : The spread of the coronavirus disease 2019 (COVID- 19) pandemic has shown important spatial heterogene- ity of in-hospital COVID-19 cases and deaths between countries and regions. Across metropolitan France, the healthcare system has been overwhelmed by the pandemic surge unequally over the regions, leading to the inability to provide care in areas with outpaced resources.

Discussion : 

Conclusion : The regions overwhelmed by the pandemic surge have experienced an unprecedented shortage of ICU beds and qualified ICU staff. We demonstrated that the benefit to remove patients from areas with out- paced resources was greatly superior to the risk of complication due to long-distance transfers of ventilated patients. In conditions with regional planning and trained teams, ICU evacuations are an appropriate solution to help manage the spatial dimension of the pandemic.

Conclusion (proposition de traduction) : Les régions submergées par la flambée de pandémie ont connu une pénurie sans précédent de lits de soins intensifs et de personnel de soins intensifs qualifié. Nous avons démontré que le bénéfice de retirer les patients des zones aux ressources dépassées était largement supérieur au risque de complications dues aux transferts à longue distance de patients ventilés. Dans des conditions d'aménagement du territoire et d'équipes formées, les évacuations en soins intensifs sont une solution appropriée pour aider à gérer la dimension spatiale de la pandémie.

Personal protective equipment and doffing procedures in out-of-hospital practice: assessment with a contamination simulation.
Pottier F, Groizard C, Briche G et al.. | Internat J Emerg Med.. 2021 jul 14(1):35
DOI: https://doi.org/10.1186/s12245-021-00362-9  | Télécharger l'article au format  
Keywords: Emergency medical service, Personal protective equipment, Simulation, Healthcare workers, Doffing

NOTES FROM THE FIELD

Introduction : The use of personal protective equipment (PPE) by emergency medical services (EMS) providers requires specific attention, as it takes place in out-of-hospital unsecured settings. The aim of this study was to evaluate which PPE gown was less contaminating during doffing procedures in an EMS setting. Six well-trained healthcare worker (HCW) subjects tested 4 different gowns: (1) surgical gowns (SG), (2) full body coveralls (FBC), (3) self-made alternative PPEs (SMP), and (4) non-surgical isolation gowns (NSIG). An invisible tracer was sprayed on the gown after donning each subject. After doffing, each HCW was photographed under UV lights to show areas of fluorescent “contamination” on their clothes. The number, size, and intensity level of contaminated areas were noted, as well as observational deviation from the procedure and doffing time. In addition, the subjects were asked to take a questionnaire about their perception of the level of comfort, ease of doffing, and overall safety for each gown.

Résultats : Despite a well-trained team of HCW subjects, contamination while doffing was observed with every type of PPE gown, and with each HCW subject. All body areas were contaminated at least once, except the face. Contamination was more frequent while doffing FBCs. On the other hand, the removal of SG was found to be the least contaminating. The mean doffing time was significantly shorter with SG 1:29 and longer with FBC 2:26 (p= 0.005).

Conclusion : Results of this study converge towards the selection of surgical gowns over other types of PPE gowns, which met both contamination criteria as well as staff appreciation in this context. Specific attention should be paid to the legs and abdomino-pelvic areas. Additional protection such as protective trousers or aprons could be added.

Conclusion (proposition de traduction) : Les résultats de cette étude convergent vers la sélection des blouses chirurgicales par rapport aux autres types de blouses EPI, qui répondaient à la fois aux critères de contamination et à l'appréciation du personnel dans ce contexte. Une attention particulière doit être portée aux jambes et aux zones abdomino-pelviennes. Des protections supplémentaires telles que des pantalons de protection ou des tabliers pourraient être ajoutées.

Acute and delayed intracranial hemorrhage in head-injured patients on warfarin versus direct oral anticoagulant therapy.
Hughes P, Alter S, Greaves S, Mazer B, Solano J, Shih R, et al.. | J Emerg Trauma Shock [Internet]. 2021 Jul 1;14(3):123–7 - DOI: 10.4103/JETS.JETS_139_20
DOI: https://www.onlinejets.org/article.asp?issn=0974-2700;year=2021;volume=14;issue=3;spage=123;epage=127;aulast=Hughes;type=0  | Télécharger l'article au format  
Keywords: Anticoagulants, direct oral anticoagulant, head injury, intracranial hemorrhage, warfarin

ORIGINAL ARTICLE

Introduction : Direct oral anticoagulant (DOAC) use for thrombosis treatment and prophylaxis is a popular alternative to warfarin. This study compares rates of traumatic intracranial hemorrhage (ICH) for patients on anticoagulant therapies and the effect of combined anticoagulant and antiplatelet therapies.

Méthode : A retrospective observational study of trauma patients was conducted at two level I trauma centers. Patients aged ≥18 years with preinjury use of an anticoagulant (warfarin, rivaroxaban, apixaban, or dabigatran) who sustained a blunt head injury within the past day were included. Patients were evaluated by head CT to evaluate for ICH.

Résultats : Three hundred and eighty-eight patients were included (140 on warfarin, 149 on a DOAC, and 99 on combined anticoagulant and antiplatelet therapies). Seventy-nine patients (20.4%) had an acute ICH, while 16 patients (4.1%) had a delayed ICH found on routine repeat CT. Those on combination therapy were not at increased risk of acute ICH (relative risk [RR] 0.90, confidence interval [CI]: 0.56–1.44; P > 0.5) or delayed ICH (RR 2.19, CI: 0.84–5.69; P = 0.10) compared to anticoagulant use only. Those on warfarin were at increased risk of acute ICH (RR 1.75, CI: 1.10–2.78, P = 0.015), but not delayed ICH (RR 0.99, CI 0.27–3.59, P > 0.5), compared to those on DOACs. No delayed ICH patients died or required neurosurgical intervention.

Conclusion : Patients on warfarin had a higher rate of acute ICH, but not delayed ICH, compared to those on DOACs. Given the low rate of delayed ICH with no resultant morbidity or mortality, routine observation and repeat head CT on patients with no acute ICH may not be necessary.

Conclusion (proposition de traduction) : Les patients sous warfarine présentaient un taux plus élevé d'hémorragie intracrânienne aiguë, mais pas d'hémorragie intracrânienne retardée, par rapport à ceux sous AOD. Étant donné le faible taux d'hémorragie intracrânienne retardée sans morbidité ou mortalité qui en résulte, une mise en observation de routine et une tomodensitométrie de la tête répétée chez les patients sans hémorragie intracrânienne aiguë peuvent ne pas être nécessaires.

Conservative oxygen therapy for critically ill patients: a meta-analysis of randomized controlled trials.
Chen XL, Zhang BL, Meng C, Huang HB, Du B. | J Intensive Care. 2021 Jul 22;9(1):47. 2021 Jul 22;9(1):47
DOI: https://doi.org/10.1186/s40560-021-00563-7  | Télécharger l'article au format  
Keywords: Conservative oxygen strategy; Critically ill; Meta-analysis; Mortality.

Research

Introduction : Conservative oxygen strategy is recommended in acute illness while its benefit in ICU patients remains controversial. Therefore, we sought to conduct a systematic review and meta-analysis to examine such oxygen strategies' effect and safety in ICU patients.

Méthode : We searched PubMed, Embase, and the Cochrane database from inception to Feb 15, 2021. Randomized controlled trials (RCTs) that compared a conservative oxygen strategy to a conventional strategy in critically ill patients were included. Results were expressed as mean difference (MD) and risk ratio (RR) with a 95% confidence interval (CI). The primary outcome was the longest follow-up mortality. Heterogeneity, sensitivity analysis, and publication bias were also investigated to test the robustness of the primary outcome.

Résultats : We included seven trials with a total of 5265 patients. In general, the conventional group had significantly higher SpO2 or PaO2 than that in the conservative group. No statistically significant differences were found in the longest follow-up mortality (RR, 1.03; 95% CI, 0.97-1.10; I2=18%; P=0.34) between the two oxygen strategies when pooling studies enrolling subjects with various degrees of hypoxemia. Further sensitivity analysis showed that ICU patients with mild-to-moderate hypoxemia (PaO2/FiO2 >100 mmHg) had significantly lower mortality (RR, 1.24; 95% CI, 1.05-1.46; I2=0%; P=0.01) when receiving conservative oxygen therapy. These findings were also confirmed in other study periods. Additional, secondary outcomes of the duration of mechanical ventilation, the length of stay in the ICU and hospital, change in sequential organ failure assessment score, and adverse events were comparable between the two strategies.

Conclusion : Our findings indicate that conservative oxygen therapy strategy did not improve the prognosis of the overall ICU patients. The subgroup of ICU patients with mild to moderate hypoxemia might obtain prognosis benefit from such a strategy without affecting other critical clinical results.

Conclusion (proposition de traduction) : Nos résultats indiquent que la stratégie d'oxygénothérapie conservatrice n'a pas amélioré le pronostic de l'ensemble des patients en soins intensifs. Le sous-groupe de patients en soins intensifs atteints d'hypoxémie légère à modérée pourrait tirer un avantage pronostique d'une telle stratégie sans affecter d'autres résultats cliniques critiques.

Primary success of electrical cardioversion for new-onset atrial fibrillation and its association with clinical course in non-cardiac critically ill patients: sub-analysis of a multicenter observational study.
Shima N, Miyamoto K, Kato S, Yoshida T, Uchino S; AFTER-ICU study group. | J Intensive Care. 2021 Jul 8;9(1):46
DOI: https://doi.org/10.1186/s40560-021-00562-8  | Télécharger l'article au format  
Keywords: Electrical cardioversion; Mortality; New-onset atrial fibrillation; Rhythm control strategy.

Research

Introduction : Electrical cardioversion (ECV) is widely used to restore sinus rhythm in critically ill adult patients with atrial fibrillation, although its prognostic value is uncertain. This study aims to elucidate the clinical meaning of successful ECV.

Méthode : This is a sub-analysis of the AFTER-ICU study, a multicenter prospective study with a cohort of 423 adult non-cardiac patients with new-onset atrial fibrillation (AF). Patients that underwent ECV within 7 days after initial onset of AF were included in the sub-analysis. We compared intensive care unit (ICU) and overall hospital mortality, survival time within 30 days, cardiac rhythm at ICU discharge, and the length of ICU and overall hospital stay between patients whose sinus rhythm was restored immediately after the first ECV session (primary success group) and those in whom it was not restored (unsuccessful group). To find the factors related to the primary success of ECV, we also compared patient characteristics, the delivered energy, and pretreatment.

Résultats : Sixty-five patients received ECV and were included in this study. Although 35 patients (54%) had primary success, recurrence of AF occurred in 24 of these patients (69%). At ICU discharge, three patients still had AF in the unsuccessful group, but no patients in the primary success group still had AF. ICU mortality was 34% in the primary success group and 17% in the unsuccessful group (P = 0.10). Survival time within 30 days did not differ between the groups. Delivered energy and pretreatment were not associated with primary success of ECV.

Conclusion : The primary success rate of ECV for new-onset AF in adult non-cardiac ICU population was low, and even if it succeeded, the subsequent recurrence rate was high. Primary success of ECV did not affect the rate of mortality. Pretreatment and delivered energy were not associated with the primary success of ECV.

Conclusion (proposition de traduction) : Le taux de réussite à la première tentative de la cardioversion électrique pour la fibrillation atriale d'apparition récente dans la population adulte de soins intensifs non cardiaques était faible, et même s'il réussissait, le taux de récidive ultérieur était élevé. Le succès à la première tentative de la cardioversion électrique n'a pas affecté le taux de mortalité. Le prétraitement et l'énergie délivrée n'étaient pas associés au succès initial de la cardioversion électrique.

Conservative oxygen therapy for critically ill patients: a meta-analysis of randomized controlled trials.
Chen XL, Zhang BL, Meng C, Huang HB, Du B. | J Intensive Care. 2021 Jul 22;9(1):47. 2021 Jul 22;9(1):47
DOI: https://doi.org/10.1186/s40560-021-00563-7  | Télécharger l'article au format  
Keywords: Conservative oxygen strategy; Critically ill; Meta-analysis; Mortality.

Research

Introduction : Conservative oxygen strategy is recommended in acute illness while its benefit in ICU patients remains controversial. Therefore, we sought to conduct a systematic review and meta-analysis to examine such oxygen strategies' effect and safety in ICU patients.

Méthode : We searched PubMed, Embase, and the Cochrane database from inception to Feb 15, 2021. Randomized controlled trials (RCTs) that compared a conservative oxygen strategy to a conventional strategy in critically ill patients were included. Results were expressed as mean difference (MD) and risk ratio (RR) with a 95% confidence interval (CI). The primary outcome was the longest follow-up mortality. Heterogeneity, sensitivity analysis, and publication bias were also investigated to test the robustness of the primary outcome.

Résultats : We included seven trials with a total of 5265 patients. In general, the conventional group had significantly higher SpO₂ or PaO₂ than that in the conservative group. No statistically significant differences were found in the longest follow-up mortality (RR, 1.03; 95% CI, 0.97-1.10; I²=18%; P=0.34) between the two oxygen strategies when pooling studies enrolling subjects with various degrees of hypoxemia. Further sensitivity analysis showed that ICU patients with mild-to-moderate hypoxemia (PaO₂/FiO₂ >100 mmHg) had significantly lower mortality (RR, 1.24; 95% CI, 1.05-1.46; I²=0%; P=0.01) when receiving conservative oxygen therapy. These findings were also confirmed in other study periods. Additional, secondary outcomes of the duration of mechanical ventilation, the length of stay in the ICU and hospital, change in sequential organ failure assessment score, and adverse events were comparable between the two strategies.

Conclusion : Our findings indicate that conservative oxygen therapy strategy did not improve the prognosis of the overall ICU patients. The subgroup of ICU patients with mild to moderate hypoxemia might obtain prognosis benefit from such a strategy without affecting other critical clinical results.

Conclusion (proposition de traduction) : Nos résultats indiquent que la stratégie d'oxygénothérapie conservatrice n'a pas amélioré le pronostic de l'ensemble des patients en soins intensifs. Le sous-groupe de patients en soins intensifs atteints d'hypoxémie légère à modérée pourrait tirer un avantage pronostique d'une telle stratégie sans affecter d'autres résultats cliniques critiques.

Identifying Risk Factors for Elbow Injury in Children Presenting to the Emergency Department With Distal Forearm Fractures.
Rubinstein M, Hirway P, Zonfrillo MR. | Pediatr Emerg Care. 2021 Jul 1;37(7):352-356
DOI: https://doi.org/10.1097/pec.0000000000002176
Keywords: Aucun

Original article

Introduction : Pediatric distal forearm fractures are one of the most common injuries seen in the emergency department. Orthopedic teaching instructs providers to radiograph the joint above and the joint below the fracture site for concurrent injury. Despite this teaching, there is little evidence to suggest that elbow injuries are common in children with distal forearm fractures. Similarly, there are few data that help the clinician predict which children are at higher risk for co-injury.

Méthode : We conducted a cross-sectional analysis of the 2011 National Emergency Department Sample data set. Children aged 2 to 17 years with an International Classification of Disease, Ninth Revision, code for a distal forearm fracture were included in the study. The primary outcome of interest was an "elbow" injury, defined as an International Classification of Disease, Ninth Revision, code for proximal radius, proximal ulna, or distal humeral fracture or dislocation. Multivariable logistic regression was performed using patient demographics, injury severity score, mechanism of injury, and underlying medical conditions.

Résultats : A total of 54,262 children with a distal forearm fracture were identified. Of these children, only 0.8% (n = 463) had an elbow injury. Supracondylar fractures of the humerus were the most common elbow injury seen (48.2% of elbow injuries seen). Children were more likely to have a co-injury if they were younger (9.8 years vs 8.3 years, P < 0.01), female (36% vs 44%, P < 0.01), injured via fall (68% vs 76%, P < 0.01), had a higher injury severity score (4.1 vs 4.5, P < 0.01), or were admitted for their injuries (1.5% vs 15.7%, P < 0.01). In the adjusted model, only age and disposition were predictors of co-injury. Isolated buckle fracture of the radius and metaphyseal fracture of the radius with dorsal angulation were protective against elbow injury (odds ratio = 0.39 and 0.60, respectively).

Conclusion : Children with distal forearm fractures very rarely have concurrent elbow injuries. These injuries are more likely in younger female children.

Conclusion (proposition de traduction) : Les enfants présentant des fractures distales de l'avant-bras ont très rarement des lésions concomitantes au coude. Ces blessures sont plus fréquentes chez les jeunes filles.

Treatment Outcomes of Pediatric Status Epilepticus in a Tertiary Pediatric Intensive Care Unit.
Cavusoglu D, Sınmaz EE, Dundar NO, Can FK, Anil AB, Sarioglu B. | Pediatr Emerg Care. 2021 Jul 1;37(7):360-364
DOI: https://doi.org/10.1097/pec.0000000000001914
Keywords: Aucun

Original article

Introduction : Status epilepticus is associated with high rates of morbidity and mortality; thus, early diagnosis and proper treatment are crucial. We aimed to study the etiology, clinical features, and treatment among pediatric patients with convulsive status epilepticus.

Méthode : The medical records of 100 patients were retrospectively obtained from pediatric intensive care unit. Etiology, clinical features, and treatment were interpreted by using Fisher exact test, χ2 test, and Spearman ρ correlation coefficient.

Résultats : Seizures had stopped with the first-, second-, and third-line treatment in 29%, 36%, and 35% of the patients, respectively. Only phenytoin treatment was efficient; it has 32.3% rate in second-line treatment. Whereas mortality rate was 10%, morbidity rate was 14% during the follow-up. Epilepsy, hemiparesis, spastic tetraparesis, and mental retardation developed. Mortality was significantly much more in the patients with refractory seizure and cerebral palsy. Development of mental retardation was much higher in the male sex.

Conclusion : Phenytoin is still one of the most efficient antiepileptic drugs. If the duration of status epilepticus can be shortened by prompt treatment, neurological complications may be prevented.

Conclusion (proposition de traduction) : La phénytoïne reste l'un des médicaments antiépileptiques les plus efficaces. Si la durée de l'état de mal épileptique est raccourcie par un traitement rapide, les complications neurologiques peuvent être évitées.

Cerebral Oximetry during Out-of-Hospital Resuscitation: Pilot Study of First Responder Implementation.
Shin J, Walker R, Blackwood J, Chapman F, Crackel J, Kudenchuk P, Rea T. | Prehosp Emerg Care. 2021 Jul 27:1-5
DOI: https://doi.org/10.1080/10903127.2021.1948647
Keywords: cerebral oximetry; emergency medical services; out-of-hospital cardiac arrest.

Article

Introduction : Anoxic brain injury is a common mode of death following out-of-hospital cardiac arrest (OHCA). We assessed the course of regional cerebral oxygen saturation (rSO2) at the outset and during first responder resuscitation to understand its relationship with return of spontaneous circulation (ROSC) and functional survival.

Méthode : We undertook a prospective observational investigation of adult OHCA patients treated by a first-responder EMS agency in King County, WA. Cerebral oximetry was performed using the SenSmart® Model X-100 Universal Oximetry System (Nonin Medical, Inc). We determined cerebral oximetry rSO2 overall and stratified according to ROSC and favorable survival status defined by Cerebral Performance Category (CPC) of 1-2.

Résultats : Among the 59 OHCA cases enrolled, 47% (n = 28) achieved ROSC and 14% (n = 8) survived with CPC 1-2. On average, initial rSO2 cerebral oximetry was 41% and was not different at the outset according to return of spontaneous circulation (ROSC) or survival status. Within 5 minutes of first responder resuscitation, those who would subsequently achieve ROSC had a higher rSO2 than those who would not achieve ROSC (51% vs. 43%, p = 0.03). Among patients who achieved ROSC, those who would survive with CPC 1-2 had a higher rSO2 cerebral oximetry following ROSC than nonsurvivors (74% vs. 60%, p = 0.04 at 5 minutes post ROSC), a difference that was not evident in the minutes prior to ROSC (55% vs. 51% at 3 minutes prior to ROSC, p = 0.5).

Conclusion : In this observational study, where first responders applied cerebral oximetry, higher rSO2 during the course of care predicted ROSC among all patients and predicted favorable survival among those who achieved ROSC. Future investigation should evaluate whether and how treatments might modify rSO2 and in turn may influence prognosis.

Conclusion (proposition de traduction) : Dans cette étude observationnelle, où les premiers intervenants utilisaient l'oxymétrie cérébrale, une saturation cérébrale régionale en oxygène plus élevée au cours des soins prédisait le retour à une activité circulatoire spontanée chez tous les patients et prédisait une survie favorable chez ceux qui ont obtenu un retour à une activité circulatoire spontanée. Les recherches futures devraient évaluer si et comment les traitements pourraient modifier la saturation cérébrale régionale en oxygène et, à son tour, influencer le pronostic.

Prehospital Airway Management: A Systematic Review.
Carney N, Totten AM, Cheney T, Jungbauer R, Neth MR, Weeks C, Davis-O'Reilly C, Fu R, Yu Y, Chou R, Daya M. | Prehosp Emerg Care. 2021 Jul 20:1-12
DOI: https://doi.org/10.1080/10903127.2021.1940400
Keywords: airway management; comparative effectiveness; prehospital; systematic review.

Article

Introduction : To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics.

Méthode : We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020.
Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age.

Résultats : We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults.

Conclusion : The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.

Conclusion (proposition de traduction) : Les preuves actuellement disponibles, basées sur la survie, la fonction neurologique, le retour à une activité circulatoire spontanée ou la réussie de l'intubation des voies aériennes, ne permettent pas de trouver un avantage pour les approches plus invasives des voies aériennes supérieures. La force des preuves était faible ou modérée ; la plupart des études incluses étaient observationnelles. Cela confirme le besoin d'essais contrôlés randomisés de haute qualité pour faire progresser la pratique clinique et l'éducation et la politique des services médicaux d'urgence, et améliorer les résultats centrés sur le patient.

Coronary angiography findings in patients with shock-resistant ventricular fibrillation cardiac arrest.
Nas J, Thannhauser J, van Dijk EGJA, Verkroost C, Damman P, van Wely M, van Geuns RJ, van Royen N, de Boer MJ, Bonnes JL, Ten Cate T, Brouwer MA. | Resuscitation. 2021 Jul;164:54-61
DOI: https://doi.org/10.1016/j.resuscitation.2021.05.006  | Télécharger l'article au format  
Keywords: Cardiac arrest; Coronary angiography; Resuscitation; Ventricular fibrillation.

Clinical paper

Introduction : Shock-resistant ventricular fibrillation (VF) poses a therapeutic challenge during out-of-hospital cardiac arrest (OHCA). For these patients, new treatment strategies are under active investigation, yet underlying trigger(s) and substrate(s) have been poorly characterised, and evidence on coronary angiography (CAG) data is often limited to studies without a control group.

Méthode : In our OHCA-registry, we studied CAG-findings in OHCA-patients with VF who underwent CAG after hospital arrival. We compared baseline demographics, arrest characteristics, CAG-findings and outcomes between patients with VF that was shock-resistant (defined as >3 shocks) or not shock-resistant (≤3 shocks).

Résultats : Baseline demographics, arrest location, bystander resuscitation and AED-use did not differ between 105 patients with and 196 patients without shock-resistant VF. Shock-resistant VF-patients required more shocks, with higher proportions endotracheal intubation, mechanical CPR, amiodaron and epinephrine. In both groups, significant coronary artery disease (≥1 stenosis >70%) was highly prevalent (78% vs. 77%, p = 0.76). Acute coronary occlusions (ACOs) were more prevalent in shock-resistant VF-patients (41% vs. 26%, p = 0.006). Chronic total occlusions did not differ between groups (29% vs. 33%, p = 0.47). There was an association between increasing numbers of shocks and a higher likelihood of ACO. Shock-resistant VF-patients had lower proportions 24-h survival (75% vs. 93%, p < 0.001) and survival to discharge (61% vs. 78%, p = 0.002).

Conclusion : In this cohort of OHCA-patients with VF and CAG after transport, acute coronary occlusions were more prevalent in patients with shock-resistant VF compared to VF that was not shock-resistant, and their clinical outcome was worse. Confirmative studies are warranted for this potentially reversible therapeutic target.

Conclusion (proposition de traduction) : Dans cette cohorte de patients en arrêt cardiaque extra-hospitalier se présentant avec une fibrillation ventriculaire et une coronarographie après transport, les occlusions coronaires aiguës étaient plus fréquentes chez les patients présentant une fibrillation ventriculaire résistante aux chocs par rapport à une fibrillation ventriculaire qui n'était pas résistante aux chocs, et leur résultat clinique était pire. Des études de confirmation sont justifiées pour cette cible thérapeutique potentiellement réversible.

To transport or to terminate resuscitation on-site. What factors influence EMS decisions in patients without ROSC? A mixed-methods study.
de Graaf C, de Kruif AJTCM, Beesems SG, Koster RW. | Resuscitation. 2021 Jul;164:84-92
DOI: https://doi.org/10.1016/j.resuscitation.2021.05.005  | Télécharger l'article au format  
Keywords: Decision-making; OHCA; ROSC; Transport practices.

Clinical paper

Introduction : If a patient in out-of-hospital cardiac arrest (OHCA) does not achieve return of spontaneous circulation (ROSC) despite advanced life support, emergency medical services can decide to either transport the patient with ongoing CPR or terminate resuscitation on scene.
Purpose : To determine differences between patients without ROSC to be transported vs. terminated on scene and explore medical and nonmedical factors that contribute to the decision-making of paramedics on scene.

Méthode : Mixed-methods approach combining quantitative and qualitative data. Quantitative data on all-cause OHCA patients without ROSC on scene, between January 1, 2012, and December 31, 2016, in the Amsterdam Resuscitation Study database, were analyzed to find factors associated with decision to transport. Qualitative data was collected by performing 16 semi-structured interviews with paramedics from the study region, transcribed and coded to identify themes regarding OHCA decision-making on the scene.

Résultats : In the quantitative Utstein dataset, of 5870 OHCA patients, 3190 (54%) patients did not achieve ROSC on scene. In a multivariable model, age (OR 0.98), public location (OR 2.70), bystander witnessed (OR 1.65), EMS witnessed (OR 9.03), and first rhythm VF/VT (OR 11.22) or PEA (OR 2.34), were independently associated with transport with ongoing CPR. The proportion of variance explained by the model was only 0.36. With the qualitative method, four main themes were identified: patient-related factors, local circumstances, paramedic-related factors, and the structure of the organization.

Conclusion : In patients without ROSC on scene, besides known resuscitation characteristics, the decision to transport a patient is largely determined by non-protocollized factors.

Conclusion (proposition de traduction) : Chez les patients sans retour d'activité cardiaque spontanée (RACS) sur les lieux d'intervention, outre les caractéristiques de réanimation connues, la décision de transporter un patient est largement déterminée par des facteurs non-protocolisés.

The effect of immediate coronary angiography after cardiac arrest without ST-segment elevation on left ventricular function. A sub-study of the COACT randomised trial.
Lemkes JS, Spoormans EM, Demirkiran A, and al.. | Resuscitation. 2021 Jul;164:93-100
DOI: https://doi.org/10.1016/j.resuscitation.2021.04.020  | Télécharger l'article au format  
Keywords: Coronary angiography; Left ventricular function; Out of hospital cardiac arrest; Percutaneous coronary intervention.

Clinical paper

Introduction : The effect of immediate coronary angiography and percutaneous coronary intervention (PCI) in patients who are successfully resuscitated after cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) on left ventricular function is currently unknown.

Méthode : This prespecified sub-study of a multicentre trial evaluated 552 patients, successfully resuscitated from out-of-hospital cardiac arrest without signs of STEMI. Patients were randomized to either undergo immediate coronary angiography or delayed coronary angiography, after neurologic recovery. All patients underwent PCI if indicated. The main outcomes of this analysis were left ventricular ejection fraction and end-diastolic and systolic volumes assessed by cardiac magnetic resonance imaging or echocardiography.

Résultats : Data on left ventricular function was available for 397 patients. The mean (± standard deviation) left ventricular ejection fraction was 45.2% (±12.8) in the immediate angiography group and 48.4% (±13.2) in the delayed angiography group (mean difference: -3.19; 95% confidence interval [CI], -6.75 to 0.37). Median left ventricular end-diastolic volume was 177 ml in the immediate angiography group compared to 169 ml in the delayed angiography group (ratio of geometric means: 1.06; 95% CI, 0.95-1.19). In addition, mean left ventricular end-systolic volume was 90 ml in the immediate angiography group compared to 78 ml in the delayed angiography group (ratio of geometric means: 1.13; 95% CI 0.97-1.32).

Conclusion : In patients successfully resuscitated after out-of-hospital cardiac arrest and without signs of STEMI, immediate coronary angiography was not found to improve left ventricular dimensions or function compared with a delayed angiography strategy.

Conclusion (proposition de traduction) : Chez les patients réanimés avec succès après un arrêt cardiaque extra-hospitalier et sans signe d'infarctus du myocarde avec élévation du segment ST, la coronarographie immédiate n'a pas amélioré les dimensions ou la fonction ventriculaire gauche par rapport à une stratégie d'angiographie différée.

Soufflet M, Thibon P, Levallois L, Huet J. | Sages-Femmes. 2021;20(4):51–6
DOI: https://www.sciencedirect.com/science/article/pii/S1637408821001061
Keywords: neonatal risk ; obstetrical risk ; out-of-hospital delivery ; predictive factor ; prevention ; training

Recherche

Editorial : Une étude rétrospective cas-témoins sur les accouchements extrahospitaliers inopinés à terme a été réalisée au centre hospitalier universitaire de Caen durant six ans. Malgré la politique de centralisation des maternités, leur incidence semble stable dans ce secteur géographique. Un certain nombre de facteurs de risque ont été identifiés. Si la morbidité maternelle n’augmente pas dans ce contexte, l’hypothermie néonatale est plus fréquente. Les efforts de prévention et de formation doivent être poursuivis.

Conclusion : Les données sur les accouchement extra-hospitalier (AEH) ont pu être actualisées dans la zone d’étude, puis comparées à celles recueillies sur le même secteur durant la période 2002-2009. L’incidence de ces événements semble être stable, ainsi que le profil des mères accouchant dans ces conditions. La distance domicile-maternité, qui croît globalement en France dans un contexte de centralisation de l’offre de soins, ne semble pas avoir eu pour conséquence une augmentation des AEH. Les efforts de prévention et de formation doivent être poursuivis pour réduire l’occurrence des accouchements inopinés et les complications associées, et améliorer a posteriori le vécu de l’accouchement

Coulm B | Sages-Femmes. 2021 juillet;20(4):28-32
DOI: https://www.sciencedirect.com/science/article/pii/S1637408821001012
Keywords: breastfeeding; medicine; newborn; prescription

Clinique

Editorial :  La prise médicamenteuse en cours d’allaitement est une situation fréquente et parfois complexe. Les données utiles pour guider la prescription sont souvent parcellaires. Toutefois, il est généralement possible de trouver un médicament compatible avec l’allaitement. Il importe de connaître quelques notions permettant d’évaluer le risque, ainsi que les diff érentes conduites à tenir pouvant être établies en fonction des infor-mations disponibles pour chaque molécule.

Conclusion :  La nécessité d’un traitement médicamenteux ne doit pas conduire à proposer systématiquement une suspension ou un arrêt de l’allaitement maternel, car, dans la très grande majorité des cas, une solution adaptée peut être proposée. Il convient de tenir compte des données pharmacologiques et cliniques disponibles concernant le médicament et l’allaitement, mais aussi des caractéristiques propres à chaque mère et à chaque enfant (âge, nombre de tétées quotidiennes, pathologies éventuelles, etc.). Le prescripteur doit donc être informé du fait que sa patiente allaite. Il doit, en outre, disposer d’une formation adéquate et/ou savoir où trouver des informations pertinentes et valides pour accompagner au mieux chaque mère.

Reliability of mechanical ventilation during continuous chest compressions: a crossover study of transport ventilators in a human cadaver model of CPR.
Orlob S, Wittig J, Hobisch C, Auinger D, Honnef G, Fellinger T, Ristl R, Schindler O, Metnitz P, Feigl G, Prause G. | Scand J Trauma Resusc Emerg Med. 2021 Jul 28;29(1):102
DOI: https://doi.org/10.1186/s13049-021-00921-2  | Télécharger l'article au format  
Keywords: Artificial respiration; Cardiac arrest; Cardiopulmonary resuscitation; Out-of-hospital cardiac arrest; Reversed airflow; Tidal volume; Ventilators, mechanical.

Original research

Introduction : Previous studies have stated that hyperventilation often occurs in cardiopulmonary resuscitation (CPR) mainly due to excessive ventilation frequencies, especially when a manual valve bag is used. Transport ventilators may provide mandatory ventilation with predetermined tidal volumes and without the risk of hyperventilation. Nonetheless, interactions between chest compressions and ventilations are likely to occur. We investigated whether transport ventilators can provide adequate alveolar ventilation during continuous chest compression in adult CPR.

Méthode : A three-period crossover study with three common transport ventilators in a cadaver model of CPR was carried out. The three ventilators 'MEDUMAT Standard²', 'Oxylog 3000 plus', and 'Monnal T60' represent three different interventions, providing volume-controlled continuous mandatory ventilation (VC-CMV) via an endotracheal tube with a tidal volume of 6 mL/kg predicted body weight. Proximal airflow was measured, and the net tidal volume was derived for each respiratory cycle. The deviation from the predetermined tidal volume was calculated and analysed. Several mixed linear models were calculated with the cadaver as a random factor and ventilator, height, sex, crossover period and incremental number of each ventilation within the period as covariates to evaluate differences between ventilators.

Résultats : Overall median deviation of net tidal volume from predetermined tidal volume was - 21.2 % (IQR: 19.6, range: [- 87.9 %; 25.8 %]) corresponding to a tidal volume of 4.75 mL/kg predicted body weight (IQR: 1.2, range: [0.7; 7.6]). In a mixed linear model, the ventilator model, the crossover period, and the cadaver's height were significant factors for decreased tidal volume. The estimated effects of tidal volume deviation for each ventilator were - 14.5 % [95 %-CI: -22.5; -6.5] (p = 0.0004) for 'Monnal T60', - 30.6 % [95 %-CI: -38.6; -22.6] (p < 0.0001) for 'Oxylog 3000 plus' and - 31.0 % [95 %-CI: -38.9; -23.0] (p < 0.0001) for 'MEDUMAT Standard²'.

Conclusion : All investigated transport ventilators were able to provide alveolar ventilation even though chest compressions considerably decreased tidal volumes. Our results support the concept of using ventilators to avoid excessive ventilatory rates in CPR. This experimental study suggests that healthcare professionals should carefully monitor actual tidal volumes to recognise the occurrence of hypoventilation during continuous chest compressions.

Conclusion (proposition de traduction) : Tous les respirateurs de transport étudiés ont été capables de fournir une ventilation alvéolaire même si les compressions thoraciques ont considérablement diminué par les volumes courants.
Nos résultats soutiennent le concept de l'utilisation de respirateurs pour éviter des taux ventilatoires excessifs lors de la RCP. Cette étude expérimentale suggère que les professionnels de la santé devraient surveiller attentivement les volumes courants réels pour reconnaître l'apparition d'une hypoventilation pendant les compressions thoraciques continues.

Complications of Hemorrhagic Shock and Massive Transfusion-a Comparison Before and After the Damage Control Resuscitation Era.
Black JA, Pierce VS, Juneja K, Holcomb JB. | Shock. 2021 Jul 1;56(1):42-51.
DOI: https://doi.org/10.1097/shk.0000000000001676
Keywords: Aucun

Review Article

Editorial : Trauma remains a leading cause of death, and hemorrhage is the leading cause of preventable trauma deaths. Resuscitation strategies in trauma have changed dramatically over the last 20 years. In the pre damage control resuscitation (DCR) era, we used large volume crystalloid resuscitation and packed red blood cells as the primary resuscitative fluids. Now, a 1:1:1 ratio of packed red blood cells, fresh plasma, and platelets with minimal crystalloids is the preferred resuscitative strategy (DCR era). As we have changed how we resuscitate patients, the detrimental effects associated with large volume resuscitation have also changed. In this article, we review the effects of large volume blood product resuscitation, and where possible present a contrast between the pre-DCR era and the DCR era resuscitation strategies.

Conclusion : With respect to hemorrhagic shock, the data is clear that DCR is the standard of care (38) and provides a mortality benefit. Balanced blood product resuscitation seeks to replicate the whole blood that the patient is losing via hemorrhage. Prospective trials comparing the efficacy of whole blood to component therapy are in the planning stages and may show that whole blood is superior to 1:1:1 blood product resuscitation, but that remains to be seen. Regardless, it seems clear that the pre-DCR era resuscitation strategies that used large-volume crystalloid and relatively little plasma and platelets subjected patients to several complications including coagulopathy, ARDS, abdominal compartment syndrome, and multisystem organ failure. Implementation of DCR occurred alongside other advances in trauma care that introduce bias when comparing outcomes from the two eras. While it may never be shown just how much DCR strategies contribute to improvements in trauma mortality, we hope we have shown that survival is better in the DCR era, and that DCR strategies decrease the other downstream complications that patients traditionally experienced when presenting in hemorrhagic shock. The sooner a hemorrhaging patient receives plasma and platelets, the more likely they are to survive and limit the complications of massive transfusion and hemorrhagic shock.

Conclusion (proposition de traduction) : En ce qui concerne le choc hémorragique, les données indiquent clairement que le damage control resuscitation est la norme de soins et offre un avantage en termes de mortalité. La réanimation équilibrée des produits sanguins cherche à compenser tout le sang que le patient perd par hémorragie. Des essais prospectifs comparant l'efficacité du sang total à celle des composants thérapeutiques sont en cours de planification et pourraient montrer que le sang total est supérieur à la réanimation par produits sanguins 1:1:1, mais cela reste à confirmer. Quoi qu'il en soit, il semble clair que les stratégies de réanimation à l'ère du damage control resuscitation qui utilisaient des cristalloïdes à grand volume et relativement peu de plasma et de plaquettes ont soumis les patients à plusieurs complications, dont la coagulopathie, le SDRA, le syndrome du compartiment abdominal et le syndrome de défaillance multiviscérale. La mise en œuvre du damage control resuscitation s’est accompagnée d’autres soins avancées de traumatologie qui introduisent un biais lors de la comparaison des résultats des deux époques. Bien que l'on ne pourra jamais démontrer à quel point les stratégies du damage control resuscitation ont contribué à l'amélioration de la mortalité par traumatisme, nous espérons avoir montré que la survie est meilleure à l'ère du damage control resuscitation et que les stratégies du damage control resuscitation diminuent les autres complications en aval dont les patients ont habituellement souffert en cas de choc hémorragique. Plus tôt un patient hémorragique reçoit du plasma et des plaquettes, plus il a de chances de survivre et de limiter les complications d'une transfusion massive et d'un choc hémorragique.

Effect of Early Central Venous Catheterization on Mortality Among Patients with Severe Sepsis: A Nationwide Inpatient Database Study.
Edakubo S, Inoue N, Fushimi K. | Shock. 2021 Jul 1;56(1):52-57
DOI: https://doi.org/10.1097/shk.0000000000001669
Keywords: Aucun

Clinical Science Aspect

Introduction : Clinical guidelines for the management of sepsis have accelerated the utilization of central venous catheterization (CVC). However, risks associated with CVC may be high in the initial phase of severe sepsis because of patient instability. The timing of CVC itself has not been fully evaluated. Therefore, we aimed to assess the association between CVC in the initial care of patients with severe sepsis and corresponding mortality rates.

Méthode : We conducted a nationwide retrospective analysis using the Japanese Diagnosis Procedure Combination database from April 1, 2014 to March 31, 2016. We identified patients who received CVC within 30 days from hospital admission. We compared the 30-day mortality between two groups: patients who received CVC within 2 days (early) after admission and those who received CVC 3 or more days (delayed) after admission, using marginal structural models with inverse probability treatment weighting.

Résultats : We identified 6,028 eligible patients from 911 hospitals among 27,497 patients with severe sepsis for this study; 4,544 (75.4%) received early CVC. Patients with early CVC had poor prognostic baselines and received more intense treatment than patients with delayed CVC. After adjusting for baseline and time-dependent treatment variables, we found that there were no significant differences between patients who received CVC within 2 days after admission and those who received CVC 3 or more days after admission (hazard ratio 0.83, 95% confidence interval 0.62-1.10).

Conclusion : Among patients with severe sepsis, early CVC was not associated with improved in-hospital mortality rates.

Conclusion (proposition de traduction) : Chez les patients présentant un sepsis sévère, le cathétérisme veineux central précoce n'était pas associé à une amélioration du taux de mortalité à l'hôpital.

P2Y12 Inhibitors Plus Aspirin Versus Aspirin Alone in Patients With Minor Stroke or High-Risk Transient Ischemic Attack.
Li ZX, Xiong Y, Gu HQ, Fisher M, Xian Y, Johnston SC, Wang YJ. | Stroke. 2021 Jul;52(7):2250-2257
DOI: https://doi.org/10.1161/strokeaha.120.033040
Keywords: clopidogrel; ischemic stroke; meta-analysis; randomized controlled trial; ticagrelor.

Original contribution

Introduction : We performed a systemic review and meta-analysis to elucidate the effectiveness and safety of dual antiplatelet (DAPT) therapy with P2Y12 inhibitors (clopidogrel/ticagrelor) and aspirin versus aspirin monotherapy in patients with mild ischemic stroke or high-risk transient ischemic attack.

Méthode : Following Preferred Reported Items for Systematic Review and Meta-Analysis standards for meta-analyses, Medline, Embase, Cochrane Central Register of Controlled Trials, and the Cochrane Library were searched for randomized controlled trials that included patients with a diagnosis of an acute mild ischemic stroke or high-risk transient ischemic attack, intervention of DAPT therapy with clopidogrel/ticagrelor and aspirin versus aspirin alone from January 2012 to July 2020. The outcomes included subsequent stroke, all-cause mortality, cardiovascular death, hemorrhage (mild, moderate, or severe), and myocardial infarction. A DerSimonian-Laird random-effects model was used to estimate pooled risk ratio (RR) and corresponding 95% CI in R package meta. We assessed the heterogeneity of data across studies with use of the Cochran Q statistic and I² test.

Résultats : Four eligible trials involving 21 493 participants were included in the meta-analysis. DAPT therapy started within 24 hours of symptom onset reduced the risk of stroke recurrence by 24% (RR, 0.76 [95% CI, 0.68-0.83], I²=0%) but was not associated with a change in all-cause mortality (RR, 1.30 [95% CI, 0.90-1.89], I²=0%), cardiovascular death (RR, 1.34 [95% CI, 0.56-3.17], I²=0%), mild bleeding (RR, 1.25 [95% CI, 0.37-4.29], I²=94%), or myocardial infarction (RR, 1.45 [95% CI, 0.62-3.39], I²=0%). However, DAPT was associated with an increased risk of severe or moderate bleeding (RR, 2.17 [95% CI, 1.16-4.08], I²=41%); further sensitivity tests found that the association was limited to trials with DAPT treatment duration over 21 days (RR, 2.86 [95% CI, 1.75-4.67], I²=0%) or ticagrelor (RR, 2.17 [95% CI, 1.16-4.08], I²=37%) but not within 21 days or clopidogrel.

Conclusion : In patients with noncardioembolic mild stroke or high-risk transient ischemic attack, DAPT with aspirin and clopidogrel/ticagrelor is more effective than aspirin alone for recurrent stroke prevention with a small absolute increase in the risk of severe or moderate bleeding.

Conclusion (proposition de traduction) : Chez les patients ayant subi un accident vasculaire cérébral léger non cardio-embolique ou un accident ischémique transitoire à haut risque, le double antiplaquettaire avec aspirine et clopidogrel/ticagrelor est plus efficace que l'aspirine seule pour la prévention des accidents vasculaires cérébraux récurrents avec une légère augmentation absolue du risque d'hémorragie sévère ou modérée.

Benefits and Risks of Dual Versus Single Antiplatelet Therapy for Secondary Stroke Prevention: A Systematic Review for the 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack.
Brown DL, Levine DA, Albright K, Kapral MK, Leung LY, Reeves MJ, Sico J, Strong B, Whiteley WN; American Heart Association Stroke Council. | Stroke. 2021 Jul;52(7):e468-e479
DOI: https://doi.org/10.1161/str.0000000000000377
Keywords: AHA Scientific Statements; dual antiplatelet therapy; ischemic attack, transient; ischemic stroke

AHA/ASA Systematic Review

Introduction : Dual antiplatelet therapy (DAPT) after ischemic stroke or transient ischemic attack may reduce recurrent stroke but also increase severe bleeding compared with single antiplatelet therapy (SAPT). The American Heart Association/American Stroke Association convened an evidence review committee to perform a systematic review and meta-analysis of the benefits and risks of DAPT compared with SAPT for secondary ischemic stroke prevention.

Méthode : The Medline, Embase, and Cochrane databases were searched on December 5, 2019, to identify phase III or IV randomized controlled trials (n≥100) from December 1999 to December 2019. We calculated unadjusted relative risks (RRs) and performed meta-analyses of studies based on the duration of treatment (short [≤90 days] versus long [>90 days]).

Résultats : Three short-duration randomized controlled trials were identified that enrolled mostly patients with minor stroke or high risk transient ischemic attack. In these trials, DAPT, compared with SAPT, was associated with a lower 90-day risk of recurrent ischemic stroke (pooled RR, 0.68 [95% CI, 0.55-0.83], I 2=37.1%). There was no significant increase in major bleeding with DAPT in short-duration trials (pooled RR, 1.88 [95% CI, 0.93-3.83], I²=8.9%). In 2 long-duration treatment randomized controlled trials (mean treatment duration, 18-40 months), DAPT was not associated with a significant reduction in recurrent ischemic stroke (pooled RR, 0.89 [95% CI, 0.79-1.02], I²=1.4%), but was associated with a higher risk of major bleeding (pooled RR, 2.42 [95% CI, 1.37-4.30], I²=75.5%).

Conclusion : DAPT was more effective than SAPT for prevention of secondary ischemic stroke when initiated early after the onset of minor stroke/high-risk transient ischemic attack and treatment duration was <90 days. However, when the treatment duration was longer and initiated later after stroke or transient ischemic attack onset, DAPT was not more effective than SAPT for ischemic stroke prevention and it increased the risk of bleeding.

Conclusion (proposition de traduction) : La double antiagrégation plaquettaire était plus efficace qu'un traitement par un seul antiplaquettaire pour la prévention de l'AVC ischémique secondaire lorsqu'elle était initiée tôt après le début d'un AVC mineur/accident ischémique transitoire à haut risque et que la durée du traitement était < 90 jours. Cependant, lorsque la durée du traitement était plus longue et initiée plus tard après un AVC ou un accident ischémique transitoire, la double antiagrégation plaquettaire n'était pas plus efficace qu'un traitement par un seul antiplaquettaire pour la prévention de l'AVC ischémique et elle augmentait le risque de saignement.

Comparison of the quick SOFA score with Glasgow-Blatchford and Rockall scores in predicting severity in patients with upper gastrointestinal bleeding.
Taslidere B, Sonmez E, Özcan AB, Mehmetaj L, Keskin EB, Gulen B. | Am J Emerg Med. 2021 Jul;45:29-36
DOI: https://doi.org/10.1016/j.ajem.2021.02.016
Keywords: Adverse event; Glasgow-Blatchford score; Risk scores; Rockall score; Upper gastrointestinal system bleeding; qSOFA score.

Research article

Introduction : Upper gastrointestinal bleeding is one of the common causes of mortality and morbidity. The Rockall score (RS) and Glasgow-Blatchford score (GBS) are frequently used in determining the prognosis and predicting in-hospital adverse events, such as mortality, re-bleeding, hospital stay, and blood transfusion requirements. The quick Sepsis Related Organ Failure Assessment (qSOFA) score is easy and swift to calculate. The commonly used scores and the qSOFA score were compared and why and when these scores are most useful was investigated.

Méthode : 133 patients admitted to the emergency department with upper gastrointestinal bleeding over the period of a year, were evaluated in this retrospective study. The RS, GBS and qSOFA score were calculated for each patient, and their relationship with in-hospital adverse events, such as length of hospitalization, rebleeding, endoscopic treatment, blood transfusion requirements, and mortality, was investigated.

Résultats : The mean overall GBS was 9.72 ± 3.72 (0-19), while that of patients who did not survive was 14.0 ± 1.1 (13-16), with an area under the curve (AUC) of 0.901, a cutoff value of 12.5, and specificity (Spe) and sensitivity (Sen) of 1 and 0.82, respectively. The median value of the GBS, in terms of transfusion need, was 7.12 ± 4.01 (0-15). (AUC = 0.752, cut-off = 9.5, Spe = 0.79, Sen = 0.69). The median value of the qSOFA score, in terms of intensive care need, was 1.73 ± 0.7 (0-3) (AUC = 0.921, cut-off = 0.5, Spe = 0.93, Sen = 0.79). The RS median, in terms of re-bleeding, was 8.22 ± 0.97 (6-9).

Conclusion : Early use of risk stratification scores in upper gastrointestinal bleeding is important due to the high risk of morbidity and mortality. All scoring systems were effective in predicting mortality, the need for intensive care, and re-bleeding. The GBS had a greater predictive power in terms of mortality and transfusion need, the qSOFA score for intensive care need, and the RS for re-bleeding. The simpler, more efficient, and more easily calculated qSOFA score can be used to estimate the severity of patients with upper gastrointestinal bleeding.

Conclusion (proposition de traduction) : L'utilisation précoce des scores de stratification du risque dans les hémorragies digestives hautes est importante en raison du risque élevé de morbidité et de mortalité. Tous les systèmes de cotation étaient efficaces pour prédire la mortalité, le besoin de soins intensifs et le risque de récidive hémorragique. Le score de Glasgow-Blatchford avait un plus grand pouvoir prédictif en termes de mortalité et de besoins transfusionnels, le score qSOFA pour les besoins en soins intensifs et le score Rockall pour les récidives hémorragiques.
Le score qSOFA plus simple, plus efficace et plus facile à calculer peut être utilisé pour estimer la gravité des patients présentant une hémorragie digestive supérieure.

Does pain severity predict stone characteristics or outcomes in emergency department patients with acute renal colic?.
Gourlay K, Splinter G, Hayward J, Innes G. | Am J Emerg Med. 2021 Jul;45:37-41
DOI: https://doi.org/10.1016/j.ajem.2021.02.049
Keywords: Diagnosis; Outcomes; Pain; Prognosis; Renal colic.

Original Contribution

Introduction : After initial emergency department (ED) management of acute renal colic, recurrent or ongoing severe pain is the usual pathway to ED revisits, hospitalizations and rescue interventions. If index visit pain severity is associated with stone size or with subsequent failure of conservative management, then it might be useful in identifying patients who would benefit from early definitive imaging or intervention. Our objectives were to determine whether pain severity correlates with stone size, and to evaluate its utility in predicting important outcomes.

Méthode : We used administrative data and structured chart review to study all ED patients with CT proven renal colic at six hospitals in two cities over one-year. Triage nurses recorded arrival numeric rating scale (NRS) pain scores. We excluded patients with missing pain assessments and stratified eligible patients into severe (NRS 8-10) and less-severe pain groups. Stone parameters were abstracted from imaging reports, while hospitalizations and interventions were identified in hospital databases. We determined the classification accuracy of pain severity for stones >5mm and used multivariable regression to determine the association of pain severity with 60-day treatment failure, defined by hospitalization or rescue intervention.

Résultats : We studied 2206 patients, 68% male, with a mean age of 49 years. Severe pain was 52.0% sensitive and 45.3% specific for larger stones >5mm. After multivariable adjustment, we found a weak negative association (adjusted OR =0.96) between pain severity and stone width. For each unit of increasing pain, the odds of a larger stone fell by 4%. Index visit pain severity was not associated with the need for hospitalization or rescue intervention within 60-days.

Conclusion : Pain severity is not helpful in predicting stone size or renal colic outcomes. More severe pain does not indicate a larger stone or a worse prognosis.

Conclusion (proposition de traduction) : L'intensité de la douleur ne permet pas de prédire la taille des calculs ou l'évolution des coliques néphrétiques. Une douleur plus intense n'indique pas un calcul plus gros ou un plus mauvais pronostic.

Comparison of physician-staffed helicopter with ground-based emergency medical services for trauma patients.
Nabeta M, Murotani K, Kannae M, Tashiro K, Hirayu N, Morita T, Uzu H, Takasu O. | Am J Emerg Med. 2021 Jul;45:75-79
DOI: https://doi.org/10.1016/j.ajem.2021.02.062
Keywords: Ground emergency medical services; Physician-staffed helicopter emergency medical services; Propensity score analysis; Severe trauma.

Original contribution

Introduction : Few studies have discussed whether physician-staffed helicopter emergency medical services (HEMS) provide temporal and geographical benefits for patients in remote locations compared to ground emergency medical services (GEMS). Our study seeks to clarify the significance of HEMS for patients with severe trauma by comparing the mortality of patients transported directly from crash scenes by HEMS or GEMS, taking geographical factors into account.

Méthode : Using medical records from a single center, collected from January 2014 to December 2018, we retrospectively identified 1674 trauma patients. Using propensity score analysis, we selected adult patients with an injury severity score ≥16, divided them into groups depending on their transport to the hospital by HEMS or GEMS, and compared their mortality within 24 h of hospitalization. For propensity score-matched groups, we analyzed distance and time.

Résultats : Of the 317 eligible patients, 202 were transported by HEMS. In the propensity score matching analysis, there was no significant difference in mortality between the HEMS and GEMS groups: 8.7% vs. 5.8%, odds ratio (OR), 1.547 (95% confidence interval [CI], 0.530-4.514). The inverse probability of treatment weighting (IPTW): 11% vs. 7.8%, OR, 1.080 (95% CI, 0.640-1.823); stabilized IPTW: 11% vs. 7.8%, OR, 1.080 (95% CI, 0.502-2.324); and truncated IPTW: 10% vs. 6.4%, OR, 1.143 (95% CI, 0.654-1.997). The distance from the crash scene to the hospital was farther in the HEMS group, and it took a longer period of time to arrive at the hospital (P < 0.001).

Conclusion : HEMS may provide equal treatment opportunities and minimize trauma deaths for patients transported from a greater distance to an emergency medical center compared to GEMS for patients transported from nearby regions.

Conclusion (proposition de traduction) : Les services médicaux d'urgence héliportés peuvent offrir des possibilités de traitement comparables et réduire au minimum les décès par traumatisme des patients transportés à une plus grande distance vers un centre médical d’urgence comparativement aux services médicaux d'urgence terrestre pour les patients transportés des régions avoisinantes. Les services médicaux d’urgence par hélicoptère peuvent offrir des possibilités de traitement égales et réduire au minimum les décès traumatiques pour les patients transportés à une plus grande distance vers un centre médical d’urgence comparativement aux services médicaux d’urgence au sol pour les patients transportés des régions avoisinantes.

Association between wide QRS pulseless electrical activity and hyperkalemia in cardiac arrest patients.
Kim YM, Park JE, Hwang SY, Lee SU, Kim T, Yoon H, Sim MS, Jo IJ, Lee GT, Shin TG. . | Am J Emerg Med. 2021 Jul;45:86-91
DOI: https://doi.org/10.1016/j.ajem.2021.02.024
Keywords: Cardiac arrest; Hyperkalemia; PEA arrest; Pulseless electrical activity; Wide QRS complex.

Original contribution

Introduction : We evaluated the relationship between hyperkalemia and wide QRS complex in patients with pulseless electrical activity (PEA) cardiac arrest.

Méthode : This was a single-center, retrospective observational study of patients over the age of 18 treated for cardiac arrest at a tertiary referral hospital whose initial electrocardiogram rhythm was PEA from February 2010 to December 2019. Wide QRS PEA was defined as a QRS interval of 120 ms or more. Hyperkalemia was defined as serum potassium level > 5.5 mmol/L. The primary outcome was hyperkalemia. Multivariable logistic regression analysis was used to evaluate the relationship between wide QRS and hyperkalemia.

Résultats : Among 617 patients, we analyzed 111 episodes in the wide QRS group and 506 episodes in the narrow QRS group. The potassium level in the wide QRS group was significantly higher than in the narrow QRS group (5.4 mmol/L, IQR 4.4-6.7 vs. 4.6 mmol/L, IQR 4.0-5.6, P < 0.001). Among all patients, 49.6% (n = 55/111) in the wide QRS group had hyperkalemia, which was significantly higher than the 26.7% (n = 135/506) in the narrow QRS group (P < 0.001). In multivariable logistic regression analysis, wide QRS PEA was significantly associated with hyperkalemia (odds ratio = 2.86, 95% confidence interval: 1.80-4.53, P < 0.001).

Conclusion : Wide QRS PEA as an initial cardiac rhythm was significantly associated with hyperkalemia in cardiac arrest patients.

Conclusion (proposition de traduction) : L'activité électrique sans pouls à QRS large initial était significativement associée à une hyperkaliémie chez les patients en arrêt cardiaque.

Prehospital hemodynamic optimisation is associated with a 30-day mortality decrease in patients with septic shock.
Jouffroy R, Gilbert B, Gueye PN, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B. | Am J Emerg Med. 2021 Jul;45:105-111
DOI: https://doi.org/10.1016/j.ajem.2021.02.060
Keywords: Hemodynamic optimisation; Mortality; Prehospital setting; Septic shock.

Original contribution

Introduction : Septic shock (SS) is characterized by low blood pressure resulting in organ failure and poor prognosis. Among SS treatments, in hospital studies reported a beneficial effect of early hemodynamic resuscitation on mortality rate. This study aims to investigate the relationship between prehospital hemodynamic optimisation and 30-day mortality in patients with SS.

Méthode : From April 6th, 2016 to December 31th, 2019, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (mICU) were included. Prehospital hemodynamic optimisation was defined as a arterial blood pressure of >65 mmHg, or >75 mmHg if previous hypertension history, at the end of the prehospital stage.

Résultats : Three hundred thirty-seven patients were retrospectively analysed. The mean age was 69 ± 15 years, and 226 patients (67%) were male. One hundred and thirty-six patients (40%) had previous hypertension history. Pulmonary, digestive and urinary infections were the suspected cause of the SS in respectively 46%, 23% and 15% of the cases. 30-day overall mortality was 30%. Prehospital hemodynamic optimisation was complete for 204 patients (61%). Cox regression analysis reports a significant association between prehospital hemodynamic optimisation and 30-day mortality (HRa = 0.52 95%CI [0.31-0.86], p = 0.01).

Conclusion : In this study, we report that prehospital hemodynamic optimisation is associated with a decrease in 30-day mortality in patients with SS cared for by a mICU in the prehospital setting. An individualized mean arterial pressure target, based on previous hypertension history, may be considered from the prehospital stage of SS resuscitation.

Conclusion (proposition de traduction) : Dans cette étude, nous rapportons que l'optimisation hémodynamique préhospitalière est associée à une diminution de la mortalité à 30 jours chez les patients en choc septique pris en charge par une unité mobile d'intervention de soins intensifs en milieu préhospitalier. Une cible de pression artérielle moyenne individualisée, basée sur les antécédents d'hypertension, peut être envisagée dès le stade préhospitalier de la réanimation du choc septique.

Using Canadian CT head rule in a developing nation: Validation and comparing utilisation by emergency physicians and neurosurgeons.
Lamba I, Luthra A, Shinde V, Daniel SS. | Am J Emerg Med. 2021 Jul;45:112-116
DOI: https://doi.org/10.1016/j.ajem.2021.02.064
Keywords: CCHR; Canadian CT head rule; Head injury in India; Head trauma; TBI.

Original contribution

Introduction : The objective of this study was to test the validity of the Canadian CT Head rule (CCHR) in cases of minor traumatic brain injury (TBI) in an Indian emergency department (ED). A secondary objective was to compare of the patterns of neuroradiology references between the emergency physician (EP) and the neurosurgeon.

Méthode : The study was prospectively conducted between July 2019 and July 2020. Patients satisfying the inclusion criteria were subjected to CCHR and the result was documented. The neurosurgeon was consulted for the final decision. In case of disagreement between the neurosurgeon and the EP, the decision of neuro-radiology was taken by the neurosurgeon.

Résultats : A total of 101 patients satisfied the inclusion criteria. 62 subjects fulfilled the CCHR. Out of 62 subjects who fulfilled the CCHR criteria, 46 (74.1%) were reported to have normal CT scans, while 16 had either haemorrhages (n = 12) or contusions (n = 4). All the subjects who didn't fulfil the CCHR (n = 39), were reported to have normal CT scans. The EPs used CCHR in all cases of mild TBI while the neurosurgeons chose to get CT brains in all the subjects based of clinical gestalt. CCHR had an observed sensitivity of 100% and specificity of 45.8%.

Conclusion : The CCHR has 100% sensitivity as a screening tool for patients requiring CT brains in case of TBI though the specificity is found to be rather low (45.8%). EPs show a higher level of awareness and inclination to use CDRs in cases of minor TBI to direct the decision for neuro-radiology, in comparison to neurosurgeons. ED residents reported comfort in mobile application based usage of the rule.

Conclusion (proposition de traduction) : La règle canadienne de prescription du scanner cérébral a une sensibilité de 100 % comme outil de dépistage des patients nécessitant une tomodensitométrie cérébrale en cas de lésion cérébrale traumatique, bien que sa spécificité soit plutôt faible (45,8 %). Les médecins urgentistes sont plus conscients et plus enclins à utiliser les règles de décision clinique en cas de traumatisme cérébral mineur pour orienter la décision de neuroradiologie, par rapport aux neurochirurgiens. Les résidents du service des urgences ont déclaré être à l'aise avec l'utilisation de la règle guidées par les applications mobiles.

Commentaire : La règle canadienne de prescription des scanners cérébraux est une règle de décision clinique largement validée pour son utilisation au service d’urgence pour les patients se présentant avec un traumatismes crâniens mineurs afin de déceler les lésions cérébrales cliniquement importantes à la tomodensitométrie pouvant nécessiter une intervention. Il comporte cinq facteurs cliniques à risque élevé qui, s’il sont présents, indiquent un risque important que le patient ait besoin d’une intervention neurochirurgicale. Deux autres facteurs de risque moyen peuvent être utilisés pour déterminer si le patient présente un risque de lésions cliniquement importantes lors de la tomodensitométrie qui ne nécessiteraient pas d’intervention neurochirurgicale. Stiell IG, Lesiuk H, Wells GA and al.; Canadian CT Head and C-Spine Study Group. The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. 2001 Aug;38(2):160-9  .

Tranexamic acid for gastrointestinal bleeding: A systematic review with meta-analysis of randomized clinical trials.
Lee PL, Yang KS, Tsai HW, Hou SK, Kang YN, Chang CC. | Am J Emerg Med. 2021 Jul;45:269-279
DOI: https://doi.org/10.1016/j.ajem.2020.08.062
Keywords: Gastrointestinal bleeding; Gastrointestinal hemorrhage; Tranexamic acid.

Original contribution

Introduction : Acute gastrointestinal bleeding is a common life-threatening emergent condition. Immediate tranexamic acid is useful for reducing hemorrhage following operation and bleeding trauma, but evidence on the effects of tranexamic acid in patients with gastrointestinal bleeding is limited or highly heterogeneous. It is still unclear about using tranexamic acid in the emergent condition of gastrointestinal bleeding. This study, therefore, aimed to determine whether or not tranexamic acid should be used in gastrointestinal bleeding management through systematic review and meta-analysis.

Méthode : We searched three biomedical databases for relevant randomized controlled trials on this topic. Two authors independently selected studies and extracted data for bias assessment and meta-analysis of bleeding, further intervention, mortality, transfusion, and intensive care unit admission. Available data were pooled using a random-effects model, and the results were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Heterogeneity and small study effects were also assessed.

Résultats : Thirteen randomized controlled trials (n = 2271) were included in the present synthesis. Our meta-analysis revealed that tranexamic acid significantly reduced the rates of continued bleeding (RR = 0.60; 95%CI, 0.43-0.84), urgent endoscopic intervention (RR = 0.35; 95%CI, 0.24-0.50), and mortality (RR = 0.60; 95%CI, 0.45-0.80) compared with the placebo.

Conclusion : According to the available evidence, the present synthesis confirms that tranexamic acid is an effective medication for patients with upper gastrointestinal bleeding. Early administration of tranexamic acid may be worth to be recommended for treating upper gastrointestinal bleeding in the emergency department. However, the effects of tranexamic acid on lower gastrointestinal bleeding warrant further clarification.

Conclusion (proposition de traduction) : Selon les preuves disponibles, la présente synthèse confirme que l'acide tranexamique est un médicament efficace pour les patients présentant une hémorragie digestive haute. L'administration précoce d'acide tranexamique peut valoir la peine d'être recommandée pour le traitement des hémorragies digestives hautes au service des urgences.
Cependant, les effets de l'acide tranexamique sur les hémorragies digestives basses méritent d'être clarifiés davantage.

Commentaire : Pour information :
1. Roberts I, Shakur-Still H, Afolabi A, Akere A, Arribas M, Brenner A, et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet [Internet]. 2020 Jun;395:1927–36  .
2. Gottlieb M, Slagle W, Ruff J. What Is the Efficacy of Tranexamic Acid for Acute Upper Gastrointestinal Bleeding? Ann Emerg Med [Internet]. 2020;77(3):371–3   (TAKE-HOME MESSAGE : Cette revue a révélé que l'acide tranexamique réduisait la mortalité chez les patients présentant une hémorragie digestive haute. Cependant, un essai récent à grande échelle n'a pas démontré de bénéfice dans cette population de patients).

Comparison of efficiency and safety of conservative versus interventional management for primary spontaneous pneumothorax: A meta-analysis.
Liu WL, Lv K, Deng HS, Hong QC. | Am J Emerg Med. 2021 Jul;45:352-357
DOI: https://doi.org/10.1016/j.ajem.2020.08.092
Keywords: Conservative treatment; Interventional; Meta-analysis; Primary spontaneous pneumothorax.

Original contribution

Introduction : There is growing opinion that primary spontaneous pneumothorax (PSP) patients without hemodynamic compromise could be safely and successfully managed with observation alone. The aims of this meta-analysis were to estimate the safety and effectiveness of conservative treatment compared with that of interventional management as the initial treatment option for patients with PSP.

Méthode : The PubMed, Embase and Cochrane library databases were systematically searched for randomized controlled trials (RCTs) and cohort studies (prospective or retrospective) until April 25, 2020, that compared conservative treatment and interventional treatment as the initial treatment for patients with PSP. The primary outcomes were success rates and recurrence rates. The secondary outcome was complication rates. Data extraction and quality assessment from eligible studies were independently conducted by two reviewers.

Résultats : 8 trials with a total of 1342 patients were identified. The success rates of conservative management were similar with interventional treatment, with a risk ratio 1.05 (95% confidence interval 0.94 to 1.17, I2 = 69.1%). There was no significant difference of recurrence rates between these two type managements. (RR, 1.43, 95% confidence interval 0.45 to 4.55, I2 = 86.7%). Complication rates were lower in conservative treatment group (13 of 215 [6.05%]) than in interventional treatment group (57 of 212, [26.89%]), although the difference did not reach statistical significance (RR, 0.15, 95% CI, 0.02 to 1.13, I2 = 56.7%).

Conclusion : Results of the meta-analysis suggest that conservative treatment offers a safe and effective alternative as compared with interventional management as the initial treatment approach for patients with PSP. However, more randomized clinical trials are need to provide more strong evidence to confirm our results.

Conclusion (proposition de traduction) : Les résultats de cette méta-analyse suggèrent que le traitement conservateur offre une alternative sûre et efficace par rapport à la gestion interventionnelle comme approche de traitement initiale pour les patients atteints de pneumothorax spontané inaugural. Cependant, davantage d'essais cliniques randomisés sont nécessaires pour fournir des preuves plus solides pour confirmer nos résultats.

A comparison of physician-staffed helicopters and ground ambulances transport for the outcome of severe thoracic trauma patients.
Kushida Y, Jitsuiki K, Muramatsu KI, Ikegami S, Nagasawa H, Takeuchi I, Ohsaka H, Oode Y, Omori K, Yanagawa Y. | Am J Emerg Med. 2021 Jul;45:358-360
DOI: https://doi.org/10.1016/j.ajem.2020.08.088
Keywords: Helicopter; Survival; Trauma.

Original contribution

Introduction : We retrospectively investigated prognostic factors for severe thoracic trauma patients evacuated by a physician-staffed helicopter emergency medical service (HEMS) and ground ambulance using the Japan Trauma Data Bank (JTDB).

Méthode : This study was a retrospective analysis of the JTDB database. The study period was from January 2004 to May 2019. The subjects were divided into two groups, according to the type of transportation: the Heli group included cases transported by the HEMS, while the Ambulance group included cases transported by ground ambulance.

Résultats : During the investigation period, a total of 57,872 patients were enrolled as subjects, including 7238 in the Heli group and 50,634 in the Ambulance group. The average age, male ratio, average injury severity score (ISS), average revised trauma score (RTS) and survival ratio were significantly greater in the Heli group than in the Ambulance group. After performing a propensity score-matched analysis, there were no statistical differences concerning the age, sex, ISS, RTS between the two groups. However, the survival ratio in the Heli group remained greater than that in the Ambulance group. When variables that showed statistical significance in the univariate analysis were included in a multivariate analysis, the RTS, transport by the HEMS, age, ISS and female gender were identified as significant predictors of a survival outcome. The HEMS was significantly associated with an increased survival ratio (odds ratio: 1.69; 95% confidence interval: 1.51-1.88) compared with a ground ambulance.

Conclusion : The present study showed that transport by the HEMS improved the survival rate compared to that by a ground ambulance for patients with severe thoracic trauma.

Conclusion (proposition de traduction) : La présente étude a montré que le transport par hélicoptère médicalisé améliorait le taux de survie par rapport à celui par une ambulance terrestre pour les patients présentant un traumatisme thoracique sévère.

Characterizing COVID-19: A chief complaint based approach.
Perotte R, Sugalski G, Underwood JP, Ullo M. | Am J Emerg Med. 2021 Jul;45:398-403
DOI: https://doi.org/10.1016/j.ajem.2020.09.019  | Télécharger l'article au format  
Keywords: COVID-19; Chief complaint; Coronavirus; Informatics; Pandemic.

Original contribution

Introduction : The COVID-19 pandemic has inundated emergency departments with patients exhibiting a wide array of symptomatology and clinical manifestations. We aim to evaluate the chief complaints of patients presenting to our ED with either suspected or confirmed COVID-19 to better understand the clinical presentation of this pandemic.

Méthode : This study was a retrospective computational analysis that investigated the chief complaints of all confirmed and suspected COVID-19 cases presenting to our adult ED (patients aged 22 and older) using a variety of data mining methods. Our study employed descriptive statistics to analyze the set of complaints that are most common, hierarchical clustering analysis to provide a nuanced way of identifying complaints that co-occur, and hypothesis testing identify complaint differences among age differences.

Résultats : A quantitative analysis of 5015 ED visits of COVID-suspected patients (1483 confirmed COVID-positive patients) identified 209 unique chief complaints. Of the 209 chief complaints, fever and shortness of breath were the most prevalent initial presenting symptoms. In the subset of COVID-19 confirmed positive cases, we discovered seven distinct clusters of presenting complaints. Patients over 65 years of age were more likely to present with weakness and altered mental status.

Conclusion : Our research highlights an important aspect of the evaluation and management of COVID-19 patients in the emergency department. Our study identified most common chief complaints, chief complaints differences across age groups, and 7 distinct groups of COVID-19 symptoms. This large-scale effort to classify the most commonly reported symptoms in ED patients provides public health officials and providers with data for identifying COVID-19 cases.

Conclusion (proposition de traduction) : Notre recherche met en évidence un aspect important de l'évaluation et de la prise en charge des patients COVID-19 au service des urgences. Notre étude a identifié les plaintes principales les plus courantes, les différences de plaintes principales entre les groupes d'âge et 7 groupes distincts de symptômes COVID-19. Cet effort à grande échelle pour classer les symptômes les plus fréquemment signalés chez les patients aux urgences fournit aux responsables de la santé publique et aux urgentistes des données pour identifier les cas de COVID-19.

Prehospital management of acute respiratory distress in suspected COVID-19 patients.
Jouffroy R, Lemoine S, Derkenne C, Kedzierewicz R, Scannavino M, Bertho K, Frattini B, Lemoine F, Jost D, Prunet B. | Am J Emerg Med. 2021 Jul;45:410-414
DOI: https://doi.org/10.1016/j.ajem.2020.09.022  | Télécharger l'article au format  
Keywords: Aucun

Original contribution

Introduction : In December 2019, coronavirus disease (COVID-19) emerged in China and became a world-wide pandemic in March 2020. Emergency services and intensive care units (ICUs) were faced with a novel disease with unknown clinical characteristics and presentations. Acute respiratory distress (ARD) was often the chief complaint for an EMS call. This retrospective study evaluated prehospital ARD management and identified factors associated with the need of prehospital mechanical ventilation (PMV) for suspected COVID-19 patients.

Méthode : We included 256 consecutive patients with suspected COVID-19-related ARD that received prehospital care from a Paris Fire Brigade BLS or ALS team, from March 08 to April 18, 2020. We performed multivariate regression to identify factors predisposing to PMV.

Résultats : Of 256 patients (mean age 60 ± 18 years; 82 (32%) males), 77 (30%) had previous hypertension, 31 (12%) were obese, and 49 (19%) had diabetes mellitus. Nineteen patients (7%) required PMV. Logistic regression observed that a low initial pulse oximetry was associated with prehospital PMV (ORa = 0.86, 95%CI: 0.73-0.92; p = 0.004).

Conclusion : This study showed that pulse oximetry might be a valuable marker for rapidly determining suspected COVID-19-patients requiring prehospital mechanical ventilation. Nevertheless, the impact of prehospital mechanical ventilation on COVID-19 patients outcome require further investigations.

Conclusion (proposition de traduction) : Cette étude a montré que l'oxymétrie de pouls pourrait être un marqueur précieux pour déterminer rapidement les patients suspectés de COVID-19 nécessitant une ventilation mécanique préhospitalière. Néanmoins, l'impact de la ventilation mécanique préhospitalière sur le devenir des patients COVID-19 nécessite des investigations supplémentaires.

Impact of creatinine screening on contrast-induced nephropathy following computerized tomography for stroke.
Becker BA, Yeich T, Jaffe JT, Sun S, Chen Y, Rebert T, Stahlman BA. | Am J Emerg Med. 2021 Jul;45:420-425
DOI: https://doi.org/10.1016/j.ajem.2020.09.044
Keywords: Acute kidney injury; Computerized tomography; Contrast material; Stroke.

Original contribution

Introduction : This study sought to evaluate rates of acute kidney injury in patients undergoing contrast-enhanced computerized tomography for acute stroke in the emergency department (ED) before and after the cessation of creatinine screening.

Méthode : This retrospective study compared ED patients receiving contrast-enhanced imaging for suspected acute stroke with and without protocolized creatinine screening. The primary outcome was CIN, defined as an increase in serum creatinine of 0.3 mg/dl within 48 hours or 50% above baseline within 7 days after contrast administration. Secondary outcomes consisted of CIN based on other definitions, renal impairment greater than 30 days from contrast administration, hemodialysis, and mortality. Outcomes were compared using difference of proportions and odds ratios with 95% confidence intervals.

Résultats : This study included 382 subjects, with 186 and 196 in the screening and post-screening cohorts, respectively. No significant differences were observed for CIN (7.0% vs 7.1%, difference 0.1% [95% CI -5.6-5.1%], OR 1.02 [95% CI 0.47-2.24]), renal impairment greater than 30 days post-contrast (8.4% vs 7.5%, OR 0.88 [0.38-2.07]), or mortality (index visit: 4.8% vs 2.6%, OR 0.51 [0.17-1.57], 90-day follow-up: 6.7% vs 4.0%, OR 0.58 [0.22-1.53]). No patients from either group required hemodialysis.

Conclusion : The elimination of creatinine screening prior to obtaining contrast-enhanced computerized tomography in patients with suspected acute stroke did not adversely affect rates of CIN, hemodialysis, or mortality at a comprehensive stroke center.

Conclusion (proposition de traduction) : L'élimination du dépistage par dosage de la créatinine avant l'obtention d'un scanner injecté chez les patients suspectés d'un AVC aigu n'a pas eu d'incidence négative sur les taux de néphropathie induite par les produits de contraste iodés, d'hémodialyse ou de mortalité dans un centre de prise en charge de l'AVC.

The index of oxygenation to respiratory rate as a prognostic factor for mortality in Sepsis.
Lee CU, Jo YH, Lee JH, Kim J, Park SM, Hwang JE, Lee DK, Park I, Jang DH, Lee SM. | Am J Emerg Med. 2021 Jul;45:426-432
DOI: https://doi.org/10.1016/j.ajem.2020.09.052
Keywords: Hypoxemia; Mortality; Prognosis; Respiratory rate; Sepsis; Septic shock.

Original contribution

Introduction : An index combining respiratory rate and oxygenation (ROX) has been introduced, and the ROX index is defined as the ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate. In sepsis, hypoxemia and tachypnea are commonly observed. We performed this study to investigate the association between the ROX index and 28-day mortality in patients with sepsis or septic shock.

Méthode : This retrospective study included 2862 patients. The patients were divided into three groups according to the ROX index: Group I (ROX index >20), Group II (ROX index >10 and ≤ 20), and Group III (ROX index ≤10).

Résultats : The median ROX index was significantly lower in the nonsurvivors than in the survivors (12.8 and 18.2, respectively) (p < 0.001). The 28-day mortality rates in Groups I, II and III were 14.5%, 21.3% and 34.4%, respectively (p < 0.001). In the multivariable Cox regression analysis, Group III had an approximately 40% higher risk of death than Group I during the 28-day period (hazard ratio = 1.41, 95% confidence interval 1.13-1.76). The area under the curve of the ROX index was significantly higher than that of the quick Sequential Organ Failure Assessment score (p < 0.001).

Conclusion : The ROX index was lower in nonsurvivors than in survivors, and a ROX index less than or equal to 10 was an independent prognostic factor for 28-day mortality in patients with sepsis or septic shock. Therefore, the ROX index could be used as a prognostic marker in sepsis.

Conclusion (proposition de traduction) : L'indice ROX était plus faible chez les non-survivants que chez les survivants, et un indice ROX inférieur ou égal à 10 était un facteur pronostique indépendant pour la mortalité à 28 jours chez les patients atteints de sepsis ou de choc septique. Par conséquent, l'indice ROX pourrait être utilisé comme marqueur pronostique dans le sepsis.

Commentaire : Voir l'article princeps sur l'indice ROX :
Roca O, Messika J, Caralt B, et al. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index. J Crit Care. 2016;35:200-5  
…et l'article de validation de l'indice ROX :
Roca O, Caralt B, Messika J, et al. An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy. Am J Respir Crit Care Med. 2019;199(11):1368-1376  .

Voir les « Préconisations de l'oxygénothérapie à Haut Débit (OHD) applicable aux patients suspects ou confirmés Covid-19 hypoxémiques nécessitant une oxygénothérapie   » (Version 1 – 27 mars 2020) proposées par Jean-Damien RICARD de l'APHP.

An evaluation of manual tidal volume and respiratory rate delivery during simulated resuscitation.
Scott JB, Schneider JM, Schneider K, Li J. | Am J Emerg Med. 2021 Jul;45:446-450
DOI: https://doi.org/10.1016/j.ajem.2020.09.091
Keywords: Manual ventilation; Respiratory rate; Resuscitation; Tidal volume.

Original contribution

Introduction : Excessive minute ventilation during cardiac arrest may cause lung injury and decrease the effectiveness of cardiopulmonary resuscitation (CPR). However, little is known about how clinicians deliver tidal volumes and respiratory rates during CPR.

Méthode : In this cross-sectional study, licensed practitioners attending an American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) course performed CPR and manual ventilation on a high-fidelity simulator during the megacode portion of the course. Delivered tidal volumes and respiratory rates were measured on a monitor. During the first scenario, results were not displayed to participants, but were displayed during the second scenario.

Résultats : Fifty-two clinicians participated in this study. Average height was 169 (157,178) cm. Pre-monitor display tidal volumes delivered were larger in male participants compared to female participants (684.6 ± 134.4 vs 586.7 ± 167.6 ml, P = 0.05). Those using medium-sized gloves delivered smaller tidal volumes than those using small or large gloves. Twenty-two (42.3%) delivered tidal volume in the range of 5-8 ml/kg of predicted body weight for the simulation manikin, and 35 (67.3%) delivered tidal volumes with >20% variability among breaths. All participants met the target respiratory rate around 10 breaths/min.

Conclusion : Tidal volume delivery varied greatly during manual ventilation and fewer than half participants delivered tidal volume at 5-8 ml/kg to the manikin. Sex and glove size appeared to impact tidal volume delivery when the participants were unaware of what they were delivering. Participants were able to meet the target respiratory rate around 10 without audio or visual feedback.

Conclusion (proposition de traduction) : L'administration du volume courant variait considérablement pendant la ventilation manuelle et moins de la moitié des participants ont administré un volume courant de 5 à 8 ml/kg au mannequin. Le sexe du pratiquant et la taille des gants semblaient avoir un impact sur l'administration du volume courant lorsque les participants n'étaient pas au courant de ce qu'ils administraient. Les participants ont pu atteindre la fréquence respiratoire cible autour de 10 sans retour audio ou visuel.

Commentaire : L'American Heart Association (AHA) et l'European Resuscitation Council (ERC) recommandent tous deux une fréquence respiratoire de 10 ventilations/min lorsqu'une sonde endotrachéale est en place pendant la RCP. L'AHA recommande des volumes courants pendant la RCP de l'ordre de 6 à 7 ml/kg ou de 500 à 600 ml et d'éviter une ventilation excessive. L'ERC recommande également de ne pas utiliser des volumes courants excessifs pouvant entraîner une hyperventilation.

The role of the serum lactate level at the first admission to the emergency department in predicting mortality.
Seker YC, Bozan O, Sam E, Topacoglu H, Kalkan A. | Am J Emerg Med. 2021 Jul;45:495-500
DOI: https://doi.org/10.1016/j.ajem.2020.09.088
Keywords: Emergency department; Lactat; Morbidity; Mortality.

Original contribution

Introduction : Lactate is an easily measurable laboratory parameter that is considered a potentially useful prognostic marker for determining risk in emergency department patients. The aim of this study was to investigate the role of serum lactate in the patients who were admitted to the emergency department at the time of admission.

Méthode : Patients who were admitted to the emergency department for various reasons between June 2017 and January 2018 were included in the study. Demographic data, laboratory findings, mortality and hospitalization rates of the patients were analyzed. The primary endpoint was determined as the role of serum lactate in predicting mortality, and the secondary endpoint in predicting hospitalization.

Résultats : Of the 1382 patients, 47.4% (n = 655) were female and 52.6% (n = 727) were male. The mean age of the patients was 60.99 ± 20.04 (18-100) years. In 59.6% (n = 824) of the patients, the most common hypertension (36%) was an additional disease. Mortality was found in 43 (3.1%) patients. It was observed that 20.5% (n = 284) of the patients were hospitalized. The ages of patients with hospitalization and mortality were found to be statistically significant higher than those without hospitalization and without mortality (p = 0.001; p < 0.01). There was no statistically significant difference between the serum lactate measurements of the patients according to hospitalization (p > 0.05). The serum lactate levels of the patients with mortality were found to be statistically significant higher than those without mortality (p = 0.001; p < 0.01). The cut off point for serum lactate level in predicting mortality was found to be ≥3.6 mmol/L. The mortality rate was found to be statistically significant higher in patients with serum lactate level 3,6 mmol/L and above (p = 0,001; p < 0,01).

Conclusion : In conclusion, we believe in the light of the findings of our study that the serum lactate level is effective and reliable in the prediction of mortality in patients who present to emergency department for any reason. However, prospective studies with broader patient groups are required in this subject.

Conclusion (proposition de traduction) : En conclusion, nous pensons, à la lumière des résultats de notre étude, que le taux de lactate sérique est efficace et fiable dans la prédiction de la mortalité chez les patients qui se présentent aux urgences pour quelque raison que ce soit. Cependant, des études prospectives avec des groupes de patients plus larges sont nécessaires dans ce sujet.

Is a Lumbar Puncture Required to Rule Out Atraumatic Subarachnoid Hemorrhage in Emergency Department Patients With Headache and Normal Brain Computed Tomography More Than Six Hours After Symptom Onset?.
April MD, Keim SM, Koyfman A, Meurer WJ, Schmitzberger F, Long B. | J Emerg Med. 2021 Jul;61(1):97-104
DOI: https://doi.org/10.1016/j.jemermed.2021.01.039
Keywords: computed tomography; decision tool; lumbar puncture; subarachnoid hemorrhage

EVIDENCE BASED MEDICINE

Introduction : Atraumatic subarachnoid hemorrhage (SAH) is a deadly condition that most commonly presents as acute, severe headache. Controversy exists concerning evaluation of SAH based on the time from onset of symptoms, specifically if the headache occurred > 6 h prior to patient presentation.
Clinical question: Do patients undergoing evaluation for atraumatic SAH who have a negative computed tomography (CT) scan of the head obtained more than 6 h after symptom onset require a subsequent lumbar puncture to rule out the diagnosis?
Evidence review: Studies retrieved included a retrospective cohort study, two prospective cohort studies, and a case-control study. These studies provide estimates of the diagnostic accuracy of head CT imaging obtained > 6 h from symptom onset and diagnostic test characteristics of subsequent lumbar puncture.

Conclusion : The probability of SAH above which emergency clinicians should perform a lumbar puncture is 1.0%. This threshold is essentially the same as the estimated probability of SAH in patients with a negative head CT obtained more than 6 h from symptom onset. Emergency physicians might reasonably decide to either perform or forego this procedure. Consequently, we contend that the decision whether to perform lumbar puncture in these instances is an excellent candidate for shared decision-making.

Conclusion (proposition de traduction) : La probabilité de survenue d'une hémorragie sous-arachnoïdienne non traumatique au-dessus de laquelle les médecins urgentistes devraient faire une ponction lombaire est de 1,0 %. Ce seuil est essentiellement le même que la probabilité estimée d'hémorragie sous-arachnoïdienne non traumatique chez les patients avec un scanner crânien négatif obtenu plus de 6 heures après l'apparition des symptômes. Les urgentistes peuvent donc raisonnablement décider d'effectuer ou de renoncer à cette onction lombaire.
Par conséquent, nous pensons que la décision d'effectuer ou non une ponction lombaire dans ces cas est un excellent sujet de décision partagée.

Commentaire : Consulter la controverse, dans Annals of Emergency Medicine, en juin 2021 :
April MD, Long B. Lumbar Puncture Is Necessary for Ruling Out Atraumatic Subarachnoid Hemorrhage Six Hours After Symptom Onset. Ann Emerg Med. 2021 Jun;77(6):641-643  .
Gottlieb M, Morgenstern J. Lumbar Puncture Should Not Be Routinely Performed For Subarachnoid Hemorrhage After A Negative Head Ct. Ann Emerg Med. 2021 Jun;77(6):643-645  .

How Should Native Crotalid Envenomation Be Managed in the Emergency Department?.
Greene S, Cheng D, Vilke GM, Winkler G. | J Emerg Med. 2021 Jul;61(1):41-48
DOI: https://doi.org/10.1016/j.jemermed.2021.01.020
Keywords: ANAVIP; CroFab; copperheads; cottonmouths; crotalid; envenomation; rattlesnakes; snakebite; toxicology.

ST; Toxicologic Emergencies

Introduction : Pit vipers, also known as crotalids, are a group of snakes including rattlesnakes, copperheads, and cottonmouths (water moccasins). Crotalids have a broad geographic distribution across the United States, and bites from these snakes can carry significant morbidity. Their envenomations are characterized by local tissue effects, hematologic effects, and systemic effects. Envenomations are generally treated with 1 of 2 antivenoms available in the United States.
Objective: We developed a series of clinical questions to assist and guide the emergency physician in the acute management of a patient envenomated by a crotalid.

Méthode : We conducted a PubMed literature review from January 1970 to May 2020 in English for articles with the keywords "bite" and "crotalidae."

Résultats : Our literature search resulted in 177 articles. A total of 33 articles met criteria for rigorous review and citation in the development of these consensus guidelines.

Conclusion : Patients should be initially evaluated, stabilized, and assessed for local effects, hematologic effects, and systemic toxicity suggestive of envenomation. Antivenom should be given if toxic effects are present. Surgical intervention including debridement and fasciotomy should be avoided. Prophylactic antibiotics are not necessary.

Conclusion (proposition de traduction) : Les patients doivent d’abord faire l’objet d’une évaluation, d’une stabilisation et d’une évaluation des effets locaux, des effets hématologiques et de la toxicité systémique suggérant une intoxication. L’antivenin doit être administré en cas d’effets toxiques. Toute intervention chirurgicale incluant débridement et fasciotomie doit être évitée. Les antibiotiques prophylactiques ne sont pas nécessaires.

Four-factor prothrombin complex concentrate in adjunct to whole blood in trauma-related hemorrhage: Does whole blood replace the need for factors?.
Khurrum M, Ditillo M, Obaid O, Anand T, Nelson A, Chehab M, Kitts DJ, Douglas M, Bible L, Joseph B. | J Trauma Acute Care Surg. 2021 Jul 1;91(1):34-39
DOI: https://doi.org/10.1097/ta.0000000000003184
Keywords: Aucun

EAST 2021 PODIUM PAPERS

Introduction : The use of whole blood (WB) for the treatment of hemorrhagic shock and coagulopathy is increasing in civilian trauma patients. Four-factor prothrombin complex concentrate (4-PCC) in adjunct to component therapy showed improved outcomes in trauma patients. Our study aims to evaluate the outcomes of trauma patients who received 4-PCC and WB (4-PCC-WB) compared with WB alone.

Méthode : We performed a 3-year (2015-2017) analysis of the American College of Surgeons-Trauma Quality Improvement Program database. All adult (age, ≥18 years) trauma patients who received WB were included. We excluded patients who were on preinjury anticoagulants. Patients were stratified into two groups, 4-PCC-WB versus WB alone, and matched in a 1:2 ratio using propensity score matching. Outcome measures were packed red blood cells, plasma, platelets, and cryoprecipitate transfused, in-hospital complications, hospital and intensive care unit (ICU) length of stay (LOS) among survivors, and mortality.

Résultats : A total of 252 patients (4-PCC-WB, 84; WB alone, 168) were matched. The mean ± SD age was 47 ± 21 years, 63% were males, median Injury Severity Score was 30 (21-40), and 87% had blunt injuries. Patients who received 4-PCC-WB had decreased requirement for packed red blood cell (8 U vs. 10 U, p = 0.04) and fresh frozen plasma (6 U vs. 8 U, p = 0.01) transfusion, lower rates of acute kidney injury (p = 0.03), and ICU LOS (5 days vs. 8 days, p = 0.01) compared with WB alone. There was no difference in the platelet transfusion (p = 0.19), cryoprecipitate transfusion (p = 0.37), hospital LOS (p = 0.72), and in-hospital mortality (p = 0.72) between the two groups.

Conclusion : Our study demonstrates that the use of 4-PCC as an adjunct to WB is associated with a reduction in transfusion requirements and ICU LOS compared with WB alone in the resuscitation of trauma patients. Further studies are required to evaluate the role of PCC with WB in the resuscitation of trauma patients.

Conclusion (proposition de traduction) : Notre étude démontre que l'utilisation de concentré de 4 facteurs de coagulation en complément du sang total est associée à une réduction des besoins transfusionnels et de la durée de séjour en unité de soins intensifs par rapport au sang total seul dans la réanimation des patients traumatisés. D'autres études sont nécessaires pour évaluer le rôle du concentré de complexe prothrombique avec du sang total dans la réanimation des patients traumatisés.

Benzodiazepines increase the likelihood of both infectious and thrombotic complications.
Skicki E, Morgan M, Brown C, Bradburn E, Rogers F. | J Trauma Acute Care Surg. 2021 Jul 1;91(1):206-211
DOI: https://doi.org/10.1097/ta.0000000000003134
Keywords: Aucun

Original article

Introduction : Benzodiazepines (BZDs) modulate peripheral γ-amino-butyric acid type A on macrophages causing immunomodulation. They inhibit proinflammatory cytokines increasing infections. Prior studies have also shown that infections can increase thrombotic complications. We sought to examine this relationship in trauma patients. We hypothesized that the presence of BZDs on admission urine drug screen (UDS) would increase rates of both complications.

Méthode : All patients submitted to the Pennsylvania Trauma Outcome Study database from 2003 to 2018 were queried. Those with a positive UDS for BZDs were analyzed. Infectious complications were defined as pneumonia, urinary tract infection, sepsis, wound, and soft tissue infection, and thrombotic complications were defined as presence of pulmonary embolism or deep vein thrombosis. Logistic regressions controlling for demographic and injury covariates assessed the adjusted impact of BZDs on infectious and thrombotic complications.

Résultats : A total of 3,393 patients (2.08%) had infectious complications, and 3,048 (1.87%) had thrombotic complications. Furthermore, 33,260 patients (20.4%) had a positive UDS for BZDs on admission. Univariate analysis showed that those positive for BZDs had higher rates of infectious (3.33% vs. 1.76%, p < 0.001) and thrombotic (2.84% vs. 1.62%, p < 0.001) complications. Multivariate analysis revealed that BZDs significantly increased the odds of infectious and thrombotic complications. Patients who tested positive for BZDs and subsequently developed infection had increased odds (adjusted odds ratio, 1.65; p < 0.001) of developing thrombotic complications.

Conclusion : Trauma patients with a positive UDS for BZDs had higher odds of both infectious and thrombotic complications. Moreover, odds of thrombotic complications were higher in those with infections.

Conclusion (proposition de traduction) : Les patients traumatisés avec un dépistage urinaire positif des benzodiazépines présentaient un risque plus élevé de complications infectieuses et thrombotiques. De plus, les risques de complications thrombotiques étaient plus élevés chez les personnes infectées.

Lactate as a mediator of prehospital plasma mortality reduction in hemorrhagic shock..
Canton SP, Lutfi W, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Guyette FX, Sperry JL, Brown JB. | J Trauma Acute Care Surg. 2021 Jul 1;91(1):186-191
DOI: https://doi.org/10.1097/ta.0000000000003173
Keywords: Aucun

Original article

Introduction : Prehospital plasma transfusion in trauma reduces mortality. However, the underlying mechanism remains unclear. Reduction in shock severity may play a role. Lactate correlates with physiologic shock severity and mortality after injury. Our objective was to determine if prehospital plasma reduces lactate and if this contributes to the mortality benefit of plasma.

Méthode : Patients in the Prehospital Air Medical Plasma trial in the upper quartile of injury severity (Injury Severity Score, >30) were included to capture severe shock. Trial patients were randomized to prehospital plasma or standard care resuscitation (crystalloid ± packed red blood cells). Regression determined the associations between admission lactate, 30-day mortality, and plasma while adjusting for demographics, prehospital crystalloid, time, mechanism, and injury characteristics. Causal mediation analysis determined what proportion of the effect of plasma on mortality is mediated by lactate reduction.

Résultats : A total of 125 patients were included. The plasma group had a lower adjusted admission lactate than standard of care group (coefficient, -1.64; 95% confidence interval [CI], -2.96 to -0.31; p = 0.02). Plasma was associated with lower odds of 30-day mortality (odds ratio [OR], 0.27; 95% CI, 0.08-0.90; p = 0.03). When adding lactate to this model, the effect of plasma on 30-day mortality was no longer significant (OR, 0.36; 95% CI, 0.07-1.88; p = 0.23), while lactate was associated with mortality (OR, 1.74 per 1 mmol/L increase; 95% CI, 1.10-2.73; p = 0.01). Causal mediation demonstrated 35.1% of the total effect of plasma on 30-day mortality was mediated by the reduction in lactate among plasma patients.

Conclusion : Prehospital plasma is associated with reduced 30-day mortality and lactate in severely injured patients. More than one third of the effect of plasma on mortality is mediated by a reduction in lactate. Thus, reducing the severity of hemorrhagic shock appears to be one mechanism of prehospital plasma benefit. Further study should elucidate other mechanisms and if a dose response exists.

Conclusion (proposition de traduction) : La transfusion de plasma préhospitalier est associé à une réduction de la mortalité à 30 jours et du lactate chez les patients gravement blessés. Plus d'un tiers de l'effet du plasma sur la mortalité est médié par une réduction du lactate. Ainsi, la réduction de la gravité du choc hémorragique semble être un mécanisme de bénéfice plasmatique préhospitalier. Une étude plus approfondie devrait élucider d'autres mécanismes et s'il existe une réponse à la dose.

Treatment of Multisystem Inflammatory Syndrome in Children.
McArdle AJ, Vito O, Patel H, Seaby EG, Shah P, Wilson C, Broderick C, Nijman R, Tremoulet AH, Munblit D, Ulloa-Gutierrez R, Carter MJ, De T, Hoggart C, Whittaker E, Herberg JA, Kaforou M, Cunnington AJ, Levin M; BATS Consortium. | N Engl J Med. 2021 Jul 1;385(1):11-22
DOI: https://doi.org/10.1056/nejmoa2102968  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : Evidence is urgently needed to support treatment decisions for children with multisystem inflammatory syndrome (MIS-C) associated with severe acute respiratory syndrome coronavirus 2.

Méthode : We performed an international observational cohort study of clinical and outcome data regarding suspected MIS-C that had been uploaded by physicians onto a Web-based database. We used inverse-probability weighting and generalized linear models to evaluate intravenous immune globulin (IVIG) as a reference, as compared with IVIG plus glucocorticoids and glucocorticoids alone. There were two primary outcomes: the first was a composite of inotropic support or mechanical ventilation by day 2 or later or death; the second was a reduction in disease severity on an ordinal scale by day 2. Secondary outcomes included treatment escalation and the time until a reduction in organ failure and inflammation.

Résultats : Data were available regarding the course of treatment for 614 children from 32 countries from June 2020 through February 2021; 490 met the World Health Organization criteria for MIS-C. Of the 614 children with suspected MIS-C, 246 received primary treatment with IVIG alone, 208 with IVIG plus glucocorticoids, and 99 with glucocorticoids alone; 22 children received other treatment combinations, including biologic agents, and 39 received no immunomodulatory therapy. Receipt of inotropic or ventilatory support or death occurred in 56 patients who received IVIG plus glucocorticoids (adjusted odds ratio for the comparison with IVIG alone, 0.77; 95% confidence interval [CI], 0.33 to 1.82) and in 17 patients who received glucocorticoids alone (adjusted odds ratio, 0.54; 95% CI, 0.22 to 1.33). The adjusted odds ratios for a reduction in disease severity were similar in the two groups, as compared with IVIG alone (0.90 for IVIG plus glucocorticoids and 0.93 for glucocorticoids alone). The time until a reduction in disease severity was similar in the three groups.

Conclusion : We found no evidence that recovery from MIS-C differed after primary treatment with IVIG alone, IVIG plus glucocorticoids, or glucocorticoids alone, although significant differences may emerge as more data accrue.

Conclusion (proposition de traduction) : Nous n’avons trouvé aucune preuve que la guérison du syndrome inflammatoire multisystémique diffère après un traitement primaire par immunoglobulines intraveineuses seules, immunoglobulines intraveineuses et glucocorticoïdes, ou glucocorticoïdes seuls, bien que des différences significatives puissent apparaître à mesure que de nouvelles données s’accumulent.

Multisystem Inflammatory Syndrome in Children - Initial Therapy and Outcomes.
Son MBF, Murray N, Friedman K and al; Overcoming COVID-19 Investigators. | N Engl J Med. 2021 Jul 1;385(1):23-34
DOI: https://doi.org/10.1056/nejmoa2102605  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : The assessment of real-world effectiveness of immunomodulatory medications for multisystem inflammatory syndrome in children (MIS-C) may guide therapy.

Méthode : We analyzed surveillance data on inpatients younger than 21 years of age who had MIS-C and were admitted to 1 of 58 U.S. hospitals between March 15 and October 31, 2020. The effectiveness of initial immunomodulatory therapy (day 0, indicating the first day any such therapy for MIS-C was given) with intravenous immune globulin (IVIG) plus glucocorticoids, as compared with IVIG alone, was evaluated with propensity-score matching and inverse probability weighting, with adjustment for baseline MIS-C severity and demographic characteristics. The primary outcome was cardiovascular dysfunction (a composite of left ventricular dysfunction or shock resulting in the use of vasopressors) on or after day 2. Secondary outcomes included the components of the primary outcome, the receipt of adjunctive treatment (glucocorticoids in patients not already receiving glucocorticoids on day 0, a biologic, or a second dose of IVIG) on or after day 1, and persistent or recurrent fever on or after day 2.

Résultats : A total of 518 patients with MIS-C (median age, 8.7 years) received at least one immunomodulatory therapy; 75% had been previously healthy, and 9 died. In the propensity-score-matched analysis, initial treatment with IVIG plus glucocorticoids (103 patients) was associated with a lower risk of cardiovascular dysfunction on or after day 2 than IVIG alone (103 patients) (17% vs. 31%; risk ratio, 0.56; 95% confidence interval [CI], 0.34 to 0.94). The risks of the components of the composite outcome were also lower among those who received IVIG plus glucocorticoids: left ventricular dysfunction occurred in 8% and 17% of the patients, respectively (risk ratio, 0.46; 95% CI, 0.19 to 1.15), and shock resulting in vasopressor use in 13% and 24% (risk ratio, 0.54; 95% CI, 0.29 to 1.00). The use of adjunctive therapy was lower among patients who received IVIG plus glucocorticoids than among those who received IVIG alone (34% vs. 70%; risk ratio, 0.49; 95% CI, 0.36 to 0.65), but the risk of fever was unaffected (31% and 40%, respectively; risk ratio, 0.78; 95% CI, 0.53 to 1.13). The inverse-probability-weighted analysis confirmed the results of the propensity-score-matched analysis.

Conclusion : Among children and adolescents with MIS-C, initial treatment with IVIG plus glucocorticoids was associated with a lower risk of new or persistent cardiovascular dysfunction than IVIG alone.

Conclusion (proposition de traduction) : Chez les enfants et les adolescents atteints d'un syndrome inflammatoire multisystémique, le traitement initial par immunoglobuline intraveineuse plus glucocorticoïdes était associé à un risque plus faible de dysfonctionnement cardiovasculaire nouveau ou persistant que l'immunoglobuline intraveineuse seule.

Cerebral Venous Thrombosis.
Ropper AH, Klein JP. | N Engl J Med. 2021 Jul 1;385(1):59-64
DOI: https://doi.org/10.1056/nejmra2106545
Keywords: Aucun

REVIEW ARTICLE

Editorial : Cerebral venous thrombosis is an unusual cerebrovascular disorder that is of current interest, in part because of rare cases associated with certain of the coronavirus disease 2019 (Covid-19) vaccines. The characteristics of infarction caused by cerebral venous thrombosis differ from those of the usual forms of ischemic stroke caused by occlusion of arterial vessels. This brief review calls attention to the diagnosis of cerebral venous thrombosis, based on clinical and imaging features, and treatments that have become available since the subject was reviewed in the Journal in 2005.

Conclusion : European Stroke Organization guidelines from 2017 suggest initiating low-molecular-weight heparin as soon as possible after the diagnosis has been established (this does not apply to HIT or VITT), considering the use of decompressive craniectomy if intracranial pressure is raised, and using anticonvulsant agents if there have been seizures, but the guidelines do not recommend glucocorticoids and acetazolamide for brain swelling. American Heart Association–American Stroke Association guidelines from 2011 provide an algorithm for the use of anticoagulant therapy, recommending full-dose unfractionated or low-molecular-weight heparin, followed by warfarin and acetazolamide, but not glucocorticoids, for raised intracranial pressure.

Conclusion (proposition de traduction) : Les recommandations de l'European Stroke Organization de 2017 suggèrent d'initier l'héparine de bas poids moléculaire dès que possible après que le diagnostic ait été établi (cela ne s'applique pas à la thrombocytopénie induite par l'héparine ou à la thrombocytopénie thrombotique immunitaire induite par la vaccination), en envisageant l'utilisation d'une craniectomie décompressive si la pression intracrânienne est augmentée et l'utilisation d'agents anticonvulsivants s'il y a eu des convulsions, mais les directives ne recommandent pas les glucocorticoïdes et l'acétazolamide dans l'oedème cérébral. Les recommandations de l'American Heart Association-American Stroke Association de 2011 proposent un algorithme pour l'utilisation d'un traitement anticoagulant, recommandant une dose complète d'héparine non fractionnée ou de faible poids moléculaire, suivie de la warfarine et de l'acétazolamide, mais pas des glucocorticoïdes, pour l'hypertension intracrânienne.

Hematuria in Adults.
Ingelfinger JR | N Engl J Med. 2021 Jul 8;385(2):153-163
DOI: https://doi.org/10.1056/nejmra1604481
Keywords: Aucun

Review article

Editorial : Visible (macroscopic) hematuria, documented since ancient times, is striking, particularly when there is no prior event, such as trau- ma, dysuria due to cystitis, or flank pain with passage of a kidney stone, to provide a clear explanation. In contrast, nonvisible (microscopic) hematuria, or microhematuria, may go undetected for years. Many patients are found to have microhematuria when a urinalysis is performed for other reasons

Conclusion : Hematuria is an important sign that may con- note serious disease, yet on many occasions no specific cause is identified. A high index of sus- picion and good communication between clini- cian and patient can result in a reasoned and reasonable approach to evaluation and therapy.

Conclusion (proposition de traduction) : L'hématurie est un signe important qui peut évoquer une maladie grave, mais dans de nombreuses occasions, aucune cause spécifique n'est identifiée. Un indice élevé de suspicion et une bonne communication entre le clinicien et le patient peuvent conduire à une approche raisonnée et raisonnable de l'évaluation et de la thérapeutique.

Mean value of B-mode optic nerve sheath diameter as an indicator of increased intracranial pressure: a systematic review and meta-analysis.
Montorfano L, Yu Q, Bordes SJ, Sivanushanthan S, Rosenthal RJ, Montorfano M. | Ultrasound J. 2021 Jul 2;13(1):35
DOI: https://doi.org/10.1186/s13089-021-00235-5  | Télécharger l'article au format  
Keywords: Intracranial pressure; Optic nerve sheath; Optic nerve sheath diameter; Point-of-care ultrasound; Trauma; ocular ultrasound; traumatic brain injury.

Original article

Introduction : Timely diagnosis and treatment of increased intracranial pressure can decrease morbidity and prevent mortality. The present meta-analysis aims to determine the mean value of the ONSD measured in patients with various elevated ICP etiologies under different clinical settings, as well as comparing the value of ONSD between patients with and without elevated ICP.

Méthode : This meta-analysis complied with the Preferred Reporting Items for Systematic Reviews and Meta-analysis Statement8. PubMed, Embase, and Cochrane Library were searched to identify ONSD measured by US for patients with increased ICP from establishment to October 2020.

Résultats : A total of 779 patients with elevated ICP among 22 studies were included in the present meta-analysis. Studies were published between 2003 and 2020. Eighteen were comparative (18/22, 81.8%), and four were single-armed study (4/22, 18.2%). Twenty were prospective studies (20/22, 90.9%). There was moderate-to-high heterogeneity based on the prediction ellipse area and variance logit of sensitivity and specificity.

Conclusion : The mean value of the ONSD among patients diagnosed with increased ICP was 5.82 mm (95% CI 5.58-6.06 mm). Variations were observed based on etiology of intracranial hypertension, clinical settings where ONSD was measured, and standards for diagnosing intracranial hypertension. The US-ONSD among patient with elevated ICP was significantly higher than the normal control. Although a cut-off value is not clearly determined, these mean values can be implemented to evaluate the sensitivity and specificity of US-ONSD in diagnosing intracranial hypertension in future studies.

Conclusion (proposition de traduction) : La valeur moyenne du diamètre de la gaine du nerf optique chez les patients diagnostiqués avec une augmentation de la pression intracrânienne était de 5,82 mm (IC à 95 % 5,58-6,06 mm).
Des variations ont été observées en fonction de l'étiologie de l'hypertension intracrânienne, des paramètres cliniques où le diamètre de la gaine du nerf optique a été mesuré et des normes de diagnostic de l'hypertension intracrânienne. Le diamètre de la gaine du nerf optique mesurée par échographie chez les patients présentant une pression intracrânienne élevée était significativement plus élevé que la mesure normale. Bien qu'une valeur seuil ne soit pas clairement déterminée, ces valeurs moyennes peuvent être mises en œuvre pour évaluer la sensibilité et la spécificité du diamètre de la gaine du nerf optique par échographie dans le diagnostic de l'hypertension intracrânienne dans les études futures.