A randomized controlled trial of ibuprofen versus ketorolac versus diclofenac for acute, nonradicular low back pain.
Irizarry E, Restivo A, Salama M, Davitt M, Feliciano C, Cortijo-Brown A, Friedman BW. | Acad Emerg Med. 2021 Nov;28(11):1228-1235
DOI: https://doi.org/10.1111/acem.14321  | Télécharger l'article au format  
Keywords: NSAIDs; diclofenac; ibuprofen; ketorolac; low back pain.

ORIGINAL CONTRIBUTION

Introduction : Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line medication for acute low back pain (LBP). It is unclear if the choice of NSAID impacts outcomes. We compared ibuprofen, ketorolac, and diclofenac for the treatment of acute, nonradicular LBP.

Méthode : This was a three-armed, double-blind, comparative effectiveness study, in which we enrolled patients at the conclusion of an ED visit for musculoskeletal LBP and determined outcomes by telephone 5 days later. Patients were randomized to receive a 5-day supply of 600 mg of ibuprofen, 10 mg of ketorolac, or 50 mg of diclofenac, each to be used every 8 h as needed. Every participant also received LBP education. The primary outcome was improvement in Roland-Morris Disability Questionnaire (RMDQ), a 24-item instrument on which lower scores indicate better LBP functional outcomes, between ED visit and day 5. Secondary outcomes included pain intensity, measured using the descriptors none, mild, moderate, and severe, and the presence of stomach irritation.

Résultats : A total of 868 patients were screened and 66 patients were enrolled in each of the three arms. Baseline characteristics were similar. Improvements in RMDQ by day 5 were as follows: ibuprofen 9.4, ketorolac 11.9, and diclofenac 10.9 (p = 0.34). Mild or no pain on day 5 was as follows: ibuprofen 38 of 61 (62%), ketorolac 47 of 59 (80%), and diclofenac 45 of 62 (71%; 95% CI for rounded mean difference of 17% between ibuprofen and ketorolac = 1, 33%, p = 0.04, number needed to treat = 6 [95% CI = 3-69]). Stomach irritation was reported by 16 of 62 (26%) ibuprofen patients versus three of 61 (5%) in the ketorolac arm and six of 64 (9%) in the diclofenac arm (p < 0.01).

Conclusion : There were no important differences between groups with regard to the primary outcome. These data do not rule out that possibility that ketorolac results in better pain relief and less stomach irritation than ibuprofen.

Conclusion (proposition de traduction) : Il n'y avait pas de différences importantes entre les groupes en ce qui concerne le critère de jugement principal. Ces données n'excluent pas la possibilité que le kétorolac entraîne un meilleur soulagement de la douleur et moins d'irritation de l'estomac que l'ibuprofène.

Comparison of the Conventional Downward and Modified Upward Laryngeal Handshake Techniques to Identify the Cricothyroid Membrane: A Randomized, Comparative Study.
Chang JE, Kim H, Won D, Lee JM, Kim TK, Min SW, Hwang JY. | Anesth Analg. 2021 Nov 1;133(5):1288-1295
DOI: https://doi.org/10.1213/ane.0000000000005744
Keywords: Aucun

ORIGINAL CLINICAL RESEARCH REPORT

Introduction : Accurate identification of the cricothyroid membrane is crucial for successful cricothyroidotomy. The aim of this study was to compare the conventional downward and modified upward laryngeal handshake techniques in terms of accuracy to identify the cricothyroid membrane in nonobese female patients.

Méthode : In 198 anesthetized female patients, the cricothyroid membrane was identified by either the conventional downward laryngeal handshake technique (n = 99) or the modified upward laryngeal handshake technique (n = 99). According to the conventional downward laryngeal handshake technique, the cricothyroid membrane was identified by palpating the neck downward from the greater cornu of the hyoid bone, thyroid laminae, and cricoid cartilage. According to the modified upward laryngeal handshake technique, the cricothyroid membrane was located by moving up from the sternal notch. The primary outcome was the accuracy of identifying the cricothyroid membrane. Secondary outcomes included the accuracy of midline identification and time taken to locate what participants believed to be the cricothyroid membrane. The primary and secondary outcomes according to the technique were analyzed using generalized estimating equations.

Résultats : The cricothyroid membrane could be identified more accurately by the modified upward laryngeal handshake technique than by the conventional downward technique (84% vs 56%, respectively; odds ratio [OR], 4.36; 95% confidence interval [CI], 2.13−8.93; P < .001). Identification of the midline was also more accurate by the modified laryngeal handshake than by the conventional technique (96% vs 83%, respectively; OR, 4.98; 95% CI, 1.65−15.01; P = .004). The time taken to identify the cricothyroid membrane was not different between the conventional and modified techniques (20.2 [16.2−26.6] seconds vs 19.0 [14.5−26.4] seconds, respectively; P = .83).

Conclusion : The modified upward laryngeal handshake technique that involved tracing the trachea and laryngeal structures upward from the sternal notch was more accurate in identifying the cricothyroid membrane than the conventional downward technique in anesthetized female patients.

Conclusion (proposition de traduction) : La technique modifiée de la prise en main du larynx vers le haut, qui consiste à remonter la trachée et les structures laryngées à partir de l'encoche sternale, s'est avérée plus précise pour identifier la membrane cricothyroïdienne que la technique conventionnelle vers le bas chez des patientes anesthésiées.

Commentaire :  Techniques de repérage laryngé conventionnelle vers le bas et modifiée vers le haut

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.
Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. | Anesthesiology. 2021 Nov 11
DOI: https://doi.org/10.1097/ALN.0000000000004002  | Télécharger l'article au format  
Keywords: Aucun

Practice Parameter

Editorial : The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care, Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

Conclusion : These updated guidelines:
• Specifically address difficult airway management. The guidelines do not address education, training, or certification requirements for practitioners who provide anesthesia and airway management.
• Differ from previous guidelines in that they were developed by an international task force of anesthesiologists representing several anesthesiology, airway, and other medical organizations.
• Provide new evidence obtained from recent scientific literature along with findings from new surveys of expert consultants, American Society of Anesthesiologists members, and 10 participating organizations.
• Provide consideration for the development of a difficult airway manage- ment strategy including considerations for awake airway management.
• Update equipment for standard and advanced difficult airway management.
• Recommend supplemental oxygen administration before initiating and throughout difficult airway management, including the extu- bation process.
• Offer noninvasive and invasive alternatives for difficult airway management.
• Emphasize awareness of the passage of time and limiting the num- ber of attempts of different devices and techniques during difficult airway management.
• Provide more robust recommendations for extubation of the difficult airway.
• Provide new algorithms and infographics for adult and pediatric difficult airway management.

Conclusion (proposition de traduction) : La mise à jour des directives porte sur :
• Aborder spécifiquement la gestion difficile des voies aériennes. Les directives ne traitent pas des exigences en matière d'éducation, de formation ou de certification pour les praticiens qui assurent l'anesthésie et la gestion des voies aériennes.
• Différent des directives précédentes en ce qu'elles ont été élaborées par un groupe de travail international d'anesthésiologistes représentant plusieurs organisations d'anesthésiologie, de voies aériennes et d'autres organisations médicales.
• Fournir de nouvelles preuves obtenues à partir de la littérature scientifique récente ainsi que les résultats de nouvelles enquêtes auprès de consultants experts, de membres de l'American Society of Anesthesiologists et de 10 organisations participantes.
• Tenir compte de l'élaboration d'une stratégie de gestion des voies aériennes difficiles, y compris des considérations pour la gestion des voies aériennes chez le patient conscient.
• Mettre à jour l'équipement pour la gestion standard et avancée des voies aériennes difficiles.
• Recommandez l'administration d'oxygène supplémentaire avant de commencer et tout au long de la gestion difficile des voies aériennes, y compris le processus d'extubation.
• Offrir des alternatives non invasives et invasives pour la gestion des voies aériennes difficiles.
• Mettre l'accent sur la prise de conscience du temps qui passe et la limitation du nombre de tentatives de différents dispositifs et techniques lors d'une gestion difficile des voies aériennes.
• Fournir des recommandations plus solides pour l'extubation des voies aériennes difficiles.
• Fournir de nouveaux algorithmes et infographies pour la gestion des voies aériennes difficiles chez l'adulte et l'enfant.

Commentaire : Voir l'analyse de l'article sur le site Medscape : Difficult Airway Management Clinical Practice Guidelines (ASA, 2021)  . Rédigé le December 03, 2021.

Arnaudet I, Montassier E, Javaudin F, Naux E, Le Bastard Q. | Ann Fr Med Urgence. 2021:11(6):367-384
DOI: https://doi.org/10.3166/afmu-2021-0360
Keywords: Burn; Prehospital care; Emergency department; Management; Treatment; Referral

Mise au point

Editorial : Une brûlure est une lésion de la peau ou d’un autre tissu organique principalement causée par la chaleur ou les rayonnements, la radioactivité, l’électricité, la friction ou le contact avec des produits chimiques. Les plus fréquentes, les brûlures thermiques (dues à la chaleur), surviennent lorsque certaines cellules ou toutes les cellules de la peau ou d’autres tissus sont détruites par des liquides bouillants, des solides chauds (brûlures de contact), ou des flammes. En France, l’incidence des brûlures prises en charge à l’hôpital est environ de 13 pour 100 000 habitants. La prise en charge en urgence du brûlé grave par lésion thermique est bien décrite, une recommandation de pratique professionnelle a été publiée en 2019 par la Société française d’anesthésie et de réanimation, en association avec la Société francophone de brûlologie, la Société française de médecine d’urgence et l’Association des anesthésistes-réanimateurs pédiatriques d’expression française. Pourtant, l’urgentiste va être confronté à de nombreuses brûlures de gravité et de nature différentes. Nous faisons ici une mise au point sur les données connues en termes d’épidémiologie, de manifestations cliniques et des différentes thérapeutiques qui peuvent être proposées dans la prise en charge des brûlures. Nous faisons aussi le point sur les localisations à risque particulier que l’urgentiste doit connaître, ainsi que sur les intoxications qui peuvent être associées aux brûlures. Nous détaillons aussi certains contaminants qui sont à connaître.

Conclusion (proposition de traduction) : La brûlure est un traumatisme du revêtement cutané qui, selon les caractéristiques de l’agent vulnérant et la durée de contact, va avoir des conséquences variables. L’urgentiste doit connaître les risques inhérents à la nature de chaque brûlure. En effet, il est le premier intervenant, et de ses connaissances dépendront les premières décisions de protection, les premières mesures thérapeutiques et l’orientation optimale du patient.

Midtarsal (Chopart) Sprain.
Kauffmann P, Luhmann L, Alamé K, Schenck B, Bilbault P, Le Borgne P. | Ann Fr Med Urgence. 2021;11(6):385-391
DOI: https://doi.org/10.3166/afmu-2021-0367
Keywords: Midfoot; Chopart; Joint injury

Mise au point

Editorial : L’entorse de Chopart est une lésion traumatique peu connue, sous-estimée et souvent confondue avec une entorse de cheville. Le traumatisme en inversion de la cheville, souvent accompagné d’une flexion plantaire forcée du pied, représente le mécanisme lésionnel le plus fréquent. Son diagnostic repose sur un examen clinique précis nécessitant une bonne connaissance anatomique. Les signes radiographiques sont indirects et souvent discrets. Il s’agit principalement d’arrachements osseux ou de lésions osseuses par impaction ; ils peuvent parfois d’emblée justifier d’un complément scanographique. L’échographie peut également être utile en première intention. A contrario, l’IRM est actuellement réservée aux difficultés diagnostiques. Le traitement de cette pathologie est essentiellement fonctionnel. Il faut cependant connaître les quelques indications pour un traitement orthopédique (immobilisation) comme la présence d’une lésion osseuse de grande taille. Le traitement chirurgical est quant à lui exceptionnel. L’instabilité calcanéocuboïdienne ainsi que l’arthrose du Chopart sont des complications possibles (à moyen ou long terme) mais peu fréquentes

Conclusion (proposition de traduction) : L’entorse du médiopied (de Chopart) peut être confondue initialement avec une entorse latérale de la cheville. Un examen clinique orienté permet de faire le diagnostic. Le bilan radiographique éventuellement complété par un examen scanographique permet de rechercher les lésions osseuses associées. Le traitement fonctionnel est privilégié, sauf pour quelques cas particuliers qu’il faut bien connaître afin d’éviter des séquelles, en particulier douloureuses, à moyen ou long terme.

Prescription of a Paid Sick Leave in Emergency Medicine.
Joly LM, Roussel M, Verin N, Buvat V, Gehanno JF, Lvovschi V. | Ann. Fr. Med. Urgence. 2021;11(6):393-401
DOI: https://doi.org/10.3166/afmu-2021-0367
Keywords: Public Health; Paid Sick Leave

Mise au point

Editorial : La prescription d’un arrêt de travail (AT) est un acte médical qui concerne les salariés atteints d’une maladie (on parle alors d’arrêt-maladie) ou à la suite d’un accident (d’origine professionnelle ou non). Il s’agit de permettre au salarié de cesser son travail quand celui-ci est incompatible avec son état de santé, tout en lui maintenant des revenus financiers. Les urgentistes ne sont normalement amenés à effectuer que des AT initiaux ; ils ne sont pas concernés si le patient est hospitalisé ou opéré. L’AT doit être prescrit à sa juste durée en fonction de la maladie ou des lésions, et des caractéristiques du travail : suffisamment long pour que l’état de santé du salarié soit compatible avec la reprise du travail ; mais sans excès puisque l’argent qui est versé au salarié fait appel à la solidarité nationale par le biais de l’assurance maladie. En l’absence de complication, la durée prescrite doit permettre au salarié de revenir au travail sans visite supplémentaire chez son médecin traitant. L’estimation de la durée optimale d’un AT doit reposer sur la pathologie en cause, sur son expression symptomatique plus ou moins sévère, sur le terrain du patient, et sur les contraintes physiques liées à sa pratique professionnelle. Deux fiches élaborées avec l’assurance maladie sont présentées pour guider l’urgentiste dans le choix de la durée, l’une pour des urgences médicales fréquentes, l’autre pour des urgences traumatologiques non chirurgicales.

Conclusion (proposition de traduction) : Nous avons rappelé dans cet article les grands principes régissant la prescription des AT. Nous avons présenté un document destiné aux urgentistes avec indication des durées d’AT pour des pathologies fréquentes en médecine d’urgence. Ces fiches ont été produites par une sélection à partir des documents préalables de l’assurance maladie et ne retiennent que les pathologies pour lesquelles l’urgentiste est le seul décideur de l’AT et de sa durée. Sauf complication ou nécessité de suivi médical, cette durée doit permettre au patient de reprendre son travail sans reconsulter chez son médecin traitant. Dans tous les cas, il s’agit de durées conseillées, et le médecin urgentiste prescripteur de l’AT peut indiquer des durées plus courtes ou plus longues s’il dispose d’éléments probants pour les justifier.

Mourou H, Latournerie G, Delisle E, Charpentier S. | Ann Fr Med Urgence. 2021;11(6):357–365
DOI: https://doi.org/10.3166/afmu-2021-0368  | Télécharger l'article au format  
Keywords: Emergency department; Self-referred patients; Healthcare quality improvement

Article original

Introduction : Peu d’études évaluent les caractéristiques des patients adressées aux urgences après un avis médical et celles des patients s’y rendant de leur propre initiative. L’objectif de cette étude était de comparer ces deux populations définies par leur mode d’adressage.

Méthode : Étude transversale rétrospective réalisée dans les services d’urgence en Occitanie de 2016 à 2018. Les analyses ont porté sur les données du résumé de passage aux urgences. Deux groupes de patients ont été créés : les adressés après avis médical et les non-adressés venant directement.

Résultats : Sur 1 812 795 passages, 80 % sont venus aux urgences de leur propre initiative. Parmi les 20 % adressés, 75 % ont été régulés par le Samu et 25 % adressés par un médecin de ville. Les patients adressés étaient plus âgés que les patients non adressés (âge moyen de 57 ± 26 versus 36 ± 24 ans). Les patients adressés étaient dirigés dans 71 % des cas vers les établissements publics et arrivaient avec un transport sanitaire dans 76 % des cas. La durée médiane de passage aux urgences était plus importante dans le groupe des patients adressés (4 h 23 min contre 2 h 25 min pour les non-adressés). Les patients adressés étaient plus graves (3 % de CCMU4-5 versus 0,4 % dans le groupe non adressé) et plus hospitalisés (38 versus 12 % dans le groupe non adressé). Les motifs de consultations, en revanche, étaient assez similaires entre les deux groupes.

Conclusion (proposition de traduction) : Les patients adressés aux urgences étaient très différents de ceux venant d’eux-mêmes.

United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department.
Loffredo AJ, Chan GK, Wang DH, Goett R, Isaacs ED, Pearl R, Rosenberg M, Aberger K, Lamba S. | Ann Emerg Med . 2021 Nov;78(5):658-669
DOI: https://doi.org/10.1016/j.annemergmed.2021.05.021
Keywords: Aucun

General Medicine

Editorial : The growing palliative care needs of emergency department (ED) patients in the United States have motivated the development of ED primary palliative care principles. An expert panel convened to develop best practice guidelines for ED primary palliative care to help guide frontline ED clinicians based on available evidence and consensus opinion of the panel. Results include recommendations for screening and assessment of palliative care needs, ED management of palliative care needs, goals of care conversations, ED palliative care and hospice consults, and transitions of care.

Conclusion : ED staff focus on delivering the right care, in theright place, at the right time to their patients. Emergencyclinicians bear a significant responsibility for setting the initial trajectory of care for patients during the ED visitand subsequent hospitalization. The ED remains animportant site for the initiation and continuation ofpalliative care for seriously ill patients. US ED primarypalliative care best practice guidelines provide aframework to deliver high-quality, patient-centered carethrough the 4 phases of emergency care for thesepatients. Readiness to implement ED palliative initiativeswill vary across institutions and locales. Tailoredintegration and/or expansion of available palliative careresources must reflect institutional priorities and ED-specific culture and protocols. Successful implementationrequires both emergency physician and nursingchampions. Formal education and training of allmembers of the ED team, including emergency medicineresidents, will need to accompany any palliative careinitiatives. Improving the ED care of seriously ill patientsand their families can enhance the well-being of staff, asthey know they are focusing on the individual patient’sgoals for care.

Conclusion (proposition de traduction) : Le personnel des urgences se concentre sur la prestation des bons soins, au bon endroit, au bon moment à leurs patients. Les urgentistes ont une responsabilité importante dans l'établissement de la trajectoire initiale des soins pour les patients lors de la visite aux urgences et de l'hospitalisation qui s'ensuit. Le service des urgences reste un site important pour l'initiation et la poursuite des soins palliatifs pour les patients gravement malades. Les lignes directrices sur les meilleures pratiques en soins palliatifs primaires aux États-Unis fournissent un cadre pour fournir des soins de haute qualité centrés sur le patient tout au long des 4 phases des soins d'urgence pour ces patients. L'état de préparation à mettre en œuvre des initiatives de soins palliatifs aux urgences variera selon les établissements et les lieux. L'intégration et/ou l'expansion sur mesure des ressources disponibles en soins palliatifs doivent refléter les priorités institutionnelles et la culture et les protocoles spécifiques aux services d'urgence. Une mise en œuvre réussie nécessite à la fois des urgentistes et des soins infirmiers de qualité. L'éducation et la formation formelles de tous les membres de l'équipe du service d'urgence, y compris les résidents en médecine d'urgence, devront accompagner toute initiative de soins palliatifs. Améliorer les soins aux urgences des patients gravement malades et de leurs familles peut améliorer le bien-être du personnel, car ils savent qu'ils se concentrent sur les objectifs de soins de chaque patient.

What is the Efficacy of Initial Therapies for Bleeding from Esophageal Varices in Adult Patients With Cirrhosis?.
Long B, Koyfman A, Gottlieb M. | Ann Emerg Med. 2021 Nov;78(5):670-673
DOI: https://doi.org/10.1016/j.annemergmed.2021.05.014
Keywords: Aucun

General Medicine

Méthode : The authors searched Cochrane CENTRAL, MEDLINE Ovid, Embase Ovid, and Web of Science databases for registered studies from database inception to December 17, 2019, for all possible comparisons formed by the interventions of interest, without language restrictions. Authors also searched for ongoing or completed trials using ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, the European Medicines Agency, the United States Food and Drug Administration, and references of identified trials.
Study selection: The authors included randomized controlled trials of adults with acutely bleeding esophageal varices due to decompensated liver cirrhosis. They included trials in which patients with esophageal varices also had gastric varices, but they excluded trials in which the target of therapy was gastric varices, those including patients with prior liver transplantation, and those in which patients had failed prior therapies or where initial hemostasis was achieved before randomization. Authors included any of the following interventions for comparison with one another alone or in combination: vasopressin or analogues, somatostatin or analogues, endoscopic sclerotherapy, balloon tamponade, tranexamic acid, no active intervention, and several others.

Résultats : Two authors independently screened articles for inclusion and resolved any discrepancies through discussion. Pairs of review authors independently extracted the data from selected studies, with differences in opinion resolved through discussion. Meta-analysis authors attempted to contact individual trial authors in the case of missing or unclear data. Primary outcomes included the proportion of patients who died from any cause, health-related quality of life based on a validated scale such as the European Quality of Life–5 Dimensions or 36-Item Short Form Health Survey, and serious adverse events (defined as any event that would increase mortality; is lifethreatening; requires hospitalization; results in persistent or significant disability; is a congenital anomaly/birth defect; or any important medical event that may jeopardize the person or require intervention for prevention). Secondary outcomes included any adverse event, the proportion of patients with variceal bleeding at 6 weeks, and the proportion of patients with other features of decompensation at 6 weeks. Sclerotherapy was used as the reference standard. Authors conducted a network meta-analysis to compare multiple interventions simultaneously through direct comparisons if possible and indirectly when not possible. Authors assessed dichotomous outcomes using odds ratios and continuous variables with mean differences and 95% confidence intervals. For count outcomes, authors calculated rate ratios, and they estimated ranking probabilities when network meta-analysis was performed. Authors assessed statistical heterogeneity by comparing results of the fixedeffects model and random-effects model meta-analyses, lack of overlap of 95% credible intervals of between-study variance, and by calculating the network metaanalysis- specific I2 statistic. Risk of bias was determined by the revised Cochrane risk of bias tool.

Conclusion : Compared to sclerotherapy, somatostatin analogues or vasopressin analogues alone increase mortality.Sclerotherapy plus somatostatin analogues does not reduce mortality but may decrease symptomaticrebleeding when compared to sclerotherapy alone.

Conclusion (proposition de traduction) : Par rapport à la sclérothérapie, les analogues de la somatostatine ou de la vasopressine seuls augmentent la mortalité. La sclérothérapie associée aux analogues de la somatostatine ne réduit pas la mortalité mais peut diminuer les saignements symptomatiques par rapport à la sclérothérapie seule.

Impact of cooling method on the outcome of initial shockable or non-shockable out of hospital cardiac arrest patients receiving target temperature management: a nationwide multicentre cohort study.
Watanabe M, Matsuyama T, Oe H, Sasaki M, Nakamura Y, Miyamoto Y, Okada N, Kitamura T, Ohta B. | Ann Intensive Care. 2021 Nov 26;11(1):163
DOI: https://doi.org/10.1186/s13613-021-00953-y  | Télécharger l'article au format  
Keywords: Cooling method; Initial non-shockable rhythm; Initial shockable rhythm; Out-of-hospital cardiac arrest; TTM; Target temperature management.

Research

Introduction : Little is known about the effectiveness of surface cooling (SC) and endovascular cooling (EC) on the outcome of out-of-hospital cardiac arrest (OHCA) patients receiving target temperature management (TTM) according to their initial rhythm.

Méthode : We retrospectively analysed data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multicentre, prospective nationwide database in Japan. For our analysis, OHCA patients aged ≥ 18 years who were treated with TTM between June 2014 and December 2017 were included. The primary outcome was 30-day survival with favourable neurological outcome defined as a Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Cooling methods were divided into the following groups: SC (ice packs, fans, air blankets, and surface gel pads) and EC (endovascular catheters and any dialysis technique). We investigated the efficacy of the two categories of cooling methods in two different patient groups divided according to their initially documented rhythm at the scene (shockable or non-shockable) using multivariable logistic regression analysis and propensity score analysis with inverse probability weighting (IPW).

Résultats : In the final analysis, 1082 patients were included. Of these, 513 (47.4%) had an initial shockable rhythm and 569 (52.6%) had an initial non-shockable rhythm. The proportion of patients with favourable neurological outcomes in SC and EC was 59.9% vs. 58.3% (264/441 vs. 42/72), and 11.8% (58/490) vs. 21.5% (17/79) in the initial shockable patients and the initial non-shockable patients, respectively. In the multivariable logistic regression analysis, differences between the two cooling methods were not observed among the initial shockable patients (adjusted odd ratio [AOR] 1.51, 95% CI 0.76-3.03), while EC was associated with better neurological outcome among the initial non-shockable patients (AOR 2.21, 95% CI 1.19-4.11). This association was constant in propensity score analysis with IPW (OR 1.40, 95% CI 0.83-2.36; OR 1.87, 95% CI 1.01-3.47 among the initial shockable and non-shockable patients, respectively).

Conclusion : We suggested that the use of EC was associated with better neurological outcomes in OHCA patients with initial non-shockable rhythm, but not in those with initial shockable rhythm. A TTM implementation strategy based on initial rhythm may be important.

Conclusion (proposition de traduction) : Nous suggérons que l'utilisation du refroidissement endovasculaire était associée à de meilleurs résultats neurologiques chez les patients en arrêt cardiaque en dehors de l'hôpital avec un rythme initial non choquable, mais pas chez ceux avec un rythme initial choquable. Une stratégie de mise en œuvre de la gestion de la température cible basée sur le rythme cardiaque initial peut être importante.

Cardiopulmonary Resuscitation Outcomes of Patients with COVID-19; a One-Year Survey.
Goodarzi A, Khodaveisi M, Abdi A, Salimi R, Oshvandi K. | Arch Acad Emerg Med. 2021 Nov 4;9(1):e70
DOI: https://doi.org/10.22037/aaem.v9i1.1381  | Télécharger l'article au format  
Keywords: COVID-19; Cardiopulmonary resuscitation; Epinephrine; Heart Arrest.

Original/Research Article

Introduction : Assessing cardiopulmonary resuscitation (CPR) outcomes of patients with COVID-19 and employing effective strategies for their improvement are essential. This study is designed in this regard.

Méthode : This cross-sectional study was conducted between January 20, 2020 and January 20, 2021 in the emergency departments of two hospitals in Hamadan and Kermanshah, Iran. Participants were 487 patients with confirmed COVID-19 and cardiac arrest (CA) who had undergone CPR during the study period. Data were collected using the available CPR documentation forms developed based on the Utstein Style and analyses were performed using Chi-square, Fisher's exact, and Mann-Whitney U tests and the logistic regression analysis.

Résultats : Participants' mean age was 69.31±14.73 years and most of them were male (61.8%) and suffered from at least one underlying disease (58.1%). The rate of total and in-hospital CA was 9.67% and 9.39%, respectively. The most prevalent first documented rhythm was asystole (67.9%) and the highest responsivity to CPR was for shockable rhythms. The rate of the return of spontaneous circulation (ROSC) was 9% and the rate of survival to hospital discharge was 2%. The significant predictors of CPR success were age (p = 0.035), epinephrine administration time interval (p = 0.00), CPR duration (p = 0.00), and First documented rhythm (p = 0.009).

Conclusion : The rate of in-hospital CA among studied COVID-19 cases was 9.39% with 9% ROSC and 2% survival to hospital discharge rates after CPR. Primary CPR success among patients with COVID-19 was poor, particularly among those with asystole and bradycardia. It seems that old age and improper doses of epinephrine can reduce CPR success.

Conclusion (proposition de traduction) : Le taux d'arrêt cardiaque à l'hôpital parmi les cas de COVID-19 étudiés était de 9,39 % avec un RACS de 9 % et un taux de survie de 2 % jusqu'à la sortie de l'hôpital après la RCP. Le succès de la RCP initiale chez les patients atteints de la COVID-19 était médiocre, en particulier chez ceux souffrant d'asystolie et de bradycardie. Il semble que la vieillesse et des doses inappropriées d'adrénaline peuvent réduire le succès de la RCP.

Drug-free tracheal intubation by specialist paramedics (critical care) in a United Kingdom ambulance service: a service evaluation.
Houghton Budd S, Alexander-Elborough E, Brandon R, Fudge C, Hardy S, Hopkins L, Paul B, Philips S, Thatcher S, Winsor P. | BMC Emerg Med. 2021 Nov 20;21(1):144
DOI: https://doi.org/10.1186/s12873-021-00533-0  | Télécharger l'article au format  
Keywords: Airway; Critical care; Intubation; Paramedic; Prehospital; Tracheal intubation.

Research article

Introduction : Drug-free tracheal intubation has been a common intervention in the context of out-of-hospital cardiac arrest for many years, however its use by paramedics has recently been the subject of much debate. Recent international guidance has recommended that only those achieving high tracheal intubation success should continue to use it.

Méthode : We conducted a retrospective service evaluation of all drug-free tracheal intubation attempts by specialist paramedics (critical care) from South East Coast Ambulance Service NHS Foundation Trust between 1st January and 31st December 2019. Our primary outcome was first-pass success rate, and secondary outcomes were success within two attempts, overall success, Cormack-Lehane grade of view, and use of bougie.

Résultats : There were 663 drug-free tracheal intubations and following screening, 605 were reviewed. There was a first-pass success rate of 81.5%, success within two attempts of 96.7%, and an overall success rate of 98.35%. There were ten unsuccessful attempts (1.65%). Bougie use was documented in 83.4% on the first attempt, 93.5% on the second attempt and 100% on the third attempt.

Conclusion : Specialist paramedics (critical care) are able to deliver drug-free tracheal intubation with good first-pass success and high overall success and are therefore both safe and competent at this intervention.

Conclusion (proposition de traduction) : Les ambulanciers paramédicaux spécialisés (en soins critiques) sont capables de pratiquer une intubation trachéale sans sédation avec un bon succès de premier passage et un succès global élevé et sont donc à la fois sûrs et compétents pour cette intervention.

Commentaire : Les résultats proposés sont les suivant :
Il y avait un taux de réussite de premier passage de 81,5 %, de réussite en deux tentatives de 96,7 % et un taux de réussite global de 98,35 %. Il y a eu dix tentatives infructueuses (1,65 %). L'utilisation d'un mandrin long béquillé (« bougie ») a été documentée dans 83,4 % à la première tentative, 93,5 % à la deuxième tentative et 100 % à la troisième tentative.
Donc, échec de l'intubation au premier essai dans 18,5 % des première tentatives et utilisation d'un mandrin long béquillé dans la majorité des cas pour améliorer la réussite de l'intubation.

La plupart des études réalisées au sein d’équipes préhospitalières médicalisées rapportent un taux d’échec d’intubation compris entre 0 et 0,5 % avec un taux d’intubation difficile le plus souvent aux alentours de 10 à 15 % (Combes X, Jabre P. Intubation préhospitalière. MAPAR 2008  ).

The timing of administering aspirin and nitroglycerin in patients with STEMI ECG changes alter patient outcome.
Todoroski KB | BMC Emerg Med. 2021 Nov 17;21(1):137
DOI: https://doi.org/10.1186/s12873-021-00523-2  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : Both chewed aspirin and sublingual nitroglycerin are fast acting medications and reach therapeutic levels within a few minutes. Current guidelines for managing acute coronary syndrome (ACS) do not recognize the importance of the order or timing of administering aspirin and nitroglycerin. This retrospective study aimed to examine if there was any benefit to the timing of giving aspirin before or after nitroglycerin in cases of ACS.

Méthode : From the large National Emergency Medical Services Information System (NEMSIS) 2017 Version database, 2594 patients with acute coronary syndrome were identified (based on chest pain and their ECG finding) that received aspirin plus nitroglycerin in prehospital settings. Based on which medication was given first, the patients were separated in 2 groups: an aspirin-first and a nitroglycerin-first group. The 2246 patients who received aspirin first were further stratified based on the time between administration of aspirin and the first dose of nitroglycerin. The other 348 patients who received nitroglycerin first were similarly stratified.

Résultats : In patients with STEMI ischemia, giving nitroglycerin 10 min after aspirin dosing (compared to giving them simultaneously) leads to a greater than 20% reduction in need for additional nitroglycerin, a greater than 7% decrease in subjective pain experienced by the patient and reduced need for additional opioids. The aspirin-first group in total, had a 39.6% decrease in subjective pain experience after giving additional nitroglycerin compared to nitroglycerin-first group.

Conclusion : In patients with ACS, this study found that giving nitroglycerin 10 min after aspirin was associated with a reduction in subjective pain scores, as well as a reduced need for additional nitroglycerin or opioids. Future prospective trials examining the timing of aspirin vs. nitroglycerin are needed to confirm these findings.

Conclusion (proposition de traduction) : Chez les patients présentant un syndrome coronarien aigu, cette étude a révélé que l'administration de dérivés nitrés 10 minutes après l'aspirine était associée à une réduction des scores subjectifs de douleur, ainsi qu'à un besoin réduit de dérivés nitrés ou de morphiniques supplémentaires. De futurs essais prospectifs examinant le moment de l'aspirine par rapport à la nitroglycérine sont nécessaires pour confirmer ces résultats.

Timely intubation with early prediction of respiratory exacerbation in acute traumatic cervical spinal cord injury.
Yonemitsu T, Kinoshita A, Nagata K, Morishita M, Yamaguchi T, Kato S. | BMC Emerg Med. 2021 Nov 13;21(1):136
DOI: https://doi.org/10.1186/s12873-021-00530-3  | Télécharger l'article au format  
Keywords: Cervical spinal cord injury; Copious airway secretion; Respiratory exacerbation; Timely intubation.

Research article

Introduction : Early routine intubation in motor-complete cervical spinal cord injury (CSCI) above the C5 level is a conventional protocol to prevent unexpected respiratory exacerbation (RE). However, in the context of recent advances in multidisciplinary respiratory management, the absolute indication for intubation in patients with CSCI based on initial neurologic assessment is controversial because of the drawbacks of intubation. This study aimed to redetermine the most important predictor of RE following CSCI after admission without routine intubation among patients admitted with motor-complete injury and/or injury above the C5 level to ensure timely intubation.

Méthode : We performed a retrospective review of patients with acute traumatic CSCI admitted to our hospital without an initial routine intubation protocol from January 2013 to December 2017. CSCI patients who developed RE (defined as unexpected emergent intubation for respiratory resuscitation) were compared with those who did not. Baseline characteristics and severity of trauma data were collected. Univariate analyses were performed to compare treatment data and clinical outcomes between the two groups. Further, multivariate logistic regression was performed with clinically important independent variables: motor-complete injury, neurologic level above C5, atelectasis, and copious airway secretion (CAS).

Résultats : Among 58 patients with CSCI, 35 (60.3%) required post-injury intubation and 1 (1.7%) died during hospitalization. Thirteen (22.4%) had RE 3.5 days (mean) post-injury; 3 (37.5%) of eight patients with motor-complete CSCI above C5 developed RE. Eleven of the 27 (40.7%) patients with motor-complete injury and five of the 22 (22.7%) patients with neurologic injury above C5 required emergency intubation at RE. Three of the eight CSCI patients with both risk factors (motor-complete injury above C5) resulted in emergent RE intubation (37.5%). CAS was an independent predictor for RE (odds ratio 7.19, 95% confidence interval 1.48-42.72, P = 0.0144) in multivariate analyses.

Conclusion : Timely intubation post-CSCI based on close attention to CAS during the acute 3-day phase may prevent RE and reduce unnecessary invasive airway control even without immediate routine intubation in motor-complete injury above C5.

Conclusion (proposition de traduction) : Une intubation opportune après lésion de la moelle épinière cervicale, basée sur une surveillance attentive de la sécrétion abondante des voies aériennes pendant la phase aiguë de 3 jours, peut prévenir l’exacerbation respiratoire et réduire le contrôle invasif inutile des voies respiratoires, même sans intubation de routine immédiate en cas de lésion motrice au-dessus de C5.

The impact of chest pain center on treatment delay of STEMI patients: a time series study.
Sun X, Yao B, Shi K, Xue Y, Liang H. | BMC Emerg Med. 2021 Nov 6;21(1):129
DOI: https://doi.org/10.1186/s12873-021-00535-y  | Télécharger l'article au format  
Keywords: Chest pain center; ST segment elevation myocardial infarction; Treatment delay.

Research

Introduction : To study the effect of the establishment of a Chest Pain Center (CPC) on the treatment delay of ST-elevation myocardial infarction (STEMI) patients and the influencing factors of treatment delay in a large hospital in China.

Méthode : The study subjects are 318 STEMI patients admitted between August 2016 and July 2019 to a large general hospital in Henan, China. Data were extracted from the electronic medical records after removing personal identifiable information. The interrupted time series regression was used to analyze the treatment delay of patients before and after the CPC establishment.

Résultats : After the CPC establishment, the patients' pre-hospital and in-hospital treatment delays were significantly reduced. SO-to-FMC (Symptom Onset to First Medical Contact time) decreased by 49.237 min and D-to-B (Door to Balloon time) decreased by 21.931 min immediately after the CPC establishment. In addition, SO-to-FMC delay is significantly correlated with age, occupation, nocturnal onset, and the way to hospital. D-to-B delay is significantly associated with time from initial diagnosis to informed consent of percutaneous coronary intervention (PCI), catheterization lab activation time, and time for PCI informed consent.

Conclusion : The CPC significantly reduced the treatment delay of STEMI patients undergoing PCI.

Conclusion (proposition de traduction) : Le Chest Pain Center a considérablement réduit le délai de traitement des patients atteints de syndrome coronarien aigu avec élévation du segment ST subissant une intervention coronarienne percutanée.

Epinephrine before defibrillation in patients with shockable in-hospital cardiac arrest: propensity matched analysis.
Evans E, Swanson MB, Mohr N, Boulos N, Vaughan-Sarrazin M, Chan PS, Girotra S; American Heart Association’s Get With The Guidelines-Resuscitation investigators. | BMJ. 2021 Nov 10;375:e066534
DOI: https://doi.org/10.1136/bmj-2021-066534  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : To determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival.
Design : Propensity matched analysis.
Participants : 2000-18 data from 497 hospitals participating in the American Heart Association's Get With The Guidelines-Resuscitation registry.
Participants: Adults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation.
Interventions: Administration of epinephrine before first defibrillation.

Méthode : Survival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for >20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes.

Résultats : Among 34 820 patients with an initial shockable rhythm, 9630 (27.6%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, pneumonia, and receive mechanical ventilation before in-hospital cardiac arrest (P<0.0001 for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 3 minutes v 0 minutes). In propensity matched analysis (9011 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (25.2% v 29.9%; adjusted odds ratio 0.81, 95% confidence interval 0.74 to 0.88; P<0.001), favorable neurological survival (18.6% v 21.4%; 0.85, 0.76 to 0.92; P<0.001), and survival after acute resuscitation (64.4% v 69.4%; 0.76, 0.70 to 0.83; P<0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time.

Conclusion : Contrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, more than one in four patients are treated with epinephrine before defibrillation, which is associated with worse survival.

Conclusion (proposition de traduction) : Contrairement aux recommandations actuelles qui donnent la priorité à la défibrillation immédiate en cas d'arrêt cardiaque à l'hôpital dû à un rythme choquable, plus d'un patient sur quatre est traité avec de l'adrénalne avant la défibrillation, ce qui est associé à une moins bonne survie.

Is ambulatory management of primary spontaneous pneumothorax safe and effective?.
Marcotte A, de Champlain F. | CJEM. 2021 Nov;23(6):750-751
DOI: https://doi.org/10.1007/s43678-021-00183-y
Keywords: Aucun

Need to Know: CJEM Journal Club

Introduction : The optimal management for primary spontaneous pneu- mothorax is not well defined and may lead to unnecessary hospitalizations.
Objectives : To describe the duration of hospitalization and safety of ambulatory management of primary spontaneous pneumo- thorax compared with standard care.

Méthode : Open-label randomized controlled trial.
Eligibility criteria: Adults (aged 16–55) with symptomatic, clinically stable pri- mary spontaneous pneumothorax.
Intervention : Insertion of an ambulatory device—Rocket pleural vent, an 8F gauge catheter attached to a self-contained, one way Heimlich valve and fluid collection chamber.
Comparison: Standard care—aspiration, chest tube insertion, or both.

Résultats : 236 patients were enrolled; 117 were assigned to ambu- latory care and 119 to standard care. The mean age was 30 years (SD 8), and the majority were male (82%). The median hospital stay at 30 days was significantly lower for the ambulatory care group (mean difference, 2 days, 95% CI 1–3). Time until successful completion of treatment (defined as adequate lung expansion following needle aspiration or removal of device or chest tube) was significantly longer in the ambulatory care group (mean difference −1 days, 95%CI −2 to 0, p = 0.0040). Fewer additional pleural procedures were required in those who received ambulatory care (21% vs. 35% p = 0.0075). However, more adverse events occurred in the ambulatory group including enlarging pneumotho- rax, blocked, dislodged or leaking device, and asymptomatic re-expansion pulmonary edema (55% vs. 39%, p = 0.0135). Re-admission rates, time off work, and mean pain, breath- lessness scores, and analgesia use were similar.

Conclusion : This study demonstrates that outpatient treatment with an ambulatory device of clinically stable patients with primary spontaneous pneumothorax is safe and effective at reduc- ing the hospital length of stay and the required number of pleural procedures.
However, ambulatory treatment options necessitate out- patient care pathways in collaboration with surgical consult- ants to ensure appropriate detection of adverse events and timely removal of the device. Guidelines should be updated to reflect this option and emphasize a shared decision-mak- ing process to highlight the importance of adequate follow- up and the risk of adverse events.

Conclusion (proposition de traduction) : Cette étude démontre que le traitement ambulatoire avec un dispositif ambulatoire de patients cliniquement stables atteints de pneumothorax spontané primaire est sûr et efficace pour réduire la durée d'hospitalisation et le nombre requis d'interventions pleurales.
Cependant, les options de traitement ambulatoire nécessitent des parcours de soins ambulatoires en collaboration avec des consultants chirurgicaux pour assurer une détection appropriée des événements indésirables et un retrait rapide du dispositif. Les lignes directrices devraient être mises à jour pour refléter cette option et mettre l'accent sur un processus décisionnel partagé pour souligner l'importance d'un suivi adéquat et le risque d'événements indésirables.

Optimal management strategies for primary headache in the emergency department.
Wells S, Stiell IG, Vishnyakova E, Lun R, Nemnom MJ, Perry JJ. | CJEM. 2021 Nov;23(6):802-811
DOI: https://doi.org/10.1007/s43678-021-00173-0  | Télécharger l'article au format  
Keywords: Emergency department; Headache; Migraine.

Content type: Original Research

Introduction : We sought to evaluate the factors associated with better outcomes for emergency department (ED) patients treated for primary headache.

Méthode : This was a health records review of consecutive patients over a 3-month period presenting to two tertiary EDs and discharged with a diagnosis of primary headache. The primary outcome was the need for second round medications, defined as medications received > 1 h after the initial physician-ordered medications were administered. We performed multivariate logistic regression analysis to determine treatment factors associated with need for second round medications.

Résultats : We included 553 patients, mean age was 42.2 years and 72.9% were females. The most common diagnoses were headache not otherwise specified (48.8%) and migraine (43%). Ketorolac IV (62.2%) and metoclopramide IV (70.2%) were the most frequently administered medications. 18% of patients met the primary outcome. Dopamine antagonists (OR 0.3 [95% CI 0.1-0.5]) and non-steroidal anti-inflammatory drugs (NSAIDs) (OR 0.5 [95% CI 0.3-0.8]) ordered with initial medications were associated with reduced need for second round medications. Intravenous fluid boluses ≥ 500 ml (OR 2.8 [95% CI: 1.5-5.2]) and non-dopamine antagonist antiemetics (OR 2.2 [95% CI 1.2-4.2]) were associated with increased need. Opioid use approached statistical significance for receiving second round medication (p = 0.06).

Conclusion : We determined that use of dopamine antagonists and NSAIDs were associated with a reduced need for second round medications in ED primary headache patients. Conversely, non-dopamine antagonist antiemetic medications and intravenous fluids were associated with a significantly increased need for second round medications. Careful choice of initial therapy may optimize management for these patients.

Conclusion (proposition de traduction) : Nous avons déterminé que l'utilisation d'antagonistes de la dopamine et d'AINS était associée à un besoin réduit de médicaments de seconde ligne chez les patients souffrant de céphalées primaires aux urgences. À l'inverse, les médicaments antiémétiques non antagonistes de la dopamine et de traitements intraveineux ont été associés à un besoin significativement accru de médicaments de seconde ligne. Un choix judicieux de traitement initial peut optimiser la prise en charge de ces patients.

Point-of-Care Ultrasound for Bedside Diagnosis of Lower Extremity DVT.
Barrosse-Antle ME, Patel KH, Kramer JA, Baston CM. | Chest. 2021 Nov;160(5):1853-1863
DOI: https://doi.org/10.1016/j.chest.2021.07.010  | Télécharger l'article au format  
Keywords: DVT; critical care; pulmonary embolism; training (internal medicine); ultrasound.

How I Do It

Editorial : The point-of-care ultrasound DVT (POCUS DVT) examination can facilitate rapid bedside diagnosis and treatment of lower extremity DVT. Awaiting radiology-performed Doppler ultrasonography and interpretation by radiologists can lead to delays in lifesaving anticoagulation, and the POCUS DVT examination can provide timely diagnostic information in the patient with lower extremity symptoms. This article outlines accepted techniques for the POCUS DVT examination, discusses the historical context from which the current recommendations have evolved, and provides illustrations alongside ultrasound images of relevant venous anatomy to orient the clinician. Finally, common pitfalls and methods to avoid them are described.

Conclusion : Competency in performing the POCUS DVT examination is attainable with an understanding of the vascular anatomy and practice. The two-zone POCUS DVT examination has a high sensitivity and specificity for proximal lower extremity DVT, and it is the scanning technique we use most commonly in the ICU. If clinical suspicion is high, however, most societies recommend extending the zone of compression as far as the vessels can be visualized. Although POCUS in the hands of skilled practitioners can lead to early diagnosis and appropriate treatment of VTE, decisions regarding initiation of treatment should be undertaken only with the support of providers experienced in POCUS. We recommend consideration of a follow-up study by radiology based on the guidelines described here. Specific recommendations for training and certification have not yet been fully developed.

Conclusion (proposition de traduction) : La compétence dans la réalisation de l'examen par ultrasons au point d'intervention de recherche de thrombose veineuse profonde est réalisable avec une compréhension de l’anatomie vasculaire et de la pratique. L’échographie bi-zone sur la thrombose veineuse profonde présente une sensibilité et une spécificité élevées pour la thrombose veineuse profonde du membre inférieur proximal, et c’est la technique de balayage que nous utilisons le plus couramment en soins intensifs. Toutefois, si les soupçons cliniques sont élevés, la plupart des sociétés recommandent d’étendre la zone de compression aussi loin que possible de visualiser les vaisseaux. Bien que l’échographie effectuée au point d'intervention par des praticiens qualifiés puisse mener à un diagnostic précoce et à un traitement approprié de la thrombophlébite veineuse, les décisions concernant l’initiation du traitement ne devraient être prises qu’avec l’appui d’intervenants expérimentés en échographie au point de service. Nous recommandons d’envisager une étude de suivi par radiologie basée sur les lignes directrices décrites ici. Des recommandations précises en matière de formation et de certification n’ont pas encore été élaborées.

Safety of Thoracentesis and Tube Thoracostomy in Patients With Uncorrected Coagulopathy: A Systematic Review and Meta-analysis.
Fong C, Tan CWC, Tan DKY, See KC. | Chest. 2021 Nov;160(5):1875-1889
DOI: https://doi.org/10.1016/j.chest.2021.04.036
Keywords: bleeding complications; pleural effusion; pneumothorax; thoracentesis; thoracostomy.

Original Research

Introduction : Thoracentesis and tube thoracostomy are common procedures with bleeding risks, but existing guidelines may be overly conservative. We reviewed the evidence on the safety of thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy.
Research question: Is it safe to perform thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy?

Méthode : This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. PubMed and Embase were searched from inception through December 31, 2019. Included studies involved patients with uncorrected coagulopathy because of disease (eg, thrombocytopenia, liver cirrhosis, kidney failure) or drugs (eg, antiplatelets, anticoagulants). Relevant outcomes were major bleeding and mortality.

Résultats : Eighteen studies (5,134 procedures) were included. Using random-effects meta-analysis, the pooled major bleeding and mortality rate was 0 (95% CI, 0%-1%). No publication bias was found. Excluding six studies that were in abstract form, meta-analysis of the remaining 12 full articles showed that the pooled major bleeding and mortality rate also was 0 (95% CI, 0%-2%). Subgroup analysis performed for patients with uncorrected coagulopathy resulting from disease or drugs showed similar results.

Conclusion : Among patients with uncorrected coagulopathy who underwent thoracentesis or tube thoracostomy, major bleeding and mortality complications were uncommon. Our results suggest that in appropriately selected patients, thoracentesis or tube thoracostomy can be performed safely.

Conclusion (proposition de traduction) : Parmi les patients présentant un coagulopathie non corrigée qui ont bénéficié d'une ponction pleurale ou d'un drainage thoracique, les complications hémorragiques majeures et la mortalité étaient rares. Nos résultats suggèrent que chez des patients sélectionnés de manière appropriée, la ponction pleurale et le drainage thoracique peut être réalisée en toute sécurité.

Commentaire : Voir :
Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations. Journal of Vascular and Interventional Radiology 2019;30(8):1168-84  .

La méta-analysede Fong C est parvenues à la même conclusion que la Society of Interventional Radiology selon laquelle la ponction pleural guidée par échographie ou la mise en place d'un drain thoracique non tunnelisé peut être réalisée en toute sécurité chez les patients qui ont des plaquettes d'au moins 20 000/µL, ont un INR < 3 sous warfarine ou AOD ou antiagrégants plaquettaires.

Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association.
Jacobs AK, Ali MJ, Best PJ, Bieniarz MC, Bufalino VJ, French WJ, Henry TD, Hollowell L, Jauch EC, Kurz MC, Levy M, Patel P, Spier T, Stone RH, Tataris KL, Thomas RJ, Zègre-Hemsey JK. | Circulation. 2021 Nov 16;144(20):e310-e327
DOI: https://doi.org/10.1161/cir.0000000000001025  | Télécharger l'article au format  
Keywords: AHA Scientific Statements; ST-segment–elevation myocardial infarction; cardiac systems of care.

Clinical Statements and Guidelines

Editorial : The introduction of Mission: Lifeline significantly increased timely access to percutaneous coronary intervention for patients with ST-segment-elevation myocardial infarction (STEMI). In the years since, morbidity and mortality rates have declined, and research has led to significant developments that have broadened our concept of the STEMI system of care. However, significant barriers and opportunities remain. From community education to 9-1-1 activation and emergency medical services triage and from emergency department and interfacility transfer protocols to postacute care, each critical juncture presents unique challenges for the optimal care of patients with STEMI. This policy statement sets forth recommendations for how the ideal STEMI system of care should be designed and implemented to ensure that patients with STEMI receive the best evidence-based care at each stage in their illness.

Reducing medication errors for adults in hospital settings.
Ciapponi A, Fernandez Nievas SE, Seijo M, Rodríguez MB, Vietto V, García-Perdomo HA, Virgilio S, Fajreldines AV, Tost J, Rose CJ, Garcia-Elorrio E. | Cochrane Database Syst Rev. 2021 Nov 25;11(11):CD009985
DOI: https://doi.org/10.1002/14651858.cd009985.pub2  | Télécharger l'article au format  
Keywords: Aucun

Review

Introduction : Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death.
Objectives: To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings

Méthode : We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments.

Résultats : We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings.

Conclusion : Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.

Conclusion (proposition de traduction) : Par rapport aux soins standard, la conciliation médicamenteuse, les systèmes de prescription électronique, les codes-barres et le retour d'information aux professionnels pourraient réduire les effets indésirables médicamenteux ou les erreurs médicamenteuses, ou les deux. Néanmoins, les meilleures modalités de mise en œuvre de ces interventions, et l'effet d'autres interventions, sont moins clairs.

Commentaire : Voir l'analyse de l'article sur le site Cochrane : Interventions visant à réduire les erreurs médicamenteuses chez les adultes en milieu hospitalier  . Rédigé le 25 November 2021 (Les traductions sur ce site ont été rendues possibles grâce à la contribution financière du Ministère français des affaires sociales et de la santé et des instituts publics de recherche canadiens).

Targeted high mean arterial pressure aggravates cerebral hemodynamics after extracorporeal resuscitation in swine.
Levy Y, Hutin A, Lidouren F, Polge N, Fernandez R, Kohlhauer M, Leger PL, Debaty G, Lurie K, Lamhaut L, Ghaleh B, Tissier R. | Crit Care. 2021 Nov 14;25(1):369
DOI: https://doi.org/10.1186/s13054-021-03783-3  | Télécharger l'article au format  
Keywords: Blood pressure; Cardiac arrest; Epinephrine; Extracorporeal circulation; Resuscitation.

Research

Introduction : Extracorporeal cardiopulmonary resuscitation (E-CPR) is used for the treatment of refractory cardiac arrest. However, the optimal target to reach for mean arterial pressure (MAP) remains to be determined. We hypothesized that MAP levels critically modify cerebral hemodynamics during E-CPR and tested two distinct targets (65-75 vs 80-90 mmHg) in a porcine model.

Méthode : Pigs were submitted to 15 min of untreated ventricular fibrillation followed by 30 min of E-CPR. Defibrillations were then delivered until return of spontaneous circulation (ROSC). Extracorporeal circulation was initially set to an average flow of 40 ml/kg/min. The dose of epinephrine was set to reach a standard or a high MAP target level (65-75 vs 80-90 mmHg, respectively). Animals were followed during 120-min after ROSC.

Résultats : Six animals were included in both groups. During E-CPR, high MAP improved carotid blood flow as compared to standard MAP. After ROSC, this was conversely decreased in high versus standard MAP, while intra-cranial pressure was superior. The pressure reactivity index (PRx), which is the correlation coefficient between arterial blood pressure and intracranial pressure, also demonstrated inverted patterns of alteration according to MAP levels during E-CPR and after ROSC. In standard-MAP, PRx was transiently positive during E-CPR before returning to negative values after ROSC, demonstrating a reversible alteration of cerebral autoregulation during E-CPR. In high-MAP, PRx was negative during E-CPR but became sustainably positive after ROSC, demonstrating a prolonged alteration in cerebral autoregulation after ROSC. It was associated with a significant decrease in cerebral oxygen consumption in high- versus standard-MAP after ROSC.

Conclusion : During early E-CPR, MAP target above 80 mmHg is associated with higher carotid blood flow and improved cerebral autoregulation. This pattern is inverted after ROSC with a better hemodynamic status with standard versus high-MAP.

Conclusion (proposition de traduction) : Au début de l'E-CPR (assistance circulatoire dans l’arrêt cardiaque), une cible de pression artérielle moyenne supérieure à 80 mmHg est associée à un débit sanguin carotidien plus élevé et à une autorégulation cérébrale améliorée. Ce schéma est inversé après le retour à une activité circulatoire spontanée (RACS) avec un meilleur état hémodynamique avec une pression artérielle moyenne standard versus une pression artérielle moyenne élevée.

Efficacy of non-invasive and invasive respiratory management strategies in adult patients with acute hypoxaemic respiratory failure: a systematic review and network meta-analysis.
Sakuraya M, Okano H, Masuyama T, Kimata S, Hokari S. | Crit Care. 2021 Nov 29;25(1):414
DOI: https://doi.org/10.1186/s13054-021-03835-8  | Télécharger l'article au format  
Keywords: Acute hypoxaemic respiratory failure; Continuous positive airway pressure; High-flow nasal oxygen; Network meta-analysis; Non-invasive ventilation.

Research

Introduction : Although non-invasive respiratory management strategies have been implemented to avoid intubation, patients with de novo acute hypoxaemic respiratory failure (AHRF) are high risk of treatment failure. In the previous meta-analyses, the effect of non-invasive ventilation was not evaluated according to ventilation modes in those patients. Furthermore, no meta-analyses comparing non-invasive respiratory management strategies with invasive mechanical ventilation (IMV) have been reported. We performed a network meta-analysis to compare the efficacy of non-invasive ventilation according to ventilation modes with high-flow nasal oxygen (HFNO), standard oxygen therapy (SOT), and IMV in adult patients with AHRF.

Méthode : The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Studies including adults with AHRF and randomized controlled trials (RCTs) comparing two different respiratory management strategies (continuous positive airway pressure (CPAP), pressure support ventilation (PSV), HFNO, SOT, or IMV) were reviewed.

Résultats : We included 25 RCTs (3,302 participants: 27 comparisons). Using SOT as the reference, CPAP (risk ratio [RR] 0.55; 95% confidence interval [CI] 0.31-0.95; very low certainty) was associated significantly with a lower risk of mortality. Compared with SOT, PSV (RR 0.81; 95% CI 0.62-1.06; low certainty) and HFNO (RR 0.90; 95% CI 0.65-1.25; very low certainty) were not associated with a significantly lower risk of mortality. Compared with IMV, no non-invasive respiratory management was associated with a significantly lower risk of mortality, although all certainties of evidence were very low. The probability of being best in reducing short-term mortality among all possible interventions was higher for CPAP, followed by PSV and HFNO; IMV and SOT were tied for the worst (surface under the cumulative ranking curve value: 93.2, 65.0, 44.1, 23.9, and 23.9, respectively).

Conclusion : When performing non-invasive ventilation among patients with de novo AHRF, it is important to avoid excessive tidal volume and lung injury. Although pressure support is needed for some of these patients, it should be applied with caution because this may lead to excessive tidal volume and lung injury.

Conclusion (proposition de traduction) : Lors de la réalisation d'une ventilation non invasive chez des patients présentant un SDRA de novo, il est important d'éviter un volume courant excessif et des lésions pulmonaires. Bien qu'une aide inspiratoire soit nécessaire pour certains de ces patients, elle doit être appliquée avec prudence car cela peut entraîner un volume courant excessif et des lésions pulmonaires.

Effect of tranexamic acid on thrombotic events and seizures in bleeding patients: a systematic review and meta-analysis.
Murao S, Nakata H, Roberts I, Yamakawa K. | Crit Care. 2021 Nov 1;25(1):380
DOI: https://doi.org/10.1186/s13054-021-03799-9  | Télécharger l'article au format  
Keywords: Bleeding; Meta-analysis; Seizure; Surgery; Thrombotic events; Tranexamic acid.

Research

Introduction : ranexamic acid (TXA) reduces surgical bleeding and reduces death from bleeding after trauma and childbirth. However, its effects on thrombotic events and seizures are less clear. We conducted a systematic review and meta-analysis to examine the safety of TXA in bleeding patients.

Méthode : For this systematic review and meta-analysis, we searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled trials from inception until June 1, 2020. We included randomized trials comparing intravenous tranexamic acid and placebo or no intervention in bleeding patients. The primary outcomes were thrombotic events, venous thromboembolism, acute coronary syndrome, stroke and seizures. A meta-analysis was performed using a random effects model and meta-regression analysis was performed to evaluate how effects vary by dose. We assessed the certainty of evidence using the grading of recommendations, assessment, development and evaluations (GRADE) approach.

Résultats : A total of 234 studies with 102,681 patients were included in the meta-analysis. In bleeding patients, there was no evidence that TXA increased the risk of thrombotic events (RR = 1.00 [95% CI 0.93-1.08]), seizures (1.18 [0.91-1.53]), venous thromboembolism (1.04 [0.92-1.17]), acute coronary syndrome (0.88 [0.78-1.00]) or stroke (1.12 [0.98-1.27]). In a dose-by-dose sensitivity analysis, seizures were increased in patients receiving more than 2 g/day of TXA (3.05 [1.01-9.20]). Meta-regression showed an increased risk of seizures with increased dose of TXA (p = 0.011).

Conclusion : Tranexamic acid did not appear to increase the risk of thrombotic events in bleeding patients. However, because there may be dose-dependent increase in the risk of seizures, very high doses should be avoided.

Conclusion (proposition de traduction) : L'acide tranexamique n'a pas semblé augmenter le risque d'événements thrombotiques chez les patients hémorragiques. Cependant, comme il peut y avoir une augmentation dose-dépendante du risque de convulsions, des doses très élevées doivent être évitées.

The role of automated compression devices in out-of- and in- hospital cardiac arrest. Can we spare rescuers’ hands?.
Toutouzas K, Tsioufis K. | Emerg Care J. 2021 November;17:9525
DOI: https://doi.org/10.4081/ecj.2021.9923  | Télécharger l'article au format  
Keywords: Aucun

Reviews

Editorial : Research regarding the use of mechanical compressions in the setting of a cardiac arrest, either outside of or inside the hospital environment has produced mixed results. The debate whether they can replace manual compressions still remains. The aim of this review is to present current literature contemplating the application of mechanical compressions in both settings, data comparing them to manual compressions as well as current guidelines regarding their implementation in everyday clinical use. Currently, their implementation in the resuscitation protocol seems to benefit the victims of an in-hospital cardiac arrest rather than the victims that sustain a cardiac arrest outside of the hospital.

Conclusion : Data regarding the use of mechanical CPR in cases of both out of-and in-hospital cardiac arrest are mixed. In general, the use of devices in OHCA situations seems to show weak and conflicting evidence on the outcomes of the victims, while in IHCA it has a rather positive impact. High-quality CPR remains the key to a successful resuscitation and as such its importance is highlighted in all studies comparing manual and mechanical CPR. Large registries and randomized trials should further elucidate this debate, CPR quality measurement being a key component in their design.

Conclusion (proposition de traduction) : Les données concernant l'utilisation de la RCP mécanique en cas d'arrêt cardiaque à la fois à l'extérieur et à l'hôpital sont mitigées. En général, l'utilisation d'appareils dans les situations d'arrêt cardiaque extra-hospitalier semble montrer des preuves faibles et contradictoires sur les résultats des victimes, alors qu'en arrêt cardiaque à l'hôpital, elle a un impact plutôt positif. Une RCP de haute qualité reste la clé d'une réanimation réussie et, en tant que telle, son importance est soulignée dans toutes les études comparant la RCP manuelle et mécanique. Les grands registres et les essais randomisés devraient élucider davantage ce débat, la mesure de la qualité de la RCP étant un élément clé de leur conception.

Prehospital risk stratification in patients with chest pain.
Sagel D, Vlaar PJ, van Roosmalen R, Waardenburg I, Nieuwland W, Lettinga R, van Barneveld R, Jorna E, Kijlstra R, van Well C, Oomen A, Bartels L, Anthonio R, Hagens V, Hofma S, Gu Y, Drenth D, Addink R, van Asselt T, van der Meer P, Lipsic E, Juarez Orozco L, van der Harst P. | Emerg Med J. 2021 Nov;38(11):814-819
DOI: https://doi.org/10.1136/emermed-2020-210212  | Télécharger l'article au format  
Keywords: Aucun

Original research

Introduction : The History, ECG, Age, Risk Factors and Troponin (HEART) Score is a decision support tool applied by physicians in the emergency department developed to risk stratify low-risk patients presenting with chest pain. We assessed the potential value of this tool in prehospital setting, when applied by emergency medical services (EMS), and derived and validated a tool adapted to the prehospital setting in order to determine if it could assist with decisions regarding conveyance to a hospital.

Méthode : In 2017, EMS personnel prospectively determined the HEART Score, including point-of-care (POC) troponin measurements, in patients presenting with chest pain, in the north of the Netherlands. The primary endpoint was a major adverse cardiac event (MACE), consisting of acute myocardial infarction or death, within 3 days. The components of the HEART Score were evaluated for their discriminatory value, cut-offs were calibrated for the prehospital setting and sex was substituted for cardiac risk factors to develop a prehospital HEART (preHEART) Score. This score was validated in an independent prospective cohort of 435 patients in 2018.

Résultats : Among 1208 patients prospectively recruited in the first cohort, 123 patients (10.2%) developed a MACE. The HEART Score had a negative predictive value (NPV) of 98.4% (96.4-99.3), a positive predictive value (PPV) of 35.5% (31.8-39.3) and an area under the receiver operating characteristic curve (AUC) of 0.81 (0.78-0.85). The preHEART Score had an NPV of 99.3% (98.1-99.8), a PPV of 49.4% (42.0-56.9) and an AUC of 0.85 (0.82-0.88), outperforming the HEART Score or POC troponin measurements on their own. Similar results were found in a validation cohort.

Conclusion : The HEART Score can be used in the prehospital setting to assist with conveyance decisions and choice of hospitals; however, the preHEART Score outperforms both the HEART Score and single POC troponin measurements when applied by EMS personnel in the prehospital setting.

Conclusion (proposition de traduction) : Le score HEART peut être utilisé en milieu préhospitalier pour faciliter les décisions de transport et le choix des hôpitaux ; cependant, le score preHEART surpasse à la fois le score HEART et les mesures de la troponine au point d'intervention unique lorsqu'il est appliqué par le personnel des services médicaux d'urgence en milieu préhospitalier.

Commentaire : Supplementary Material  .

European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years.
Gaillard EA, , Kuehni CE, Turner S, Goutaki M, Holden KA, de Jong CCM, Lex C, Lo DKH, Lucas JS, Midulla F, Mozun R, Piacentini G, Rigau D, Rottier B, Thomas M, Tonia T, Usemann J, Yilmaz O, Zacharasiewicz A, Moeller A. | Eur Respir J. 2021 Nov 4;58(5):2004173
DOI: https://doi.org/10.1183/13993003.04173-2020  | Télécharger l'article au format  
Keywords: Aucun

ERS Official Documents - ERS Guidelines

Introduction : Diagnosing asthma in children represents an important clinical challenge. There is no single gold-standard test to confirm the diagnosis. Consequently, over- and under-diagnosis of asthma is frequent in children.

Méthode : A task force supported by the European Respiratory Society has developed these evidence-based clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years using nine Population, Intervention, Comparator and Outcome (PICO) questions. The task force conducted systematic literature searches for all PICO questions and screened the outputs from these, including relevant full-text articles. All task force members approved the final decision for inclusion of research papers. The task force assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Résultats : The task force then developed a diagnostic algorithm based on the critical appraisal of the PICO questions, preferences expressed by lay members and test availability. Proposed cut-offs were determined based on the best available evidence. The task force formulated recommendations using the GRADE Evidence to Decision framework.

Conclusion : Based on the critical appraisal of the evidence and the Evidence to Decision framework, the task force recommends spirometry, bronchodilator reversibility testing and exhaled nitric oxide fraction as first-line diagnostic tests in children under investigation for asthma. The task force recommends against diagnosing asthma in children based on clinical history alone or following a single abnormal objective test. Finally, this guideline also proposes a set of research priorities to improve asthma diagnosis in children in the future.

Conclusion (proposition de traduction) : Sur la base de l'évaluation critique des preuves et du cadre de la preuve à la décision, le groupe de travail recommande la spirométrie, les tests de réversibilité des bronchodilatateurs et la fraction d'oxyde nitrique expiré comme tests de diagnostic de première intention chez les enfants faisant l'objet d'une enquête pour l'asthme. Le groupe de travail recommande de ne pas diagnostiquer l'asthme chez les enfants sur la seule base des antécédents cliniques ou à la suite d'un seul test objectif anormal. Enfin, cette ligne directrice propose également un ensemble de priorités de recherche pour améliorer le diagnostic de l'asthme chez les enfants à l'avenir.

European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years.
Gaillard EA, Kuehni CE, Turner S, Goutaki M, Holden KA, de Jong CCM, Lex C, Lo DKH, Lucas JS, Midulla F, Mozun R, Piacentini G, Rigau D, Rottier B, Thomas M, Tonia T, Usemann J, Yilmaz O, Zacharasiewicz A, Moeller A. | Eur Respir J. 2021 Nov 4;58(5):2004173
DOI: https://doi.org/10.1183/13993003.04173-2020  | Télécharger l'article au format  
Keywords: Aucun

ERS Guidelines

Introduction : Diagnosing asthma in children represents an important clinical challenge. There is no single gold-standard test to confirm the diagnosis. Consequently, over- and under-diagnosis of asthma is frequent in children.

Méthode : A task force supported by the European Respiratory Society has developed these evidence-based clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years using nine Population, Intervention, Comparator and Outcome (PICO) questions. The task force conducted systematic literature searches for all PICO questions and screened the outputs from these, including relevant full-text articles. All task force members approved the final decision for inclusion of research papers. The task force assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Résultats : The task force then developed a diagnostic algorithm based on the critical appraisal of the PICO questions, preferences expressed by lay members and test availability. Proposed cut-offs were determined based on the best available evidence. The task force formulated recommendations using the GRADE Evidence to Decision framework.

Conclusion : Based on the critical appraisal of the evidence and the Evidence to Decision framework, the task force recommends spirometry, bronchodilator reversibility testing and exhaled nitric oxide fraction as first-line diagnostic tests in children under investigation for asthma. The task force recommends against diagnosing asthma in children based on clinical history alone or following a single abnormal objective test. Finally, this guideline also proposes a set of research priorities to improve asthma diagnosis in children in the future.

Conclusion (proposition de traduction) : Sur la base de l'évaluation critique des données probantes et du cadre de l'Evidence to Decision, le groupe de travail recommande la spirométrie, les tests de réversibilité des bronchodilatateurs et la fraction d'oxyde nitrique expiré comme tests diagnostiques de première intention chez les enfants sous investigation pour l'asthme. Le groupe de travail déconseille de diagnostiquer l'asthme chez les enfants sur la seule base des antécédents cliniques ou à la suite d'un seul test objectif anormal. Enfin, cette ligne directrice propose également un ensemble de priorités de recherche pour améliorer le diagnostic de l'asthme chez les enfants à l'avenir.

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.
Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Hylander Møller M, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A&helipp;. | Intensive Care Med. 2021 Nov;47(11):1181-1247
DOI: https://doi.org/10.1007/s00134-021-06506-y  | Télécharger l'article au format  
Keywords: Aucun

Guideline

Editorial : Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis and septic shock are major healthcare problems, impacting millions of people around the world each year and killing between one in three and one in six of those it affects. Early identification and appropriate management in the initial hours after the development of sepsis improve outcomes.

Conclusion : The recommendations in this document are intended to provide guidance for the clinician caring for adult patients with sepsis or septic shock in the hospital setting. Recommendations from these guidelines cannot replace the clinician’s decision-making capability when presented with a unique patient’s clinical variables. These guidelines are intended to reflect best prac- tice.

Conclusion (proposition de traduction) : Les (ndlr : 93) recommandations contenues dans ce document visent à fournir des conseils au clinicien qui s'occupe de patients adultes atteints de sepsis ou de choc septique en milieu hospitalier. Les recommandations de ces directives ne peuvent pas remplacer la capacité de prise de décision du clinicien lorsqu'elles sont présentées avec les variables cliniques d'un patient unique. Ces lignes directrices visent à refléter les meilleures pratiques.

Commentaire : 

Sodium chloride or Plasmalyte-148 evaluation in severe diabetic ketoacidosis (SCOPE-DKA): a cluster, crossover, randomized, controlled trial.
Ramanan M, Attokaran A, Murray L, Bhadange N, Stewart D, Rajendran G, Pusapati R, Petty M, Garrett P, Kruger P, Peake S, Billot L, Venkatesh B; SCOPE-DKA Collaborators and Queensland Critical Care Research Network (QCCRN). | Intensive Care Med. 2021 Nov;47(11):1248-1257
DOI: https://doi.org/10.1007/s00134-021-06480-5
Keywords: Critical care; Diabetes; Diabetic ketoacidosis; Fluid therapy; Plasmalyte-148; Sodium chloride.

Original

Introduction : To determine whether treatment with Plasmalyte-148 (PL) compared to sodium chloride 0.9% (SC) results in faster resolution of diabetic ketoacidosis (DKA) and whether the acetate in PL potentiates ketosis.

Méthode : We conducted a cluster, crossover, open-label, randomized, controlled Phase 2 trial at seven hospitals in adults admitted to intensive care unit (ICU) with severe DKA with hospital randomised to PL or SC as fluid therapy. The primary outcome, DKA resolution, was defined as a change in base excess to ≥ - 3 mEq/L at 48 h.

Résultats : Ninety-three patients were enrolled with 90 patients included in the modified-intention-to-treat population (PL n = 48, SC n = 42). At 48 h, mean fluid administration was 6798 ± 4850 ml vs 6574 ± 3123 ml, median anion gap 6 mEq/L (IQR 5-7) vs 7 mEq/L (IQR 5-7) and median blood ketones 0.3 mmol/L (IQR 0.1-0.5) vs 0.3 (IQR 0.1-0.5) in the PL and SC groups. DKA resolution at 48 h occurred in 96% (PL) and 86% (SC) of patients; odds ratio 3.93 (95% CI 0.73-21.16, p = 0.111). At 24 h, DKA resolution occurred in 69% (PL) and 36% (SC) of patients; odds ratio 4.24 (95% CI 1.68-10.72, p = 0.002). The median ICU and hospital lengths of stay were 49 h (IQR 23-72) vs 55 h (IQR 41-80) and 81 h (IQR 58-137) vs 98 h (IQR 65-195) in the PL and SC groups.

Conclusion : Plasmalyte-148, compared to sodium chloride 0.9%, may lead to faster resolution of metabolic acidosis in patients with DKA without an increase in ketosis. These findings need confirmation in a large, Phase 3 trial.

Conclusion (proposition de traduction) : Le plasmalyte-148, par rapport au chlorure de sodium à 0,9 %, peut conduire à une résolution plus rapide de l'acidose métabolique chez les patients présentant une acidocétose diabétique sévère sans augmentation de la cétose. Ces résultats doivent être confirmés dans un grand essai de phase 3.

Management of patients with cervical spine trauma in the emergency department: a systematic critical appraisal of guidelines with a view to developing standardized strategies for clinical practice.
Gesu E, Bellone P, Bonzi M, Bertani GA, Brignolo Ottolini B, Bosco P, Conte G, Ferrari M, Fiorelli EM, Kurihara H, Solbiati M, Solimeno LP, Costantino G. | Intern Emerg Med. 2021 Nov;16(8):2277-2296
DOI: https://doi.org/10.1007/s11739-021-02838-1  | Télécharger l'article au format  
Keywords: ervical spine; Cervical spine trauma; Emergency Department; Guidelines.

CE-Systematic reviews and meta-analysis

Editorial : Several guidelines on the evaluation of patients with suspected cervical spine trauma in the Emergency Department (ED) exist. High heterogeneity between different guidelines has been reported. Aim of this study was to find areas of agreement and disagreement between guidelines, to identify topics in which further research is needed and to provide an evidence-based cervical spine trauma algorithm for ED physicians. The three most relevant guidelines published on cervical spine trauma in the last 10 years were selected screening websites of the main scientific societies and through the comparison of a normalized Google Scholar and SCOPUS citation index. We compared the selected guidelines through seven a-priori defined questions. In case of disagreement between the guidelines or if the quality of evidence appeared low, evidence from published systematic reviews on the topic was added to build an evidence-based algorithm for approach to spinal trauma in the ED. The three selected guidelines were: NICE 2016, Eastern Association for the Surgery of Trauma 2009 and American Association of Neurological Surgeons and Congress of Neurological Surgeons 2013. We found complete agreement on one question, partial agreement for one questions, no agreement for two questions, while agreement was not assessable for 3 questions. The agreement between different guidelines and the evidence on which recommendations are based is low. An attempt to build an evidence-based algorithm has been made. More studies are needed on many topics.

Conclusion : It would be reasonable to state that every trauma patient, with the exception of minor isolated limb lesions, should be clinically evaluated for cervical injuries. It could be assumed that any patient suspected of having cervical spine trauma is eligible for cervical injury screening, from trivial to high- energy traumas. The selection of patients eligible for evalu- ation for cervical spine trauma remains a decision for the clinician.

Conclusion (proposition de traduction) : Il serait raisonnable d'affirmer que chaque patient traumatisé, à l'exception des lésions mineures isolées des membres, devrait être évalué cliniquement pour les lésions cervicales. On pourrait supposer que tout patient suspecté d'avoir subi un traumatisme de la colonne cervicale est éligible au dépistage des lésions cervicales, des traumatismes insignifiants aux traumatismes à haute énergie. La sélection des patientes éligibles pour l'évaluation d'un traumatisme du rachis cervical reste une décision du clinicien.

Commentaire :  Algorithme proposé pour la prise en charge des patients suspectés de traumatisme du rachis cervical

A simulation-based pilot study of crisis checklists in the emergency department.
Knoche BB, Busche C, Grodd M, Busch HJ, Lienkamp SS. | Intern Emerg Med. 2021 Nov;16(8):2269-2276
DOI: https://doi.org/10.1007/s11739-021-02670-7  | Télécharger l'article au format  
Keywords: Checklist; Emergency medicine; Resuscitation; Simulation.

EM - ORIGINAL

Introduction : Checklists can improve adherence to standardized procedures and minimize human error. We aimed to test if implementation of a checklist was feasible and effective in enhancing patient care in an emergency department handling internal medicine cases.

Méthode : We developed four critical event checklists and confronted volunteer teams with a series of four simulated emergency scenarios. In two scenarios, the teams were provided access to the crisis checklists in a randomized cross-over design. Simulated patient outcome plus statement of the underlying diagnosis defined the primary endpoint and adherence to key processes such as time to commence CPR represented the secondary endpoints. A questionnaire was used to capture participants' perception of clinical relevance and manageability of the checklists. Six teams of four volunteers completed a total of 24 crisis sequences.

Résultats : The primary endpoint was reached in 8 out of 12 sequences with and in 2 out of 12 sequences without a checklist (Odds ratio, 10; CI 1.11, 123.43; p = 0.03607, Fisher's exact test). Adherence to critical steps was significantly higher in all scenarios for which a checklist was available (performance score of 56.3% without checklist, 81.9% with checklist, p = 0.00284, linear regression model). All participants rated the checklist as useful and 22 of 24 participants would use the checklist in real life.

Conclusion : Checklist use had no influence on CPR quality. The use of context-specific checklists showed a statistically significant influence on team performance and simulated patient outcome and contributed to adherence to standard clinical practices in emergency situations.

Conclusion (proposition de traduction) : L'utilisation de la liste de contrôle n'a eu aucune influence sur la qualité de la RCP. L'utilisation de checklists spécifiques au contexte a montré une influence statistiquement significative sur la performance de l'équipe et les résultats des patients simulés et a contribué au respect des pratiques cliniques standard dans les situations d'urgence.

Frequency of alterations in qSOFA, SIRS, MEWS and NEWS scores during the emergency department stay in infectious patients: a prospective study.
Latten GHP, Polak J, Merry AHH, Muris JWM, Ter Maaten JC, Olgers TJ, Cals JWL, Stassen PM. | Int J Emerg Med. 2021 Nov 27;14(1):69
DOI: https://doi.org/10.1186/s12245-021-00388-z  | Télécharger l'article au format  
Keywords: Clinical rules; Emergency department; Infection.

Original Research

Introduction : For emergency department (ED) patients with suspected infection, a vital sign-based clinical rule is often calculated shortly after the patient arrives. The clinical rule score (normal or abnormal) provides information about diagnosis and/or prognosis. Since vital signs vary over time, the clinical rule scores can change as well. In this prospective multicentre study, we investigate how often the scores of four frequently used clinical rules change during the ED stay of patients with suspected infection.

Méthode : Adult (≥ 18 years) patients with suspected infection were prospectively included in three Dutch EDs between March 2016 and December 2019. Vital signs were measured in 30-min intervals and the quick Sequential Organ Failure Assessment (qSOFA) score, the Systemic Inflammatory Response Syndrome (SIRS) criteria, the Modified Early Warning Score and the National Early Warning Score (NEWS) score were calculated. Using the established cut-off points, we analysed how often alterations in clinical rule scores occurred (i.e. switched from normal to abnormal or vice versa). In addition, we investigated which vital signs caused most alterations.

Résultats : We included 1433 patients, of whom a clinical rule score changed once or more in 637 (44.5%) patients. In 6.7-17.5% (depending on the clinical rule) of patients with an initial negative clinical rule score, a positive score occurred later during ED stay. In over half (54.3-65.0%) of patients with an initial positive clinical rule score, the score became negative later on. The respiratory rate caused most (51.2%) alterations.

Conclusion : After ED arrival, alterations in qSOFA, SIRS, MEWS and/or NEWS score are present in almost half of patients with suspected infection. The most contributing vital sign to these alterations was the respiratory rate. One in 6-15 patients displayed an abnormal clinical rule score after a normal initial score. Clinicians should be aware of the frequency of these alterations in clinical rule scores, as clinical rules are widely used for diagnosis and/or prognosis and the optimal moment of assessing them is unknown.

Conclusion (proposition de traduction) : Après l'arrivée au service des urgences, des altérations du score qSOFA, SIRS, MEWS et/ou NEWS sont présentes chez près de la moitié des patients suspectés d'infection. Le signe vital le plus contributif à ces altérations était la fréquence respiratoire. Un patient sur 6 à 15 présentait un score de règle clinique anormal après un score initial normal. Les cliniciens doivent être conscients de la fréquence de ces altérations des scores de règles cliniques, car les règles cliniques sont largement utilisées pour le diagnostic et/ou le pronostic et le moment optimal pour les évaluer est inconnu.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
Writing Committee Members, Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. | J Am Coll Cardiol. 2021 Nov 30;78(22):e187-e285
DOI: https://doi.org/10.1016/j.jacc.2021.07.053  | Télécharger l'article au format  
Keywords: ACC/AHA Clinical Practice Guidelines; accelerated diagnostic pathway; acute coronary syndrome; angina; biomarkers; cardiac imaging; chest pain; chest pain syndromes; clinical decision pathway; coronary artery disease; myocardial infarction; myocardial injury; myocardial ischemia; noncardiac; noncardiac chest pain; sex differences; shared decision-making; troponins.

Practice guideline

Introduction : This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

Méthode : A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

Conclusion : Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

Conclusion (proposition de traduction) : La douleur thoracique est une cause fréquente de consultation aux urgences aux États-Unis. La « 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain » fournit des recommandations basées sur des preuves contemporaines sur le bilan et l'évaluation de la douleur thoracique. Cette ligne directrice présente une approche fondée sur des preuves pour la stratification du risque et le bilan diagnostique pour l'évaluation de la douleur thoracique. Des considérations de rapport coût-efficacité ont été intégrées aux tests diagnostiques, et il est recommandé de partager la prise de décision avec les patients.

Commentaire : 

Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia).
Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Rollins Z, Kane JA, Dodd KW, Meyers KE, Shroff GR, Singer AJ, Smith SW. | J Am Heart Assoc. 2021 Nov 15:e022866
DOI: https://doi.org/10.1161/jaha.121.022866  | Télécharger l'article au format  
Keywords: ST‐segment depression; ST‐segment elevation myocardial infarction; acute coronary syndromes; non–ST‐segment–elevation myocardial infarction; occlusion myocardial infarction; posterior myocardial infarction; subendocardial ischemia.

ORIGINAL RESEARCH

Introduction : Occlusion myocardial infarctions (OMIs) of the posterolateral walls are commonly missed by ST-segment-elevation myocardial infarction (STEMI) criteria, with >50% of patients with circumflex occlusion not receiving emergent reperfusion and experiencing increased mortality. ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) has been suggested as an indicator of posterior OMI.

Méthode : We retrospectively reviewed a high-risk population with acute coronary syndrome. OMI was defined from prior studies as a culprit lesion with TIMI (Thrombolysis in Myocardial Infarction) 0 to 2 flow or TIMI 3 flow plus peak troponin T >1.0 ng/mL or troponin I >10 ng/mL. STEMI was defined by the Fourth Universal Definition of Myocardial Infarction. ECGs were interpreted blinded to outcomes.

Résultats : Among 808 patients, there were 265 OMIs, 108 (41%) meeting STEMI criteria. A total of 118 (15%) patients had "suspected ischemic" STDmaxV1-4, of whom 106 (90%) had an acute culprit lesion, 99 (84%) had OMI, and 95 (81%) underwent percutaneous coronary intervention. Suspected ischemic STDmaxV1-4 had 97% specificity and 37% sensitivity for OMI. Of the 99 OMIs detected by STDmaxV1-4, 34% had <1 mm ST-segment depression, and only 47 (47%) had accompanying STEMI criteria, of which 17 (36%) were identified a median 1.00 hour earlier by STDmaxV1-4 than STEMI criteria. Despite similar infarct size, TIMI flow, and coronary interventions, patients with STEMI(-) OMI and STDmaxV1-4 were less likely than STEMI(+) patients to undergo catheterization within 90 minutes (46% versus 68%; P=0.028)

Conclusion : Among patients with high-risk acute coronary syndrome, the specificity of ischemic STDmaxV1-4 was 97% for OMI and 96% for OMI requiring emergent percutaneous coronary intervention. STEMI criteria missed half of OMIs detected by STDmaxV1-4. Ischemic STDmaxV1-V4 in acute coronary syndrome should be considered OMI until proven otherwise.

Conclusion (proposition de traduction) : Parmi les patients présentant un syndrome coronarien aigu à haut risque, la spécificité du sous-décalage ischémique du segment ST maximal dans les dérivations V1-V4 était de 97 % pour l'infarctus du myocarde par occlusion et de 96 % pour l'infarctus du myocarde par occlusion nécessitant une intervention coronarienne percutanée urgente. Les critères d'infarctus du myocarde avec élévation du segment ST ont manqué la moitié des infarctus du myocarde d'occlusion détectés par un sous-décalage du segment ST maximal dans les dérivations V1-V4.
Le sous-décalage ischémique du segment ST maximal dans les dérivations V1-V4 dans le syndrome coronarien aigu doit être considérée comme un infarctus du myocarde par occlusion jusqu'à preuve du contraire.

Commentaire :  Une femme de 65 ans a présenté une douleur thoracique aiguë au repos pendant 4 heures.
L'ECG de triage (illustré ci-dessus) présente un sus-décalage du segment ST en V1-V3, maximale en V1-V2. Il existe également des preuves subtiles d'infarctus du myocarde à occlusion inférieure et latérale avec une légère élévation du segment ST, un redressement du segment ST et une onde T de grand volume en II, III et V6 (sans critères d'infarctus du myocarde avec élévation du segment ST [STEMI] ). La troponine T a culminé à 8,45 ng/mL. Parce que l'ECG ne répondait pas aux critères STEMI, le patient a présenté un délai de 15 heures jusqu'à l'angiographie, lorsqu'une occlusion complète (TIMI [Thrombolyse dans l'infarctus du myocarde] 0) de l'artère circonflexe gauche a été trouvée et stentée. Le patient a survécu.

Lower-Dose Propofol Use for MRI: A Retrospective Review of a Pediatric Sedation Team's Experience.
Johnson KL, Cochran J, Webb S. | Pediatr Emerg Care. 2021 Nov 1;37(11):e700-e706
DOI: https://doi.org/10.1097/pec.0000000000002289
Keywords: Aucun

Original article

Introduction : The aim of the study was to evaluate, in children undergoing procedural sedation for magnetic resonance imaging (MRI) scans, whether lower doses of propofol than previously published permitted a high rate of successful MRI completion, whether lower dosages result in a more rapid recovery, and whether age or behavioral diagnosis increases propofol requirements.

Méthode : After institutional review board approval, we retrospectively reviewed the pediatric sedation team's sedation database of children receiving propofol infusion for MRI scans between 2007 and 2016. Data collected included propofol induction dose (in milligrams per kilogram), propofol infusion dose (in micrograms per kilogram per hour), total propofol dose (in milligrams per kilogram and in milligrams per kilogram per hour), and the number of administered ancillary sedative medications. Additional data included the American Society of Anesthesiologist status, sedation duration, recovery duration, and successful completion of MRI. Dosing data were also stratified by age.

Résultats : A total of 2354 patients met inclusion criteria. Eight percent of patients received propofol infusion alone, 79% received midazolam before their propofol induction, and 13% received a combination of propofol and other drugs. Mean induction dose was 2.2 + 0.9 mg/kg, mean infusion dose was 93.5 + 29.0 μg/kg per minute, and total mean dose was 9.0 + 3.0 mg/kg per hour. Mean recovery time was 44 minutes, and 99.3% of the scans were completed with good images. We noted an increase requirement in the mean induction dose and total dose in children younger than 1 year.

Conclusion : Propofol infusion doses lower than commonly reported permit successful completion of scans and similar recovery times in a single institution. Younger children require more propofol for successful procedural sedation.

Conclusion (proposition de traduction) : Des doses de perfusion de propofol inférieures à celles couramment rapportées permettent la réussite des analyses et des temps de récupération similaires dans un seul établissement. Les enfants plus jeunes ont besoin de plus de propofol pour une sédation procédurale réussie.

Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program.
Abulebda K, Whitfill T, Montgomery EE, Kirby ML, Ahmed RA, Cooper DD, Nitu ME, Auerbach MA, Lutfi R, Abu-Sultaneh S. | Pediatr Emerg Care. 2021 Nov 1;37(11):543-549
DOI: https://doi.org/10.1097/pec.0000000000001751
Keywords: Aucun

Original Article

Introduction : The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs.

Méthode : This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores.

Résultats : A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline.

Conclusion : This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.

Conclusion (proposition de traduction) : Cette étude a démontré une amélioration significative de l'adhésion aux recommandations sur l'acidocétose diabétique pédiatrique dans les services d'urgence communautaires de l'État après l'exécution d'un programme d'amélioration collaborative basé sur la simulation in situ.

Commentaire : Voir sur le sujet de l'acido-basique-cétose diabétique de l'enfant :
Tzimenatos L, Nigrovic LE. Managing Diabetic Ketoacidosis in Children. Ann Emerg Med. 2021 Sep;78(3):340-345  .

Evaluation of the Efficacy and Safety of 3 Different Management Protocols in Pediatric Diabetic Ketoacidosis.
Akcan N, Uysalol M, Kandemir I, Soydemir D, Abali ZY, Poyrazoglu S, Bas F, Bundak R, Darendeliler F. | Pediatr Emerg Care. 2021 Nov 1;37(11):e707-e712
DOI: https://doi.org/10.1097/pec.0000000000001770
Keywords: Aucun

Original article

Introduction : Management protocols for pediatric diabetic ketoacidosis (DKA) vary considerably among medical centers. The aim of this study was to investigate the efficacy and safety of 3 different fluid protocols in the management of DKA.

Méthode : Fluid management protocols with sodium contents of 75, 100, and 154 mEq/L NaCl were compared. In all groups, after the initial rehydration, the protocols differed from each other in terms of the maintenance fluid, which had different rates of infusion and sodium contents. Clinical status and blood glucose levels were checked every hour during the first 12 hours. Biochemical tests were repeated at 2, 6, 12, 24, and 36 hours.

Résultats : The medical records of 144 patients were evaluated. Cerebral edema developed in 18% of the patients. The incidence of cerebral edema was lowest in the group that received fluid therapy with a sodium content of 154 mEq/L NaCl at least 4 to 6 hours and had a constant rate of infusion for 48 hours. The patients with cerebral edema had lower initial pH and HCO3 and severe dehydration with higher initial plasma osmolality. There was no significant difference between the groups in terms of the recovery times of blood glucose, pH, HCO3, and the time of transition to subcutaneous insulin therapy.

Conclusion : Severity of acidosis and dehydration are associated with the development of cerebral edema. It can be concluded that fluid therapy with higher Na content and a constant maintenance rate may present less risk for the patient with DKA.

Conclusion (proposition de traduction) : La sévérité de l'acidose et de la déshydratation sont associées au développement d'un œdème cérébral. On peut conclure qu'un remplissage vasculaire avec une teneur en Na plus élevée et un taux d'entretien constant peut présenter moins de risque pour les patients atteint d'acidocétose diabétique.

Commentaire : Voir sur le sujet de l'acido-basique-cétose diabétique de l'enfant :
Tzimenatos L, Nigrovic LE. Managing Diabetic Ketoacidosis in Children. Ann Emerg Med. 2021 Sep;78(3):340-345  .

The Administration of Postintubation Sedation in the Pediatric Emergency Department.
Berg K, Gregg V, Cosgrove P, Wilkinson M. | Pediatr Emerg Care. 2021 Nov 1;37(11):e732-e735
DOI: https://doi.org/10.1097/pec.0000000000001744
Keywords: Aucun

Original article

Introduction : The administration of postintubation sedation (PIS) is an essential component of postintubation care. Recent studies in the adult emergency medicine literature have highlighted both delays in time to administration of PIS and subtherapeutic dosing of sedative agents in the emergency department. We aimed to investigate the administration of PIS in the pediatric population as this has not been adequately reviewed to date.
Objectives: The aim of this study was to determine the percentage of pediatric emergency department patients who received PIS within an adequate time frame. We also investigated the relationship between this primary outcome and the rapid sequence intubation (RSI) agents used, the reason for intubation, and individual patient characteristics.

Méthode : This was a retrospective cohort analysis of all pediatric patients who underwent RSI at a tertiary care pediatric emergency department from July 2007 to January 2016. The primary outcome of "sedation in an adequate time frame" was defined as a time to post-RSI sedative administration that was shorter than the duration of action of the RSI sedative agent used. Logistic regression was performed to identify predictors of adequate sedation.

Résultats : A total of 240 patients were included in the analysis. Of these, 28% (95% confidence interval, 22.7%-34.1%) met the primary outcome of sedation within an adequate time frame; 72.8% (95% confidence interval, 66.8%-78.1%) of patients received some form of PIS during their emergency department stay. Patients receiving long-acting paralytic agents were much less likely to receive PIS with an odds ratio (OR) of 0.16 for meeting the primary outcome (P < 0.001, adjusted OR [AOR] = 0.13, P < 0.001). Children with higher systolic blood pressure were more likely to receive appropriate PIS with an OR of 1.02 for every mm Hg increase in systolic blood pressure (P = 0.006, AOR = 1.02, P = 0.021). Finally, patients who were ultimately admitted to the pediatric intensive care unit (vs the operating room, transfer, or neonatal intensive care unit) were less likely to receive PIS as evidenced by an OR of 0.37 (P = 0.009, AOR = 0.27, P = 0.004).

Conclusion : Most pediatric patients do not receive PIS within an adequate time frame. Patients who receive long-acting paralytic agents are much less likely to be adequately sedated after RSI compared with those receiving succinylcholine.

Conclusion (proposition de traduction) : La plupart des enfants ne reçoivent pas de sédation après une intubation dans un délai adéquat. Les patients qui reçoivent des curares à longue durée d'action sont beaucoup moins susceptibles d'être suffisamment sédatés après une intubation à séquence rapide par rapport à ceux qui reçoivent de la succinylcholine.

Evaluation of inhaler use technique in a pediatric appointment.
Ribeiro J C D d C, Alves C d S F, Zarcos M M. | Pediatr Oncall J. 2021 Nov 29
DOI: https://doi.org/10.7199/ped.oncall.2022.26  | Télécharger l'article au format  
Keywords: inhaler use, asthma, child

ORIGINAL ARTICLE

Introduction : Inhalers are recommended for asthma prophylactic and crisis therapy. In order to have a good deposition of drugs at pulmonary tissue, the correct use of the devices is necessary. Objective: To verify the inhaler use technique with pressurized metered-dose inhalers (pMDIs) with spacers and dry-powder inhalers (DPIs) in a pediatric sample (ages between 1 and 17 years old).

Méthode : Descriptive, observational and cross-sectional study. Application of a checklist that included the steps of the correct inhaler use technique, which was performed under physician observation, and other questions related to the use of the devices.

Résultats : We observed a total of 83 inhaler use techniques: 46 pMDIs with spacers and 37 DPIs. About 54% of pMDIs with spacers users and 27% of DPIs users performed the inhaler use technique correctly, p=0.012. The most frequent mistakes in pMDIs with spacers users were: 50% didn’t waste the first puff, 17.4% didn’t shake the device prior to use and 28.3% didn’t wait between inhalations. The mistakes observed in DPIs users were: 43.2% didn’t perform a forced expiration before inhaler use, 13.5% didn’t start with a forced inspiration, 24.3% didn’t pause at the end of inspiration, 32.4% didn’t exhale slowly and 35.1% didn´t wait between inhalations.

Conclusion : Multiple mistakes were observed even in the users who had been followed up for several years. The most frequent mistakes occurred in DPIs users. Thus, the inhaler use technique must always be observed by the physician in all appointments, especially in users of DPIs in which the correct use depends on their autonomy.

Conclusion (proposition de traduction) : De multiples erreurs ont été observées même chez les utilisateurs qui avaient été suivis pendant plusieurs années. Les erreurs les plus fréquentes sont survenues chez les utilisateurs d'inhalateurs à poudre sèche. Ainsi, la technique d'utilisation de l'inhalateur doit toujours être observée par le médecin lors de tous les rendez-vous, en particulier chez les utilisateurs d'inhalateurs à poudre sèche dont l'utilisation correcte dépend de leur autonomie.

Trends in Management of Simple Febrile Seizures at US Children’s Hospitals.
Raghavan VR, Porter JJ, Neuman MI, Lyons TW. | Pediatrics. 2021 Nov;148(5):e2021051517
DOI: https://doi.org/10.1542/peds.2021-051517
Keywords: Aucun

Article

Introduction : We sought to measure trends in evaluation and management of children with simple febrile seizures (SFSs) before and after the American Academy of Pediatrics updated guidelines published in 2011.

Méthode : In this retrospective, cross-sectional analysis, we used the Pediatric Health Information System database comprising 49 tertiary care pediatric hospitals in the United States from 2005 to 2019. We included children aged 6 to 60 months with an emergency department visit for first SFS identified using codes from the International Classification of Diseases, Ninth Revision, and International Classification of Diseases 10th Revision.

Résultats : We identified 142 121 children (median age 21 months, 42.4% female) with an emergency department visit for SFS. A total of 49 668 (35.0%) children presented before and 92 453 (65.1%) after the guideline. The rate of lumbar puncture for all ages declined from 11.6% (95% confidence interval [CI], 10.8% to 12.4%) in 2005 to 0.6% (95% CI, 0.5% to 0.8%) in 2019 (P < .001). Similar reductions were noted in rates of head computed tomography (10.6% to 1.6%; P < .001), complete blood cell count (38.8% to 10.9%; P < .001), hospital admission (19.2% to 5.2%; P < .001), and mean costs ($1523 to $601; P < .001). Reductions in all outcomes began before, and continued after, the publication of the American Academy of Pediatrics guideline. There was no significant change in delayed diagnosis of bacterial meningitis (preperiod 2 of 49 668 [0.0040%; 95% CI, 0.00049% to 0.015%], postperiod 3 of 92 453 [0.0032%; 95% CI, 0.00066% to 0.0094%]; P = .99).

Conclusion : Diagnostic testing, hospital admission, and costs decreased over the study period, without a concomitant increase in delayed diagnosis of bacterial meningitis. These data suggest most children with SFSs can be safely managed without lumber puncture or other diagnostic testing.

Conclusion (proposition de traduction) : Les tests diagnostic, les admissions à l'hôpital et les coûts ont diminué au cours de la période d'étude, sans augmentation concomitante des retards de diagnostic de la méningite bactérienne. Ces données suggèrent que la plupart des enfants présentant des convulsions fébriles simples peuvent être pris en charge en toute sécurité sans ponction lombaire ou autre test de diagnostic.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : LP for Febrile Seizure - Less Is More?  . Rédigé le 9 December 2021.

Consumption of coffee and tea and risk of developing stroke, dementia, and poststroke dementia: A cohort study in the UK Biobank.
Zhang Y, Yang H, Li S, Li WD, Wang Y. | PLoS Med. 2021 Nov 16;18(11):e1003830
DOI: https://doi.org/10.1371/journal.pmed.1003830  | Télécharger l'article au format  
Keywords: Aucun

RESEARCH ARTICLE

Introduction : Previous studies have revealed the involvement of coffee and tea in the development of stroke and dementia. However, little is known about the association between the combination of coffee and tea and the risk of stroke, dementia, and poststroke dementia. Therefore, we aimed to investigate the associations of coffee and tea separately and in combination with the risk of developing stroke and dementia.

Méthode : This prospective cohort study included 365,682 participants (50 to 74 years old) from the UK Biobank. Participants joined the study from 2006 to 2010 and were followed up until 2020. We used Cox proportional hazards models to estimate the associations between coffee/tea consumption and incident stroke and dementia, adjusting for sex, age, ethnicity, qualification, income, body mass index (BMI), physical activity, alcohol status, smoking status, diet pattern, consumption of sugar-sweetened beverages, high-density lipoprotein (HDL), low-density lipoprotein (LDL), history of cancer, history of diabetes, history of cardiovascular arterial disease (CAD), and hypertension. Coffee and tea consumption was assessed at baseline.

Résultats : During a median follow-up of 11.4 years for new onset disease, 5,079 participants developed dementia, and 10,053 participants developed stroke. The associations of coffee and tea with stroke and dementia were nonlinear (P for nonlinear <0.01), and coffee intake of 2 to 3 cups/d or tea intake of 3 to 5 cups/d or their combination intake of 4 to 6 cups/d were linked with the lowest hazard ratio (HR) of incident stroke and dementia. Compared with those who did not drink tea and coffee, drinking 2 to 3 cups of coffee and 2 to 3 cups of tea per day was associated with a 32% (HR 0.68, 95% CI, 0.59 to 0.79; P < 0.001) lower risk of stroke and a 28% (HR, 0.72, 95% CI, 0.59 to 0.89; P = 0.002) lower risk of dementia. Moreover, the combination of coffee and tea consumption was associated with lower risk of ischemic stroke and vascular dementia. Additionally, the combination of tea and coffee was associated with a lower risk of poststroke dementia, with the lowest risk of incident poststroke dementia at a daily consumption level of 3 to 6 cups of coffee and tea (HR, 0.52, 95% CI, 0.32 to 0.83; P = 0.007). The main limitations were that coffee and tea intake was self-reported at baseline and may not reflect long-term consumption patterns, unmeasured confounders in observational studies may result in biased effect estimates, and UK Biobank participants are not representative of the whole United Kingdom population.

Conclusion : We found that drinking coffee and tea separately or in combination were associated with lower risk of stroke and dementia. Intake of coffee alone or in combination with tea was associated with lower risk of poststroke dementia.

Conclusion (proposition de traduction) : Nous avons constaté que la consommation de café et de thé séparément ou en combinaison était associée à un risque plus faible d'accident vasculaire cérébral et de démence. La consommation de café seul ou en association avec du thé était associée à un risque plus faible de démence post-AVC.

The Association Between the Number of Prehospital Providers On-Scene and Out-of-Hospital Cardiac Arrest Outcomes.
Lupton JR, Neth MR, Sahni R, Wittwer L, Le N, Jui J, Newgard CD, Daya MR. | Prehosp Emerg Care. 2021 Nov 22:1-10
DOI: https://doi.org/10.1080/10903127.2021.1995799
Keywords: cardiac arrest; dispatch; emergency medical services; number of providers; out-of-hospital cardiac arrest.

Research Article

Introduction : The ideal number of emergency medical services (EMS) providers needed on-scene during an out-of-hospital cardiac arrest (OHCA) resuscitation is unknown. Our objective was to evaluate the association between the number of providers on-scene and OHCA outcomes.

Méthode : This was a secondary analysis of adults ( ≥ 18 years old) with non-traumatic OHCA from a 10-site North American prospective cardiac arrest registry (Resuscitation Outcomes Consortium) including a 2005-2011 cohort and a 2011-2015 cohort. The primary outcome was survival to hospital discharge. We calculated the median number of EMS providers on-scene during the first 10 minutes of the resuscitation and used multivariable logistic regression adjusting for age, sex, witness status, bystander CPR, arrest location, initial rhythm, and dispatch to EMS arrival time.

Résultats : There were 30,613 and 41,946 patients with necessary variables in the 2005-2011 and 2011-2015 cohorts, respectively. Survival to hospital discharge (95% CI) was higher with 9 or more providers on-scene (17.2% [15.8-18.5] and 14.0% [12.6-15.4]) compared to 7-8 (14.1% [13.4-14.8] and 10.5% [9.9-11.1]), 5-6 (10.0% [9.5-10.5] and 8.5% [8.1-8.9]), 3-4 (10.5% [9.3-11.6] and 9.3% [8.5-10.1]), and 1-2 (8.6% [7.2-10.0] and 8.0% [7.1-9.0]) providers for the 2005-2011 and 2011-2015 cohorts, respectively. In multivariable logistic regressions, compared to 5-6 providers, there were no significant differences in survival to hospital discharge for 1-2 or 3-4 providers, while having 7-8 (adjusted odds ratios (aORs) 1.53 [1.39-1.67] and 1.31 [1.20-1.44]) and 9 or more (aORs 1.76 [1.56-1.98] and 1.63 [1.41-1.89]) providers were associated with improved survival in both the 2005-2011 and 2011-2015 cohorts, respectively.

Conclusion : The presence of seven or more prehospital providers on-scene was associated with significantly greater adjusted odds of survival to hospital discharge after OHCA compared to fewer on-scene providers.

Conclusion (proposition de traduction) : La présence d'au moins sept secouristes préhospitaliers sur place était associée à des probabilités ajustées significativement plus élevées de survie à la sortie de l'hôpital après un arrêt cardiaque en dehors de l'hôpital par rapport à moins de prestataires sur place.

Prehospital Lactate is Associated with the Need for Blood in Trauma.
Zadorozny EV, Weigel T, Stone A, Gruen DS, Galvagno SM Jr, Yazer MH, Brown JB, Guyette FX. | Prehosp Emerg Care. 2021 Nov 16:1-10
DOI: https://doi.org/10.1080/10903127.2021.1983096
Keywords: emergency medical services; hemorrhagic shock; hospital blood use; normotensive subgroup; prehospital lactate.

Research Article

Introduction : Traumatic hemorrhage is the leading cause of preventable death, and its effects are often evident within the first 24 hours of hospital admission. We investigated the relationship between prehospital lactate measurement and administration of hospital blood products and life-saving interventions (LSIs) within 24 hours of hospital admission.

Méthode : We included trauma patients with recorded prehospital venous lactate transported by a single critical care transport service to a Level I trauma center between 2012 and 2019. We abstracted vital signs, mission type, anatomic location of injury, prehospital administration of crystalloid and blood products, and hospital LSIs started within 24 hours of admission. We used logistic regression to determine the association of prehospital lactate and in-hospital administration of blood products in groups with or without hypotensive patients. We investigated the effect of prehospital lactate concentration on secondary outcomes such as LSIs and mortality.

Résultats : We included 2,170 patients transported from the scene or emergency department (ED), of whom 1,821 (84%) were normotensive. The median concentration of prehospital lactate was 2.10 mmol/L for the main population (IQR = 1.40-3.30) and 2.00 mmol/L for the normotensive subgroup (IQR = 1.30-2.90). A higher prehospital lactate concentration was associated with higher odds of needing early hospital blood products in the whole study population (OR = 1.12, (95% CI 1.06-1.20), p < 0.01) and in the normotensive subgroup (OR = 1.13, (95% CI 1.03-1.22), p = 0.01). These positive associations were also observed with the secondary outcome of hospital LSIs, and higher prehospital lactate was also associated with higher odds of mortality (OR = 1.32, (95% CI 1.20-1.45), p < 0.01).

Conclusion : Higher concentrations of prehospital lactate were associated with the need for in-hospital blood transfusion within 24 hours of admission. The relationship between lactate and blood transfusion persisted among normotensive patients. Further work is needed to incorporate prehospital lactate into decision support tools for prehospital blood administration.

Conclusion (proposition de traduction) : Des concentrations plus élevées des taux de lactate préhospitalier étaient associées à la nécessité d'une transfusion sanguine à l'hôpital dans les 24 heures suivant l'admission. La relation entre le lactate et la transfusion sanguine a persisté chez les patients normotendus. Des travaux supplémentaires sont nécessaires pour incorporer le lactate préhospitalier dans les outils d'aide à la décision pour l'administration de sang préhospitalier.

Prehospital Predictors of Atypical STEMI Symptoms.
Taylor TG, Stickney RE, French WJ, Jollis JG, Kontos MC, Niemann JT, Sanko SG, Eckstein MK, Bosson N. | Prehosp Emerg Care. 2021 Nov 8:1-8
DOI: https://doi.org/10.1080/10903127.2021.1987597
Keywords: ST-elevation myocardial infarction; STEMI; epidemiologic factors; signs and symptoms.

Research Article

Introduction : Rapid prehospital identification of patients with ST-elevation myocardial infarction (STEMI) is a critical step to reduce time to treatment. Broad screening with field 12-lead ECGs can lead to a high rate of false positive STEMI activations due to low prevalence. One strategy to reduce false positive STEMI interpretations is to limit acquisition of 12-lead ECGs to patients who have symptoms strongly suggestive of STEMI, but this may delay care in patients who present atypically and lead to disparities in populations with more atypical presentations. We sought to assess patient factors associated with atypical STEMI presentation.

Méthode : We retrospectively analyzed consecutive adult patients for whom Los Angeles Fire Department paramedics obtained a field 12-lead ECG from July 2011 through June 2012. The regional STEMI receiving center registry was used to identify patients with STEMI. Patients were designated as having typical symptoms if paramedics documented provider impressions of chest pain/discomfort, cardiac arrest, or cardiac symptoms, otherwise they were designated as having atypical symptoms. We utilized logistic regression to determine patient factors (age, sex, race) associated with atypical STEMI presentation.

Résultats : Of the 586 patients who had STEMI, 70% were male, 43% White, 16% Black, 20% Hispanic, 5% Asian and 16% were other or unspecified race. Twenty percent of STEMI patients (n = 117) had atypical symptoms. Women who had STEMI were older than men (74 years [IQR 62-83] vs. 60 years [IQR 53-70], p < 0.001). Univariate predictors of atypical symptoms were older age and female sex (p < 0.0001), while in multivariable analysis older age [odd ratio (OR) 1.05 per year, [95%CI 1.04-1.07, p < 0.0001] and black race (OR vs White 2.18, [95%CI 1.20-3.97], p = 0.011) were associated with atypical presentation.

Conclusion : Limiting prehospital acquisition of 12-lead ECGs to patients with typical STEMI symptoms would result in one in five patients with STEMI having delayed recognition, disproportionally impacting patients of older age, women, and Black patients. Age, not sex, may be a better predictor of atypical STEMI presentation.

Conclusion (proposition de traduction) : En limitant l'acquisition préhospitalière d'ECG à 12 dérivations aux patients présentant des symptômes typiques d'infarctus du myocarde avec élévation du segment ST, un patient sur cinq présentant un infarctus du myocarde avec élévation du segment ST aurait un retard de diagnostic, affectant de manière disproportionnée les patients plus âgés, les femmes et les patients noirs. L'âge, et non le sexe, peut être un meilleur prédicteur d'une présentation atypique d'infarctus du myocarde avec élévation du segment ST.

Association between Scene Time Interval and Survival in EMS-Treated Major Trauma Admitted to the Intensive Care Unit: A Multinational, Multicenter Observational Study.
Van DB, Song KJ, Shin SD, Ro YS, Jeong J, Bao HL, Duc CN, Kim KH. | Prehosp Emerg Care. 2021 Nov 3:1-8
DOI: https://doi.org/10.1080/10903127.2021.1992053
Keywords: emergency medical service; major trauma; prehospital intervention; scene time interval; survival outcome.

Research Article

Introduction : Major trauma is a major concern in public health and a leading cause of mortality worldwide. This study aimed to evaluate the association between the prehospital scene time interval (STI) and survival in emergency medical service (EMS)-assessed major trauma patients admitted to the intensive care unit (ICU).

Méthode : A retrospective observational study using the Pan-Asian Trauma Outcomes Study (PATOS) database was conducted. Adult trauma patients with injury severity scores (ISSs) greater than 15 who were admitted to the ICU were selected. EMS STIs were categorized into three groups: short (0-8 minutes), intermediate (9-16 minutes), and long (over 16 minutes). The primary outcome was survival to hospital discharge, and the secondary outcome was good neurological outcome at hospital discharge. Multivariable logistic regression analysis was conducted to calculate odds ratios and confidence intervals, adjusting for age, sex, mechanism of injury, prehospital alertness, prehospital shock index, response time interval, and EMS intervention (airway, oxygen supplementation, and intravenous fluid administration). Sensitivity analysis for patients who underwent surgery or nontraumatic brain injury cases and interaction analysis by EMS intervention were performed.

Résultats : Data from a total of 1,874 eligible patients were analyzed. Intermediate and long STIs showed significant associations with outcomes, with adjusted ORs (95% CI) of 1.21 (1.07-1.38) in the intermediate STI group and 1.74 (1.55-1.96) in the long STI group for survival and 1.37 (1.32-1.40) in the intermediate STI group and 1.31 (1.22-1.41) in the long STI group for neurological outcome. In the sensitivity analysis, the highest ORs were found in the intermediate STI group, with adjusted ORs (95% CI) of 1.40 (1.37-1.42) for survival and 1.32 (1.26-1.38) for neurological outcome. In the interaction analysis, EMS intervention showed a positive interaction effect with an intermediate STI on survival.

Conclusion : In EMS-assessed adult major trauma patients admitted to the ICU, we found significant associations between STIs longer than 8 minutes and outcomes. EMS intervention has a positive interaction effect with an intermediate STI on survival. More research is needed to understand the implications of practice for major trauma in the field.

Conclusion (proposition de traduction) : Chez les patients adultes victimes de traumatismes majeurs évalués par les services médicaux d'urgence et admis à l'USI, nous avons trouvé des associations significatives entre les intervalles de temps sur la scène de plus de 8 minutes et les résultats. L'intervention des services médicaux d'urgence a un effet d'interaction positif avec un intervalle de temps intermédiaire sur la survie. Des recherches supplémentaires sont nécessaires pour comprendre les implications de la pratique pour les traumatismes majeurs sur le terrain.

Survival after Resuscitated Out-of-Hospital Cardiac Arrest in Patients with Paramedic-Identified ST-Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention.
Doan TN, Prior M, Vollbon W, Rogers B, Rashford S, Bosley E. | Prehosp Emerg Care. 2021 Nov 3:1-8
DOI: https://doi.org/10.1080/10903127.2021.1992054
Keywords: ST-segment elevation myocardial infarction; out-of-hospital cardiac arrest; paramedics; percutaneous coronary intervention; prehospital.

Research Article

Introduction : ST-segment elevation myocardial infarction (STEMI) is a common cause of out-of-hospital cardiac arrest (OHCA). For these patients, urgent angiography and revascularization is an important treatment goal. There is a lack of data on the prognosis of STEMI patients after OHCA, who are diagnosed and treated by paramedics prior to hospital transport for primary percutaneous coronary intervention (PCI).

Méthode : Included were adult STEMI patients identified and treated by paramedics in Queensland (Australia) from January 2016 to December 2019, transported to a hospital for primary PCI, and receiving primary PCI. Patients were grouped into those with resuscitated OHCA and those without OHCA. Clinically-important time intervals, angiographic and clinical profiles, and survival were described.

Résultats : Patients with OHCA had longer time intervals from prehospital STEMI identification to reperfusion than those without OHCA (median 97 versus 87 mins, p = 0.001). The former had higher rates of cardiac arrhythmia history (50.5 versus 12.4%, p < 0.001), classified low left ventricular ejection fraction on admission (64.9 versus 50.1%, p = 0.006), and cardiogenic shock (5.2 versus 1.2%, p = 0.011) than the latter. A significantly higher proportion of patients with OHCA had multiple diseased vessels (16.9 versus 8.3%, p = 0.005). In-hospital, 30-day, and one-year mortality was low, being 4.1%, 4.1% and 5.2%, respectively, for STEMI patients with OHCA. The corresponding figures for those without OHCA were 1.6%, 1.8% and 3.3%, respectively.

Conclusion : Survival in paramedic-identified STEMI patients treated with primary PCI following OHCA resuscitation was high. Rapid angiography and reperfusion are critical in these patients.

Conclusion (proposition de traduction) : La survie chez les patients atteints d'infarctus du myocarde avec sus-décalage du segment ST identifiés par les ambulanciers et traités par intervention coronarienne percutanée primaire après réanimation d'un arrêt cardiaque hors hôpital était élevée. Une angiographie rapide et une reperfusion sont essentielles chez ces patients.

The effect of fluid bolus administration on cerebral tissue oxygenation in post-cardiac arrest patients.
Bogaerts E, Ferdinande B, Palmers PJ, Malbrain MLNG, Van Regenmortel N, Wilmer A, Lemmens R, Janssens S, Nijst P, De Deyne C, Verhaert D, Mullens W, Dens J, Dupont M, Ameloot K. | Resuscitation. 2021 Nov;168:1-5
DOI: https://doi.org/10.1016/j.resuscitation.2021.08.044
Keywords: Cardiac arrest; Fluid bolus; Haemodynamic monitoring; Resuscitation; Stroke volume variation.

Clinical Paper

Introduction : Fluid boluses (FB) are often used in post-cardiac arrest (CA) patients with haemodynamic instability. Although FB may improve cardiac output (CO) and mean arterial pressure (MAP), FB may also increase central venous pressure (CVP), reduce arterial PaO2, dilute haemoglobin and cause interstitial oedema. The aim of the present study was to investigate the net effect of FB administration on cerebral tissue oxygenation saturation (SctO2) in post-CA patients.

Méthode : Pre-planned sub-study of the Neuroprotect post-CA trial (NCT02541591). Patients with anticipated fluid responsiveness based on stroke volume variation (SVV) or passive leg raising test were administered a FB of 500 ml plasma-lyte A (Baxter Healthcare) and underwent pre- and post-FB assessments of stroke volume, CO, MAP, CVP, haemoglobin, PaO2 and SctO2.

Résultats : 52 patients (mean age 64 ± 12 years, 75% male) received a total of 115 FB. Although administration of a FB resulted in a significant increase of stroke volume (63 ± 22 vs 67 ± 23 mL, p = 0.001), CO (4,2 ± 1,6 vs 4,4 ± 1,7 L/min, p = 0.001) and MAP (74,8 ± 13,2 vs 79,2 ± 12,9 mmHg, p = 0.004), it did not improve SctO2 (68.54 ± 6.99 vs 68.70 ± 6.80%, p = 0.49). Fluid bolus administration also resulted in a significant increase of CVP (10,0 ± 4,5 vs 10,7 ± 4,9 mmHg, p = 0.02), but did not affect PaO2 (99 ± 31 vs 94 ± 31 mmHg, p = 0.15) or haemoglobin concentrations (12,9 ± 2,1 vs 12,8 ± 2,2 g/dL, p = 0.10). In a multivariate model, FB-induced changes in CO (beta 0,77; p = 0.004) and in CVP (beta -0,23; p = 0.02) but not in MAP (beta 0,02; p = 0.18) predicted post-FB ΔSctO2.

Conclusion : Despite improvements in CO and MAP, FB administration did not improve SctO2 in post-cardiac arrest patients.

Conclusion (proposition de traduction) : Malgré des améliorations du débit cardiaque et de la pression artérielle moyenne, l'administration d'un bolus liquidien n'a pas amélioré la saturation en oxygénation des tissus cérébraux chez les patients en post-arrêt cardiaque.

The effect of the localisation of an underlying ST-elevation myocardial infarction on the VF-waveform: A multi-centre cardiac arrest study.
Nas J, van Dongen LH, Thannhauser J, Hulleman M, van Royen N, Tan HL, Bonnes JL, Koster RW, Brouwer MA, Blom MT. | Resuscitation. 2021 Nov;168:11-18
DOI: https://doi.org/10.1016/j.resuscitation.2021.08.049  | Télécharger l'article au format  
Keywords: Out-of-hospital cardiac arrest; ST-elevation myocardial infarction; Ventricular fibrillation; Waveform analysis.

Clinical Paper

Introduction : In cardiac arrest, ventricular fibrillation (VF) waveform characteristics such as amplitude spectrum area (AMSA) are studied to identify an underlying myocardial infarction (MI). Observational studies report lower AMSA-values in patients with than without underlying MI. Moreover, experimental studies with 12-lead ECG-recordings show lowest VF-characteristics when the MI-localisation matches the ECG-recording direction. However, out-of-hospital cardiac arrest (OHCA)-studies with defibrillator-derived VF-recordings are lacking.

Méthode : Multi-centre (Amsterdam/Nijmegen, the Netherlands) cohort-study on the association between AMSA, ST-elevation MI (STEMI) and its localisation. AMSA was calculated from defibrillator pad-ECG recordings (proxy for lead II, inferior vantage point); STEMI-localisation was determined using ECG/angiography/autopsy findings.

Résultats : We studied AMSA-values in 754 OHCA-patients. There were statistically significant differences between no STEMI, anterior STEMI and inferior STEMI (Nijmegen: no STEMI 13.0mVHz [7.9-18.6], anterior STEMI 7.5mVHz [5.6-13.8], inferior STEMI 7.5mVHz [5.4-11.8], p = 0.006. Amsterdam: 11.7mVHz [5.0-21.9], 9.6mVHz [4.6-17.2], and 6.9mVHz [3.2-16.0], respectively, p = 0.001). Univariate analyses showed significantly lower AMSA-values in inferior STEMI vs. no STEMI; there was no significant difference between anterior and no STEMI. After correction for confounders, adjusted absolute AMSA-values were numerically lowest for inferior STEMI in both cohorts, and the relative differences in AMSA between inferior and no STEMI was 1.4-1.7 times larger than between anterior and no STEMI.

Conclusion : This multi-centre VF-waveform OHCA-study showed significantly lower AMSA in case of underlying STEMI, with a more pronounced difference for inferior than for anterior STEMI. Confirmative studies on the impact of STEMI-localisation on the VF-waveform are warranted, and might contribute to earlier diagnosis of STEMI during VF.

Conclusion (proposition de traduction) : Cette étude multicentrique sur la forme d'onde de fibrillation ventriculaire en dehors de l'hôpital a montré une aire spectrale d’amplitude significativement plus faible en cas d’infarctus du myocarde sous-jacent avec sus-décalage du segment ST, avec une différence plus prononcée pour l'infarctus du myocarde inférieur avec sus-décalage du segment ST que pour l'infarctus du myocarde antérieur. Des études de confirmation sur l'impact de la localisation de l'infarctus du myocarde avec sus-décalage du segment ST sur la forme d'onde de fibrillation ventriculaire sont justifiées et pourraient contribuer à un diagnostic plus précoce de l'infarctus du myocarde avec sus-décalage du segment ST au cours de la fibrillation ventriculaire.

Peripheral perfusion index and diagnostic accuracy of the post-ROSC electrocardiogram in patients with medical out-of-hospital cardiac arrest.
Compagnoni S, Gentile FR, Baldi E, Contri E, Palo A, Primi R, Currao A, Bendotti S, Ziliani P, Ferrario Ormezzano M, Oltrona Visconti L, Savastano S. | Resuscitation. 2021 Nov;168:19-26
DOI: https://doi.org/10.1016/j.resuscitation.2021.08.050
Keywords: Coronary angiography; Out-of-hospital cardiac arrest; Perfusion index.

Clinical Paper

Introduction : A 12-lead electrocardiogram (ECG) after the return of spontaneous circulation (ROSC) is recommended to diagnose a ST-segment elevation myocardial infarction (STEMI). In the early post-ROSC phase, the ECG can show signs of ischemia not necessarily of coronary origin and post-ROSC hypoperfusion could affect ECG reliability. We sought for an association between peripheral perfusion index (PI) values after ROSC and the percentage of false-positive ECG for STEMI.

Méthode : We considered all the consecutive patients with sustained ROSC after OHCA, admitted to the Fondazione IRCCS Policlinico San Matteo (Pavia) between January 1st, 2015 and December 31st, 2020. ECGs were defined false-positive if meeting the STEMI criteria but without a critical obstructive coronary artery disease worthy of treatment. The mean value of PI over 30 min-monitoring (MPI30) were calculated.

Résultats : Among 351 eligible patients post-ROSC ECG, PI monitoring and an invasive coronary angiography (ICA) were available in 84 cases. The rate of false positive was 16/54 (29.6%) and it differed significantly in the three MPI30 tertiles [T1 (0.2-1): 28.6%; T2 (1.1-2.5): 24.1%; T3 (2.6-6.9): 3.7%, p = 0.04; p for trend = 0.02]. Cardiac arrest duration [OR 1.06 (95 %CI 1-1.1), p = 0.007] and MPI30 [T3 vs T1: OR 0.09 (95 %CI 0.01-0.8), p = 0.03] were significantly associated with the probability of acquiring a false-positive ECG. This association was also confirmed when MPI30 was adjusted for cardiac arrest duration [OR 0.2 (95 %CI 0.1-0.6), p=<0.001].

Conclusion : The rate of false-positive ECG for STEMI after ROSC is related with low perfusion. Our results could help to identify the adequate candidates for an immediate ICA.

Conclusion (proposition de traduction) : Le nombre d'ECG faussement positifs pour syndrome coronarien avec sus-décalage du segment ST après reprises d'activité circulatoire spontanée est lié à une faible perfusion. Nos résultats pourraient aider à identifier les candidats adéquats pour une ICA immédiate.

Live video from bystanders' smartphones to improve cardiopulmonary resuscitation.
Linderoth G, Rosenkrantz O, Lippert F, Østergaard D, Ersbøll AK, Meyhoff CS, Folke F, Christensen HC. | Resuscitation. 2021 Nov;168:35-43
DOI: https://doi.org/10.1016/j.resuscitation.2021.08.048  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Dispatcher; Emergency call; Out-of-hospital cardiac arrest; Technology; Video.

Clinical paper

Introduction : To investigate whether live video streaming from the bystander's smartphone to a medical dispatcher can improve the quality of bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA).

Méthode : After CPR was initiated, live video was added to the communication by the medical dispatcher using smartphone technology. From the video recordings, we subjectively evaluated changes in CPR quality after themedical dispatcher had used live video to dispatcher-assisted CPR (DA-CPR). CPR quality was registered for each bystander and compared with CPR quality after video-instructed DA-CPR. Data were analysed using logistic regression adjusted for bystander's relation to the patient and whether the arrest was witnessed.

Résultats : CPR was provided with live video streaming in 52 OHCA calls, with 90 bystanders who performed chest compressions. Hand position was incorrect for 38 bystanders (42.2%) and improved for 23 bystanders (60.5%) after video-instructed DA-CPR. The compression rate was incorrect for 36 bystanders (40.0%) and improved for 27 bystanders (75.0%). Compression depth was incorrect for 57 bystanders (63.3%) and improved for 33 bystanders (57.9%). The adjusted odds ratios for improved CPR after video-instructed DA-CPR were; hand position 5.8 (95% CI: 2.8-12.1), compression rate 7.7 (95% CI: 3.4-17.3), and compression depth 7.1 (95% CI: 3.9-12.9). Hands-off time was reduced for 34 (37.8%) bystanders.

Conclusion : Live video streaming from the scene of a cardiac arrest to medical dispatchers is feasible. It allowed an opportunity for dispatchers to coach those providing CPR which was associated with a subjectively evaluated improvement in CPR performance.

Conclusion (proposition de traduction) : La diffusion vidéo en direct (ndlr : vidéo-régulation au Samu) de la scène d'un arrêt cardiaque vers les assistants de régulateur médical est possible. Cela a permis aux assistants de régulateur médical d'encadrer ceux qui prodiguaient la RCP, ce qui était associé à une amélioration évaluée de manière subjective des performances de la RCP.

Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study.
Le Bastard Q, Rouzioux J, Montassier E, Baert V, Recher M, Hubert H, Leteurtre S, Javaudin F; GR-RéAC. | Resuscitation. 2021 Nov;168:191-198
DOI: https://doi.org/10.1016/j.resuscitation.2021.08.015
Keywords: Airway management; Endotracheal intubation; Paediatric out-of-hospital cardiac arrest; Supraglottic ventilation.

Clinical paper

Introduction : Out-of-hospital cardiac arrest (OHCA) in children is associated with a low survival rate. Conclusions in the literature are conflicting regarding the best way to handle ventilation. The purpose of this study was to assess the impact of two airway management strategies, endotracheal intubation (ETI) vs. supraglottic procedure, during cardiopulmonary resuscitation (CPR) on 30-day survival in paediatric OHCA.

Méthode : This was a retrospective, observational, multicentre, registry-based study conducted from July 2011 to March 2018. All paediatric OHCA patients under 18 years of age and managed by a mobile intensive care unit were included. The primary endpoint was 30-day survival in a weighted population (based on propensity scores).

Résultats : Of 1579 children, 1355 (85.8%) received ETI and 224 (14.2%) received supraglottic ventilation during CPR. We observe a lower 30-day survival in the ETI group compared to the supraglottic group (7.7% vs. 14.3%, absolute difference, 6.6 percentage points; 95% confidence interval [CI], 2.3-12.0; propensity-adjusted odds ratio [paOR], 0.39; 95% CI, 0.25-0.62; p < 0.001), and also a poorer neurological outcome (paOR, 0.32; 95% CI, 0.19-0.54; p < 0.001). However, we did not identify any significant association between airway management strategy and return of spontaneous circulation (paOR, 1.15; 95% CI, 0.80-1.65; p = 0.46).

Conclusion : The findings of this large cohort study suggest that ETI in paediatric OHCA, although performed by trained physicians, is associated with a worse outcome, regardless of traumatic or non-traumatic aetiology.

Conclusion (proposition de traduction) : Les résultats de cette vaste étude de cohorte suggèrent que l'intubation endotrachéale dans les arrêts cardiaques pédiatriques extra-hospitaliers, bien qu'effectuée par des médecins qualifiés, est associée à un résultat plus défavorable, quelle que soit l'étiologie traumatique ou non traumatique.

Adrenaline improves regional cerebral blood flow, cerebral oxygenation and cerebral metabolism during CPR in a porcine cardiac arrest model using low-flow extracorporeal support.
Putzer G, Martini J, Spraider P, Abram J, Hornung R, Schmidt C, Bauer M, Pinggera D, Krapf C, Hell T, Glodny B, Helbok R, Mair P. | Resuscitation. 2021 Nov;168:151-159
DOI: https://doi.org/10.1016/j.resuscitation.2021.07.036  | Télécharger l'article au format  
Keywords: Adrenaline; Blood pressure; Cardiac arrest; Cardiopulmonary resuscitation; Cerebral cortex/metabolism; Ecmo; Heart arrest/therapy; Microdialysis/methods; Near infrared spectroscopy; Oxygen/blood; Oxygen/metabolism; Pigs.

Experimental

Introduction : The effects of adrenaline on cerebral blood vessels during cardiopulmonary resuscitation (CPR) are not well understood. We developed an extracorporeal CPR model that maintains constant low systemic blood flow while allowing adrenaline-associated effects on cerebral vasculature to be assessed at different mean arterial pressure (MAP) levels independently of the effects on systemic blood flow.

Méthode : After eight minutes of cardiac arrest, low-flow extracorporeal life support (ECLS) (30 ml/kg/min) was started in fourteen pigs. After ten minutes, continuous adrenaline administration was started to achieve MAP values of 40 (n = 7) or 60 mmHg (n = 7). Measurements included intracranial pressure (ICP), cerebral perfusion pressure (CePP), laser-Doppler-derived regional cerebral blood flow (CBF), cerebral regional oxygen saturation (rSO2), brain tissue oxygen tension (PbtO2) and extracellular cerebral metabolites assessed by cerebral microdialysis.

Résultats : During ECLS without adrenaline, regional CBF increased by only 5% (25th to 75th percentile: -3 to 14; p = 0.2642) and P_btO₂ by 6% (0-15; p = 0.0073) despite a significant increase in MAP to 28 mmHg (25-30; p < 0.0001) and CePP to 10 mmHg (8-13; p < 0.0001). Accordingly, cerebral microdialysis parameters showed a profound hypoxic-ischemic pattern. Adrenaline administration significantly improved regional CBF to 29 ± 14% (p = 0.0098) and 61 ± 25% (p < 0.001) and P_btO₂ to 15 ± 11% and 130 ± 82% (both p < 0.001) of baseline in the MAP 40 mmHg and MAP 60 mmHg groups, respectively. Importantly, MAP of 60 mmHg was associated with metabolic improvement.

Conclusion : This study shows that adrenaline administration during constant low systemic blood flow increases CePP, regional CBF, cerebral oxygenation and cerebral metabolism.

Conclusion (proposition de traduction) : Cette étude montre que l'administration d'adrénaline pendant un débit sanguin systémique faible et constant augmente la pression de perfusion cérébrale, le débit sanguin cérébral régional, l'oxygénation cérébrale et le métabolisme cérébral.

Less is more: Detecting clinical deterioration in the hospital with machine learning using only age, heart rate, and respiratory rate.
Akel MA, Carey KA, Winslow CJ, Churpek MM, Edelson DP. | Resuscitation. 2021 Nov;168:6-10
DOI: https://doi.org/10.1016/j.resuscitation.2021.08.024
Keywords: Clinical deterioration; Limited dataset; Machine learning; Prediction.

Short Paper

Introduction : We sought to develop a machine learning analytic (eCART Lite) for predicting clinical deterioration using only age, heart rate, and respiratory data, which can be pulled in real time from patient monitors and updated continuously without need for additional inputs or cumbersome electronic health record integrations.

Méthode : We utilized a multicenter dataset of adult admissions from five hospitals. We trained a gradient boosted machine model using only current and 24-hour trended heart rate, respiratory rate, and patient age to predict the probability of intensive care unit (ICU) transfer, death, or the combined outcome of ICU transfer or death. The area under the receiver operating characteristic curve (AUC) was calculated in the validation cohort and compared to those for the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), and eCARTv2, a previously-described, 27-variable, cubic spline, logistic regression model without trends.

Résultats : Of the 556,848 included admissions, 19,509 (3.5%) were transferred to an ICU and 5764 (1.0%) died within 24 hours of a ward observation. eCART Lite significantly outperformed the MEWS, NEWS, and eCART v2 for predicting ICU transfer (0.79 vs 0.71, 0.74, and 0.78, respectively; p < 0.01) and the combined outcome (0.80 vs 0.72, 0.76, and 0.79, respectively; p < 0.01). Two of the strongest predictors were respiratory rate and heart rate.

Conclusion : Using only three inputs, we developed a tool for predicting clinical deterioration that is similarly or more accurate than commonly-used algorithms, with potential for use in inpatient settings with limited resources or in scenarios where low-cost tools are needed.

Conclusion (proposition de traduction) : En utilisant seulement trois données, nous avons développé un outil pour prédire la détérioration clinique qui est similaire ou plus précis que les algorithmes couramment utilisés, avec un potentiel d'utilisation en milieu hospitalier avec des ressources limitées ou dans des scénarios où des outils à faible coût sont nécessaires.

Commentaire : Le Machine Learning est une technologie d’intelligence artificielle permettant aux ordinateurs d’apprendre sans avoir été programmés explicitement à cet effet. Pour apprendre et se développer, les ordinateurs ont toutefois besoin de données à analyser et sur lesquelles s’entraîner. De fait, le Big Data est l’essence du Machine Learning, et c’est la technologie qui permet d’exploiter pleinement le potentiel du Big Data. Découvrez pourquoi cette technique et le Big Data sont interdépendants.

Helicopter emergency medical services use of thoracic point of care ultrasound for pneumothorax: a systematic review and meta-analysis.
Griffiths E | Scand J Trauma Resusc Emerg Med. 2021 Nov 20;29(1):163
DOI: https://doi.org/10.1186/s13049-021-00977-0  | Télécharger l'article au format  
Keywords: HEMS; POCUS; Pneumothorax; Pre-hospital; Ultrasound.

REVIEW

Introduction : Auscultating for breath sounds to assess for pneumothorax in the helicopter emergency medical services (HEMS) settings can be extremely challenging. Thoracic point of care ultrasound (POCUS) offers a seemingly more useful visual (rather than audible) alternative. This review critically and quantitatively evaluates the use of thoracic POCUS for pneumothorax in the HEMS setting.

Méthode : A systematic literature review with meta-analysis was conducted. Only papers reporting on patients undergoing POCUS for pneumothorax in the helicopter or pre-hospital setting were included. Primary outcome was accuracy, focusing on sensitivity and specificity. Secondary outcome was practicality. PubMed, Embase and the Cochrane Library were searched. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess validity of studies.

Résultats : Twelve studies reporting on n = 1,936 images from medical and trauma patients were included in qualitative synthesis. Studies were nearly all observational designs. Most images were acquired by nurses or paramedics who were previously novices to ultrasound. The reference standard was predominantly CT. Specificity results were unanimously precise and very high, whereas sensitivity results were imprecise and extremely variable. Meta-analysis of eight studies involving n = 1,713 images yielded pooled sensitivity 61% (95% CI: 27-87%; I2 = 94%) and pooled specificity 99% (95% CI: 98-100%; I2 = 89%). Six studies involving n = 315 images reported practicality. The highest or second highest categorisation of image quality was reported in around half of those images.

Conclusion : Thoracic POCUS is highly specific but has extremely variable sensitivity for pneumothorax when performed in the HEMS setting. This is from purely a diagnostic (not clinical) perspective. Sensitivity increases when only clinically significant pneumothoraces are considered. Case reports reveal thoracic POCUS can appropriately alter treatment and triage decisions, but only for a small number of patients. It appears predominantly useful in mitigating against unnecessary interventions. More research reporting patient focused outcomes is required. In the meantime, thoracic POCUS appears to offer a more appropriate visual alternative to auscultation for breath sounds when assessing for pneumothorax in the HEMS setting.

Conclusion (proposition de traduction) : L'échographie thoracique au point d'intervention est très spécifique mais a une sensibilité extrêmement variable pour le pneumothorax lorsqu'elle est effectuée dans le cadre des services médicaux d'urgence en hélicoptère. Il s'agit d'un point de vue purement diagnostique (et non clinique). La sensibilité augmente lorsque seuls les pneumothorax cliniquement significatifs sont pris en compte. Les rapports de cas révèlent que l'échographie thoracique au point d'intervention peut modifier de manière appropriée les décisions de traitement et de triage, mais seulement pour un petit nombre de patients. Il semble principalement utile pour atténuer les interventions inutiles. Davantage de recherches rapportant des résultats axés sur le patient sont nécessaires. En attendant, l'échographie thoracique au point d'intervention semble offrir une alternative visuelle plus appropriée que l'auscultation des bruits respiratoires lors de l'évaluation du pneumothorax dans le cadre des services médicaux d'urgence en hélicoptère.

Association Between Converting Asystole From Initial Shockable ECG Rhythm Before Extracorporeal Cardiopulmonary Resuscitation and Outcome.
Maeda K, Inoue A, Kuroda Y, Inoue F, Suga M, Ijuin S, Kai S, Koga T, Igarashi N, Matsuyama S, Kawase T, Ishihara S, Naitou H, Nakayama S. | Shock. 2021 Nov 1;56(5):701-708
DOI: https://doi.org/10.1097/shk.0000000000001727
Keywords: Aucun

Clinical Science Aspect

Introduction : Initial electrocardiogram (ECG) rhythm is a predictor of outcomes in out-of-hospital cardiac arrest (OHCA) in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). However, ECG rhythm often changes before ECPR, and the consequence of this change remains unclear. This study aimed to assess the relationship between the conversion of ECG rhythm from initial shockable rhythm before ECPR and mortality.

Méthode : This was a retrospective cohort study of OHCA patients with initial shockable rhythm who underwent ECPR between January 2010 and September 2020. Patients were classified into two groups: asystole (patients whose ECG rhythm converted to asystole at any time before initiating ECPR) and non-asystole (patients whose ECG rhythm did not convert to asystole at any time before initiating ECPR) groups. The primary outcome was in-hospital mortality.

Résultats : A total of 102 patients were included in the study; in-hospital mortality rate was 46.1% (n = 47) and 76 (74.5%) patients had unfavorable neurological outcomes (Cerebral Performance Category: 3-5). There were 33 and 69 patients in the asystole and non-asystole groups, respectively. The mortality rates in the asystole and non-asystole groups were 69.7% and 34.8%, respectively (P = 0.001). On multivariable analysis, the asystole group showed a significant association with mortality (odds ratio, 5.42; 95% confidence interval, 2.11-15.36; P < 0.001).

Conclusion : Conversion to asystole before ECPR at any time in patients with OHCA is associated with mortality in patients with an initial shockable ECG rhythm.

Conclusion (proposition de traduction) : La conversion en asystolie à tout moment avant l'ECPR chez les patients présentant un arrêt cardiaque en dehors de l'hôpital est associée à la mortalité chez les patients avec un rythme ECG initial choquable.

Timing of Intravenous Epinephrine Administration During Out-of-Hospital Cardiac Arrest.
Fukuda T, Ohashi-Fukuda N, Inokuchi R, Kondo Y, Taira T, Kukita I. | Shock. 2021 Nov 1;56(5):709-717
DOI: https://doi.org/10.1097/shk.0000000000001731
Keywords: Aucun

Clinical Science Aspect

Introduction : Current guidelines for cardiopulmonary resuscitation recommend that standard dose of epinephrine be administered every 3 to 5 min during cardiac arrest. However, there is controversy about the association between timing of epinephrine administration and outcomes after out-of-hospital cardiac arrest (OHCA). This study aimed to determine whether the timing of intravenous epinephrine administration is associated with outcomes after OHCA.

Méthode : We analyzed Japanese government-led nationwide population-based registry data for OHCA. Adult OHCA patients who received intravenous epinephrine by emergency medical service personnel in the prehospital setting from 2011 to 2017 were included. Multivariable logistic regression models were used to assess the associations between time to first epinephrine administration and outcomes after OHCA. Subsequently, associations between early (≤20 min) versus delayed (>20 min) epinephrine administration and outcomes after OHCA were examined using propensity score-matched analyses. The primary outcome was 1-month neurologically favorable survival.

Résultats : A total of 119,946 patients (mean [SD] age, 75.2 [14.8] years; 61.4% male) were included. The median time to epinephrine was 23 min (interquartile range, 19-29). Longer time to epinephrine was significantly associated with a decreased chance of 1-month neurologically favorable survival (multivariable adjusted OR per minute delay, 0.91 [95% CI, 0.90-0.92]). In the propensity score-matched cohort, when compared with early (≤20 min) epinephrine, delayed (>20 min) epinephrine was associated with a decreased chance of 1-month neurologically favorable survival (959/42,804 [2.2%] vs. 330/42,804 [0.8%]; RR, 0.34; 95% CI, 0.30-0.39; NNT, 69).

Conclusion : Delay in epinephrine administration was associated with a decreased chance of 1-month neurologically favorable survival among patients with OHCA.

Conclusion (proposition de traduction) : Le retard dans l'administration d'adrénaline était associé à une diminution des chances de survie neurologiquement favorable à 1 mois chez les patients ayant subi un arrêt cardiaque en dehors de l'hôpital.

Ischemic Benefit and Hemorrhage Risk of Ticagrelor-Aspirin Versus Aspirin in Patients With Acute Ischemic Stroke or Transient Ischemic Attack.
Johnston SC, Amarenco P, Aunes M, Denison H, Evans SR, Himmelmann A, Jahreskog M, James S, Knutsson M, Ladenvall P, Molina CA, Nylander S, Röther J, Wang Y; THALES Investigators. | Stroke. 2021 Nov;52(11):3482-3489
DOI: https://doi.org/10.1161/strokeaha.121.035555
Keywords: aspirin; benefit-risk assessment; ischemic attack, transient; ischemic stroke; ticagrelor; treatment outcome.

Original Contribution

Introduction : In patients with acute mild-moderate ischemic stroke or high-risk transient ischemic attack, the THALES trial (Acute Stroke or Transient Ischemic Attack Treated With Ticagrelor and Aspirin for Prevention of Stroke and Death) demonstrated that when added to aspirin, ticagrelor reduced stroke or death but increased risk of severe hemorrhage compared with placebo. The primary efficacy outcome of THALES included hemorrhagic stroke and death, events also counted in the primary safety outcome. We sought to disentangle risk and benefit, assess their relative impact, and attempt to identify subgroups with disproportionate risk or benefit.

Méthode : In a randomized, placebo-controlled, double-blind trial of patients with mild-to-moderate acute noncardioembolic ischemic stroke or high-risk transient ischemic attack, patients were randomized within 24 hours after symptom onset to a 30-day regimen of either ticagrelor plus aspirin or matching placebo plus aspirin. For the present analyses, we defined the efficacy outcome, major ischemic events, as the composite of ischemic stroke or nonhemorrhagic death, and defined the safety outcome, major hemorrhage, as intracranial hemorrhage or hemorrhagic death. Net clinical impact was defined as the combination of these 2 end points.

Résultats : In 11 016 patients (5523 ticagrelor-aspirin and 5493 aspirin), a major ischemic event occurred in 294 patients (5.3%) in the ticagrelor-aspirin group and in 359 patients (6.5%) in the aspirin group (absolute risk reduction 1.19% [95% CI, 0.31%–2.07%]). Major hemorrhage occurred in 22 patients (0.4%) in the ticagrelor-aspirin group and 6 patients (0.1%) in the aspirin group (absolute risk increase 0.29% [95% CI, 0.10%–0.48%]). Net clinical impact favored ticagrelor-aspirin (absolute risk reduction 0.97% [95% CI, 0.08%–1.87%]). Findings were similar when different thresholds for disability were applied and over a range of predefined subgroups.

Conclusion : In patients with mild-moderate ischemic stroke or high-risk transient ischemic attack, ischemic benefits of 30-day treatment with ticagrelor-aspirin outweigh risks of hemorrhage.

Conclusion (proposition de traduction) : Chez les patients victimes d'un AVC ischémique léger à modéré ou d'un accident ischémique transitoire à haut risque, les bénéfices sur l'ischémie d'un traitement de 30 jours par ticagrélor-aspirine l'emportent sur les risques d'hémorragie.

Pneumothorax diagnosis with lung sliding quantification by speckle tracking: A prospective multicentric observational study.
Fissore E, Zieleskiewicz L, Markarian T, Muller L, Duclos G, Bourgoin M, Michelet P, Leone M, Claret PG, Bobbia X. | Am J Emerg Med. 2021 Nov;49:14-17
DOI: https://doi.org/10.1016/j.ajem.2021.05.022
Keywords: Lung; Pneumothorax; Point-of-care system; Speckle tracking analysis; Ultrasonography.

Research article

Introduction : Lung ultrasound is commonly used for the diagnosis of pneumothorax. However, recognition of pleural sliding is subjective and can be difficult for novice. The primary objective was to compare a novices physician's performance in diagnosing pneumothorax from ultrasound (US) scans either with visual evaluation or with maximum longitudinal pleural strain (MLPS). The secondary objective was to compare the diagnostic relevance of US with visual evaluation or MLPS to diagnose pneumothorax with an intermediately experienced and an expert physician.

Méthode : We conducted a prospective, observational study in two emergency department and two intensive care unit, between February 2019 and June 2020. We included 99 adult patients with suspected pneumothorax, who received a chest computed tomography (CT). Three physicians with different experience of interpreting US scans (a novice physician, an intermediately experienced physician, and an expert) analyzed the US scans of 99 patients with suspected pneumothorax (50 (51%) with confirmed pneumothorax), which were confirmed by CT scan.

Résultats : With a threshold of 5%, the MLPS sensitivity was 94% (95% CI [83%; 98%]), and the specificity was 100% (95% CI [93%; 100%]). The novice physician had an area under the curve (AUC) with visual analysis of 0.75 (95% CI [0.67; 0.83]) vs 0.86 (95% CI [0.79; 0.94]) with MLPS (p = 0.04). The intermediate physician's AUC for diagnosing pneumothorax with visual analysis was 0.93 (95% CI [0.88; 0.99]) vs 1.00 (95% CI [1.00; 1.00]) with MLPS (p < 0.01) and for the expert physician it was 0.98 (95% CI [0.95;1.00]) vs 0.97 (95% CI [0.93; 1.00]), respectively (p = 0.69).

Conclusion : In our study, speckle tracking analysis improved the accuracy of US for the novice and the intermediate but not the expert sonographer in the diagnosis of pneumothorax.

Conclusion (proposition de traduction) : Dans notre étude, l'analyse par speckle tracking a amélioré la précision de l'échographie pour le novice et l'intermédiaire mais pas pour l'échographiste expert dans le diagnostic du pneumothorax.

Commentaire : Le speckle tracking est une nouvelle technique ultrasonore qui permet le calcul des paramètres de déformation tel que le strain et strain rate en utilisant un algorithme qui se base sur des images 2D en noir et blanc (« speckles ») et non pas sur le Doppler.
Le strain est défini comme le pourcentage de changement de la dimension (déformation) d’un objet par rapport à sa dimension initiale, alors que le strain rate est défini comme la vitesse à laquelle la déformation s’effectue. Le calcul du strain par Speckle tracking a été validé par sonomicrométrie et IRM.
Ces paramètres (strain et strain rate) permettent l’évaluation de façon plus directe par rapport à l’échocardiographie conventionnelle. Les mesures traditionnelles de dimension et de volume sont relativement insensibles à des modifications débutantes.

Awake intubations in the emergency department: A report from the National Emergency Airway Registry.
Kaisler MC, Hyde RJ, Sandefur BJ, Kaji AH, Campbell RL, Driver BE, Brown CA 3rd. | Am J Emerg Med. 2021 Nov;49:48-51
DOI: https://doi.org/10.1016/j.ajem.2021.05.038
Keywords: Airway management; Awake; Endotracheal; Intubation; NEAR.

Research article

Introduction : To describe awake intubation practices in the emergency department (ED) and report success, complications, devices used, and rescue techniques using multicenter surveillance.

Méthode : We analyzed data from the National Emergency Airway Registry (NEAR). Patients with an awake intubation attempt between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals (CIs).

Résultats : Of 19,071 discrete patient encounters, an awake technique was used on the first attempt in 82 (0.4%) patients. The majority (91%) of first attempts were performed by emergency medicine physicians. Angioedema (32%) and non-angioedema airway obstruction (31%) were the most common indications for an awake intubation attempt. The most common initial device used was a flexible endoscope (78%). Among all awake intubations first-attempt success was achieved in 85% (95% CI [76%-95%]), and peri-intubation complications occurred in 16% (95% CI [9%-26%]).

Conclusion : Awake intubation in this multicenter cohort of emergency department patients was rare and was performed most often in patients with airway edema or obstruction. Emergency physicians performed the majority of first intubation attempts with high first-attempt success. Further studies are needed to determine optimal emergency airway management in this patient population.

Conclusion (proposition de traduction) : L'intubation sans sédation dans cette cohorte multicentrique de patients des services d'urgence était rare (0,4 %) et a été réalisée le plus souvent chez des patients présentant un angiœdème ou une obstruction des voies respiratoires. Les médecins urgentistes ont effectué la majorité des premières tentatives d'intubation avec un succès élevé (avec un endoscope flexible dans 78 % des cas). D'autres études sont nécessaires pour déterminer la gestion optimale des voies respiratoires d'urgence dans cette population de patients.

Cardiac markers of multisystem inflammatory syndrome in children (MIS-C) in COVID-19 patients: A meta-analysis.
Zhao Y, Patel J, Huang Y, Yin L, Tang L. | Am J Emerg Med. 2021 Nov;49:62-70
DOI: https://doi.org/10.1016/j.ajem.2021.05.044  | Télécharger l'article au format  
Keywords: BNP; COVID-19; Children; Meta-analysis; PMIS/PIMS-TS/MIS-C; Troponin.

Research article

Introduction : A meta-analysis of laboratory cardiac markers for multisystem inflammatory syndrome in children (MIS-C) was performed in patients with coronavirus disease 2019 (COVID-19).

Méthode :  Eight databases were searched until April 10, 2021, for studies on cardiac markers, including B-type natriuretic peptide (BNP)/N-terminal pro-BNP (NT-proBNP), troponin, aspartate aminotransferase (AST), in MIS-C patients.

Résultats : Of the 2583 participants enrolled in 24 studies, 1613 patients were diagnosed with MIS-C. MIS-C patients exhibited higher BNP levels than patients with non-severe COVID-19 [SMD (95% CI): 1.13 (0.48, 1.77), p < 0.05]. No significant differences in BNP levels were observed between patients with MIS-C and severe COVID-19 [SMD (95% CI): 0.29 (-0.07, 0.65), p = 0.117]. Comparisons of MIS-C patients to all COVID-19 patients revealed no significant differences in levels of troponin [SMD (95% CI): 0.13 (-0.07, 0.32), p = 0.212] or AST [SMD (95% CI): 0.10 (-0.11, 0.31), p = 0.336]. Compared to patients with non-severe MIS-C, those with severe MIS-C exhibited higher levels of BNP [SMD (95% CI): 0.26 (0.04, 0.48), p < 0.05], but no differences in troponin [SMD (95% CI): 0.05 (-0.06, 0.16) p = 0.387] or AST [SMD (95% CI): 0.19 (-0.34, 0.71), p = 0.483] were observed. Moreover, there was no significant difference in BNP [SMD (95% CI): -0.21 (-1.07, 0.64), p = 0.624] or troponin [SMD (95% CI): -0.07 (-0.45, 0.31), p = 0.710] between MIS-C with and without coronary artery abnormality. Sensitivity analyses were performed to assess stability. No publication bias was detected based on Begg's test.

Conclusion : The key cardiac marker that showed differences between patients with MIS-C/non-severe COVID-19 and between patients with severe/non-severe MIS-C was BNP. Other markers, such as troponin and AST, did not exhibit notable differences in indicating cardiac injury between patients with MIS-C and COVID-19.

Conclusion (proposition de traduction) : Le marqueur cardiaque clé qui a montré des différences entre les patients atteints de MIS-C/COVID-19 non sévère et entre les patients atteints de MIS-C sévère/non sévère était le BNP. D'autres marqueurs, tels que la troponine et l'aspartate aminotransférase, n'ont pas montré de différences notables dans l'indication d'une lésion cardiaque entre les patients atteints de MIS-C et de la COVID-19.

Commentaire : Voir sur le PIMS (syndrome inflammatoire multisystémique pédiatrique ou MIS-C) :
• HAS. Réponse rapide dans le cadre de la COVID-19 : Repérage et prise en charge du syndrome inflammatoire multi-systémique pédiatrique (PIMS) post-infectieux  . Validée par le Collège le 1er juillet 2021.
• Kortz TB, Connolly E, Cohen CL, Cook RE, Jonas JA, Lipnick MS, Kissoon N. Diagnosis and Acute Management of COVID-19 and Multisystem Inflammatory Syndrome in Children. Pediatr Emerg Care. 2021 Oct 1;37(10):519-525  .
• Gottlieb M, Bridwell R, Ravera J, Long B. Multisystem inflammatory syndrome in children with COVID-19.Am J Emerg Med. 2021 Nov;49:148-152  .

10% Lidocaine spray as a local anesthetic in blood gas sampling: A randomized, double-blind, placebo-controlled study.
Gur A, Tekin E. | Am J Emerg Med. 2021 Nov;49:89-93
DOI: https://doi.org/10.1016/j.ajem.2021.05.060
Keywords: Anesthesia; Blood gas; Lidocaine spray; Pain; Radial artery.

Research article

Introduction : Radial artery blood gas sampling is a very common procedure undertaken in the emergency department to evaluate respiratory and metabolic parameters. This intervention causes both anxiety and pain for the patient. Therefore, the current study aimed to examine the analgesic efficacy of lidocaine spray compared to a placebo during radial artery blood gas sampling.

Méthode : This study was conducted in the emergency department of a tertiary hospital with a randomized, double-blind, placebo-controlled design. A total of 144 patients were randomly divided into two groups: One group (n = 72) received 10% lidocaine spray and the other (n = 72) was the placebo group. The analgesic efficacy of the 10% lidocaine spray was compared with the placebo group using the Visual Analog Scale (VAS).

Résultats : In the evaluation of the analgesic efficacy of the 10% lidocaine spray, the VAS score was 1.5 [interquartile range (IQR): 2.0] for the lidocaine group and 5 (IQR: 2.0) for the placebo group. The role of lidocaine spray in reducing pain was statistically significant compared to the placebo (p = 0.000).

Conclusion : In blood gas sampling, 10% lidocaine spray has analgesic efficacy. Therefore, we recommend the use of lidocaine spray while performing arterial blood gas sampling in emergency departments.

Conclusion (proposition de traduction) : Dans le prélèvement des gaz du sang, le spray de lidocaïne à 10  % a une efficacité analgésique. Par conséquent, nous recommandons l'utilisation de spray de lidocaïne lors du prélèvement des gaz du sang artériel dans les services d'urgence.

The prospective evaluation of the effectiveness of scoring systems in the emergency department in cases with suspected ureteral stones: STONE? CHOKAI?.
Eraybar S, Yuksel M. | Am J Emerg Med. 2021 Nov;49:94-99
DOI: https://doi.org/10.1016/j.ajem.2021.05.069
Keywords: Emergency service; Hydronephrosis; Scoring system; Ureteral stone.

Research article

Introduction : This study evaluates the effectiveness of CHOKAI and STONE scores in patients presenting to the emergency department with ureteral stones.

Méthode : Patients over the age of 18 who were admitted to the emergency department with flank pain, groin pain, scrotal pain, and hematuria and who were performed non-contrast abdominal computed tomography (CT) for diagnostic imaging were included. The numeric pain, CHOKAI, and STONE scores of the patients were calculated. The effectiveness of these scoring systems in the presence of stones was examined.

Résultats : A total of 105 patients were included in the study. In the analysis performed to investigate whether there was a difference between the numeric pain, STONE, and CHOKAI scores in terms of the presence of stones on CT, it was seen that the CHOKAI score was significantly different from the others (p < 0.001). A significant positive correlation was found between the CHOKAI score and stone size (r = 0.343, p < 0.001).When the cut-off value of the CHOKAI score was >7, the sensitivity was found to be 60.49%, and specificity was 83.33%. The cut-off value for the STONE score was >8 with a sensitivity of 70.37% and specificity of 58.33%. The corresponding area under curve values for the CHOHAI and STONE scores was 0.788 (p < 0.0001) and 0.615 (p = 0.087). Male sex, the CHOKAI, and STONE scores were the independent risk factors for ureteral stone. A significant positive correlation was found between the CHOKAI score and stone size (r = 0.343, p < 0.001).

Conclusion : The CHOKAI score has a higher performance than the STONE score in detecting the presence of ureteral stones.

Conclusion (proposition de traduction) : Le score CHOKAI est plus performant que le score STONE pour détecter la présence de calculs urétéraux.

Commentaire : Score CHOKAI :
• Fukuhara H, Kobayashi T, Takai S, Tawara T, Kikuta M, Sugiura A, Yamagishi A, Toyohara T, Nakane M, Tsuchiya N. External validation of the CHOKAI score for the prediction of ureteral stones: A multicenter prospective observational study. Am J Emerg Med. 2020 May;38(5):920-924  .
• Fukuhara H, Ichiyanagi O, Midorikawa S, Kakizaki H, Kaneko H, Tsuchiya N. Internal validation of a scoring system to evaluate the probability of ureteral stones: The CHOKAI score. Am J Emerg Med. 2017 Dec;35(12):1859-1866  .

Association between length of stay in the emergency department and outcomes in out-of-hospital cardiac arrest.
Jang DH, Lee DK, Shin J, Jo YH, Park SM; SNU CARE Investigators. | Am J Emerg Med. 2021 Nov;49:124-129
DOI: https://doi.org/10.1016/j.ajem.2021.05.072
Keywords: Emergency department; Length of stay; Out-of-hospital cardiac arrest; Prognosis.

Research article

Introduction : Several studies have previously reported that a prolonged emergency department length of stay (EDLOS) is associated with poor outcomes in critically ill patients. This study was performed to investigate the relationship between the EDLOS and the neurologic outcome at 28 days in out-of-hospital cardiac arrest (OHCA) patients.

Méthode : We conducted a retrospective analysis of prospectively collected data from OHCA patients who achieved the return of spontaneous circulation (ROSC) in the EDs of three urban tertiary teaching hospitals from December 2013 to October 2020. Patients were divided into four groups according to the EDLOS, according to the quartile distribution: EDLOS <107 min, EDLOS 107-176 min, EDLOS 176-275 min, and EDLOS ≥275 min. Comparisons of outcomes among the groups and multivariable logistic regression analysis were performed.

Résultats : A total of 807 patients were included in the analysis. The proportions of patients with a good neurologic outcome at 28 days in the groups with EDLOS <107 min, EDLOS 107-176 min, EDLOS 176-275 min, and EDLOS ≥275 min were 37.0%, 29.8%, 26.9, and 20.4%, respectively (p < 0.001). In the multivariable analysis, the odds ratios for a poor neurologic outcome at 28 days in the groups with EDLOS 107-176 min, EDLOS 176-275 min, and EDLOS ≥275 min compared with the group with EDLOS <107 min were 1.19 (95% CI, 0.67-2.13), 1.73 (95% CI, 0.95-3.21), and 1.91 (95% CI, 1.03-3.57), respectively.

Conclusion : An EDLOS longer than 275 min after the ROSC was independently associated with a poor neurologic outcome at 28 days.

Conclusion (proposition de traduction) : Une durée de séjour aux urgences supérieure à 275 minutes (près de 5 heures) après le retour de la circulation spontanée était indépendamment associée à un mauvais pronostic neurologique à 28 jours.

Prehospital, post-ROSC blood pressure and associated neurologic outcome.
Lacocque J, Siegel L, Sporer KA. | Am J Emerg Med. 2021 Nov;49:195-199
DOI: https://doi.org/10.1016/j.ajem.2021.05.073
Keywords: Age factors; Body temperature; Cardiopulmonary resuscitation; Cardiotonic agents/therapeutic use; Comorbidity; Databases; Emergency medical services/EMS; Factual; Heart arrest/mortality; Heart arrest/therapy; Hemodynamic goals; Humans; Hypotension/mortality; Hypothermia; Induced/methods*; Out-of-hospital cardiac arrest/complications; Out-of-hospital cardiac arrest/mortality; Out-of-hospital cardiac arrest/therapy*; Ventricular fibrillation/etiology.

Research article

Introduction : To investigate the relationship between hypotension and neurologic outcome in adults with return of spontaneous circulation after out-of-hospital cardiac arrest.

Méthode : Blood pressure and medication data were extracted from adult patients who had ROSC after OHCA in Alameda County and matched with neurologic outcome using the CARES database from January 1, 2018 through July 1, 2019. We used univariate logistic regression with p ≤ 0.2 followed by multivariate logistic regression and reported an odds ratio with 95% confidence intervals.

Résultats : Among the 781 adult patients who had ROSC after OHCA, 107 (13.7%) were noted to be hypotensive and 61 (57% of the hypotensive group) received vasopressors. Patients with a final prehospital blood pressure recording of <90 mmHg were more likely to have a poor neurologic outcome (adjusted odds ratio 2.13, adj p = 0.048). About twice as many patients who were not hypotensive had a good neurologic outcome compared to hypotensive patients who had a good neurologic outcome (23% to 10.3%). Additionally, patients who were hypotensive and did not receive vasopressors had a similar neurologic outcome compared to patients who did receive vasopressors.

Conclusion : Prehospital post-ROSC hypotension was associated with worse neurologic outcome and giving hypotensive patients vasopressors may not improve neurologic outcome in the prehospital setting.

Conclusion (proposition de traduction) : L'hypotension en préhospitalière après un retour à une circulation cardiaque spontanée (RACS) a été associée à de moins bons résultats neurologiques et l'administration de vasopresseurs aux patients hypotendus peut ne pas améliorer les résultats neurologiques en milieu préhospitalier.

Predictors of intubation in COVID-19 patients undergoing awake proning in the emergency department.
Downing J, Cardona S, Alfalasi R, Shadman S, Dhahri A, Paudel R, Buchongo P, Schwartz B, Tran QK. | Am J Emerg Med. 2021 Nov;49:276-286
DOI: https://doi.org/10.1016/j.ajem.2021.06.010  | Télécharger l'article au format  
Keywords: Awake proning; COVID-19; Coronavirus; Intubation; Mortality; Prone positioning.

Research article

Introduction : Awake prone positioning (PP) has been used to avoid intubations in hypoxic COVID-19 patients, but there is limited evidence regarding its efficacy. Moreover, clinicians have little information to identify patients at high risk of intubation despite awake PP. We sought to assess the intubation rate among patients treated with awake PP in our Emergency Department (ED) and identify predictors of need for intubation.

Méthode : We conducted a multicenter retrospective cohort study of adult patients admitted for known or suspected COVID-19 who were treated with awake PP in the ED. We excluded patients intubated in the ED. Our primary outcome was prevalence of intubation during initial hospitalization. Other outcomes were intubation within 48 h of admission and mortality. We performed classification and regression tree analysis to identify the variables most likely to predict the need for intubation.

Résultats : We included 97 patients; 44% required intubation and 21% were intubated within 48 h of admission. Respiratory oxygenation (ROX) index and P/F (partial pressure of oxygen / fraction of inspired oxygen) ratio measured 24 h after admission were the variables most likely to predict need for intubation (area under the receiver operating characteristic curve = 0.82).

Conclusion : Among COVID-19 patients treated with awake PP in the ED prior to admission, ROX index and P/F ratio, particularly 24 h after admission, may be useful tools in identifying patients at high risk of intubation.

Conclusion (proposition de traduction) : Parmi les patients COVID-19 traités en décubitus ventral sans sédation aux urgences avant l'admission, l'index ROX et le rapport P/F, en particulier 24 h après l'admission, peuvent être des outils utiles pour identifier les patients à haut risque d'intubation.

Commentaire : Rappels :
• L'index ROX permet de prédire le succès ou l'échec d'un traitement de la détresse respiratoire aiguë par haut débit nasal (type Optiflow) dans le cadre d'une pneumopathie Covid-19. Un index ROX ≥ 4,88 à h2, h6 ou h12 du traitement est prédictif d'un succès du traitement par haut débit nasal. Un index ROX ≤ 2,85 à h2, 3,47 à h6 ou 3,85 à h12 est prédictif d'un échec du traitement par haut débit nasal et d'une nécessité d'intubation. Retrouvez un calculateur en ligne sur : ROX Index   par MDCalc.
• Le rapport PaO₂/FiO₂ ou P/F permet de caractériser le degré d'hypoxémie, c'est-à-dire la sévérité de l’atteinte clinique. Il est habituel de classer les SDRA en léger (300 < P/F < 200 mmHg), modéré (200 < P/F < 100 mmHg) ou sévère (P/F < 100 mmHg).

Sedation - Effects of disorders of abuse on therapeutic efficacy (SEDATE): A retrospective cohort study.
Albala L, Loesche MA, Hayes BD, McEvoy DS, Filbin M, Dutta S, Eyre AJ. | Am J Emerg Med. 2021 Nov;49:294-299
DOI: https://doi.org/10.1016/j.ajem.2021.06.023
Keywords: Alcohol use disorder; Analgesia; Conscious sedation; Opioid use disorder; Orthopedic manipulation; Sedation.

Research article

Introduction : The impact of alcohol or opioid use disorders on medication dosing for procedural sedation in the emergency department (ED) is unclear, as most of the literature is from gastrointestinal endoscopy. Exploring how these patient factors affect sedative and analgesic medications may inform more nuanced sedation strategies in the emergency department.

Méthode : This was a retrospective chart-review cohort study across five EDs from 2015 to 2020. Included were adult patients who underwent procedural sedation in the ED, categorized into three a priori groups: alcohol use disorder (AUD), opioid use disorder (OUD), and individuals with neither (non-SUD). Wilcoxon test was used to compare the time-averaged dose of agents between groups. Logistic regression was used to model multi-agent sedations. The propofol time-averaged dose was the primary outcome. Secondary outcomes included other agents, sedation duration, and switching to other agents.

Résultats : 2725 sedations were included in the analysis. 59 patients had a history of AUD, and 40 had a history of OUD. Time-averaged doses of medications did not differ significantly between AUD and non-SUD patients. Likewise, patients with OUD did not receive different doses of medications compared to non-SUD. The propofol doses for non-SUD, AUD, and OUD were 0.033 IQR 0.04; 0.042 IQR 0.05; and 0.058 IQR 0.04 mg/kg*min, respectively. Sedation duration was not different across groups. Having AUD or OUD is not associated with increased odds of requiring multiple sedative agents.

Conclusion : Although sedation in patients with AUD or OUD may be associated with significant case bias, these patient factors did not significantly alter outcomes compared to the general population. This study suggests there is no evidence to proactively adjust medication strategy in ED patients with AUD or OUD.

Conclusion (proposition de traduction) : Bien que la sédation chez les patients souffrant de troubles liés à la consommation d'alcool ou d'opioïdes puisse être associée à un biais significatif des cas, ces facteurs liés aux patients n'ont pas modifié de manière significative les résultats par rapport à la population générale. Cette étude suggère qu'il n'y a aucune preuve pour ajuster de manière proactive la stratégie médicamenteuse chez les patients aux urgences souffrant d'un trouble lié à la consommation d'alcool ou d'un trouble lié à l'utilisation d'opioïdes.

Screening performance of the chest X-ray in adult blunt trauma evaluation: Is it effective and what does it miss?.
Dillon DG, Rodriguez RM. | Am J Emerg Med. 2021 Nov;49:310-314
DOI: https://doi.org/10.1016/j.ajem.2021.06.034
Keywords: Blunt trauma; Chest-xray; Screening.

Research article

Introduction : Although chest x-ray (CXR) is often used as a screening tool for thoracic injury in adult blunt trauma assessment, its screening performance is unclear. Using chest CT as the referent standard, we sought to determine the screening performance of CXR for injury.

Méthode : We analyzed data from the NEXUS Chest CT study, in which we prospectively enrolled blunt trauma patients older than 14 years who received chest imaging as part of their evaluation at nine level I trauma centers. For this analysis, we included patients who had both CXR and chest CT. We used CT as the referent standard and categorized injuries as clinically major or minor according to an a priori expert panel classification.

Résultats : Of 11,477 patients enrolled, 4501 had both CXR and chest CT; 1496 (33.2%) were found to have injury, of which 256 (17%) were classified as major injury. CXR missed injuries in 818 patients (54.7%), of which 63 (7.7%) were classified as major injuries. For injuries of major clinical significance, CXR had a sensitivity of 75.4% (95% confidence interval [CI] 69.6-80.4%), specificity of 86.2% (95% CI 85.1-87.2%), negative predictive value of 98.3 (95%CI 97.9-98.6%), and positive predictive value of 24.7 (95%CI 22.9-26.7%). For any injury CXR had a sensitivity of 45.3% (95% CI 42.8-47.9%), specificity of 96.6% (95% CI 95.9-97.2%), negative predictive value of 78% (95% CI 77.2-78.8%), and positive predictive value of 86.9% (95% CI 84.5-89.0%). The most common missed major injuries were pneumothorax (30/185; 16.2%), spinal fractures (19/39; 48.7%), and hemothorax (8/70; 11.4%). The most common missed minor injuries were rib fractures (381/836; 45.6%), pulmonary contusion (203/462; 43.9%), and sternal fractures (153/229; 66.8%).

Conclusion : When used alone, without other trauma screening criteria, CXR has poor screening performance for blunt thoracic injury.

Conclusion (proposition de traduction) : Lorsqu'elle est utilisée seule, sans autres critères de dépistage des traumatismes, la radiographie pulmonaire a de faibles performances de dépistage des lésions thoraciques traumatiques.

eFAST exam errors at a level 1 trauma center: A retrospective cohort study.
Khosravian K, Boniface K, Dearing E, Drake A, Ogle K, Pyle M, Frasure SE. | Am J Emerg Med. 2021 Nov;49:393-398
DOI: https://doi.org/10.1016/j.ajem.2021.07.036
Keywords: Aucun

Research article

Introduction : Extended Focused Assessment with Sonography for Trauma (eFAST) ultrasound exams are central to the care of the unstable trauma patient. We examined six years of eFAST quality assurance data to identify the most common reasons for false positive and false negative eFAST exams.

Méthode : This was an observational, retrospective cohort study of trauma activation patients evaluated in an urban, academic Level 1 trauma center. All eFAST exams that were identified as false positive or false negative exams compared with computed tomography (CT) imaging were included.

Résultats : 4860 eFAST exams were performed on trauma patients. 1450 (29.8%) were undocumented, technically limited, or incomplete (missing images). Of the 3410 remaining exams, 180 (5.27%) were true positive and 3128 (91.7%) were true negative. 27 (0.79%) exams were identified as false positive and 75 (2.19%) were identified as false negative. Of the false positive scans, 7 had no CT scan and 8 had correct real-time trauma paper documentation of eFAST exam results when compared to CT and were excluded, leaving 12 false positive scans. Of the false negative scans, 11 were excluded for concordant documentation in real-time trauma room paper documentation, 20 were excluded for no CT scan, and 2 were excluded as incomplete, leaving 42 false negative scans. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam were the most common source of errors.

Conclusion : The eFAST exams in trauma activation patients are highly accurate. Unfortunately poor documentation and technically limited/incomplete studies represent 29.8% of our eFAST exams. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam are the most common source of errors.

Conclusion (proposition de traduction) : Les examens eFAST chez les patients traumatisés sont très précis. Malheureusement, une documentation insuffisante et des examens techniquement limités/incomplets représentent 29,8 % de nos examens eFAST. La présence de liquide pelvien, le signe à double ligne, le coussinet de graisse péricardique et la partie thoracique de l’examen eFAST sont les sources d’erreurs les plus courantes.

Emergency medicine updates: Anaphylaxis.
Long B, Gottlieb M. | Am J Emerg Med. 2021 Nov;49:35-39
DOI: https://doi.org/10.1016/j.ajem.2021.05.006
Keywords: Allergy; Anaphylaxis; Epinephrine; Evidence-based medicine.

Review article

Introduction : Anaphylaxis is a potentially deadly condition that requires emergent therapy. While frequently treated in the emergency department (ED), recent evidence updates may improve the diagnosis and management of this condition.

Méthode : This paper evaluates key evidence-based updates concerning the diagnosis and management of anaphylaxis for the emergency clinician.

Résultats : The presentation of anaphylaxis can vary. Current diagnostic criteria can be helpful when evaluating patients for anaphylaxis, though multiple criteria exist. While the most common causes of anaphylaxis include medications, insect venom, and foods, recent literature has identified an IgE antibody response to mammalian galactose alpha-1,3-galactose, known as alpha-gal anaphylaxis. Epinephrine is the first-line therapy and is given in doses of 0.01 mg/kg (up to 0.5 mg in adults) intramuscularly (IM) in the anterolateral thigh. Intravenous (IV) epinephrine administration is recommended in patients refractory to IM epinephrine and IV fluids, or those with cardiovascular collapse. Antihistamines and glucocorticoids should not delay administration of epinephrine and do not demonstrate a significant reduction in risk of biphasic reactions. Biphasic reactions may affect 1-7% of patients with anaphylaxis. Risk factors for biphasic reaction include severe initial presentation and repeated doses of epinephrine. Disposition of patients with anaphylaxis requires consideration of several factors.

Conclusion : Emergency clinicians must be aware of current updates in the evaluation and management of this disease.

Conclusion (proposition de traduction) : Les urgentistes doivent être au courant des mises à jour dans l'évaluation et la gestion de cette maladie.

Commentaire : Prise en charge de l’anaphylaxie en médecine d’urgence. Recommandations de la Société française de médecine d’urgence (SFMU) en partenariat avec la Société française d’allergologie (SFA) et le Groupe francophone de réanimation et d’urgences pédiatriques (GFRUP), et le soutien de la Société pédiatrique de pneumologie et d’allergologie (SP2A). Ann. Fr. Med. Urgence (2016) 6:342-364  .

Murmurs other than the early diastolic murmur in aortic dissection.
Jolobe OMP | Am J Emerg Med. 2021 Nov;49:133-136
DOI: https://doi.org/10.1016/j.ajem.2021.05.041
Keywords: Aortic; Dissection; Murmurs; Pretest; Probability; Systolic.

Review article

Introduction : The purpose of this review is to draw attention to the presence and significance of murmurs other than the murmur of aortic regurgitation, in patients with aortic dissection.

Méthode : For that purpose, a literature search was conducted using Pubmed and Googlescholar. The search terms were "dissecting aneurysm of the aorta", "systolic murmurs", "ejection systolic murmurs", "holosystolic" murmurs, "continuous murmurs", and "Austin-Flint" murmur.

Résultats : Murmurs other than the murmur of aortic regurgitation, which were associated with aortic dissection, fell into the categories of systolic murmurs, some of which were holosystolic, and continuous murmurs, the latter attributable to fistulae between the dissecting aneurysm and the left atrium, right atrium, and the pulmonary artery, respectively. Mid-diastolic murmurs were also identified, and these typically occurred in association with both the systolic and the early diastolic murmurs. Among patients with systolic murmurs clinical features which enhanced the pre-test probability of aortic dissection included back pain, stroke, paraplegia, unilateral absence of pulses, interarm differences in blood pressure, hypertension, shock, bicuspid aortic valve, aortic coarctation, Turner's syndrome, and high D-dimer levels, respectively.

Conclusion : In the absence of the murmur of aortic regurgitation timely diagnosis of aortic dissection could be expedited by increased attention to parameters which enhance pretest probability of aortic dissection. That logic would apply even if the only murmurs which were elicited were systolic murmurs.

Conclusion (proposition de traduction) : En l'absence de souffle de régurgitation aortique, le diagnostic rapide de la dissection aortique pourrait être accéléré par une attention accrue aux paramètres qui améliorent la probabilité de pré-test de dissection aortique. Cette logique s'appliquerait même si les seuls souffles qui ont été retrouvés étaient des souffles systoliques.

Commentaire : Le souffle diastolique au foyer aortique est évocateur d’une insuffisance de la valve aortique (insuffisance aortique non documentée) et peut être entendu en présence d’une dissection aortique. Ce souffle est doux, aspiratif, mieux perçu en position assise, penché en avant, en expiration, au 3^e-4^e espace intercostal, le long du bord gauche du sternum. Le souffle est parfois mieux perçu au bord droit sternal. Il est perçu chez environ 50 % des patients qui ont une dissection proximale.

Differential diagnosis of the association of gastrointestinal symptoms and ST segment elevation, in the absence of chest pain.
Jolobe OMP | Am J Emerg Med. 2021 Nov;49:137-141
DOI: https://doi.org/10.1016/j.ajem.2021.05.067
Keywords: Emergency; Gastroenterological; STEMI; Surgical; Symptoms;; Takotsubo.

Review article

Introduction : This is a review of the underlying causes of the association of ST segment elevation and gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and anorexia, in patients who do not have chest pain.

Méthode : The review was based on anecdotal reports in Googlescholar and Pubmed using the search terms, abdominal pain, nausea, vomiting, anorexia, ST elevation, myocardial infarction, and Takotsubo cardiomyopathy.

Résultats : Those patients who did not have acute myocardial infarction as the cause of the association of ST segment elevation and gastrointestinal symptoms were compared with counterparts with similar symptoms who had well authenticated acute myocardial infarction or Takotsubo cardiomyopathy as the underlying cause of ST segment elevation. The underlying causes of gastrointestinal symptoms which could be associated with ST segment elevation in the absence of either acute myocardial infarction or Takotsubo cardiomyopathy comprised pneumonia, pulmonary embolism, perforated gastric ulcer, intestinal obstruction, acute appendicitis, acute pancreatitis, acute cholecystitis, pheochromocytoma, bacterial meningitis, diabetic keto acidosis, and cannabis abuse. However, each of those disorders could also coexist either with acute myocardial infarction or with Takotsubo cardiomyopathy. The coexistence of ST segment elevation and gastrointestinal symptoms(without chest pain) was also documented in patients with esophageal perforation, mesenteric ischaemia, aortic dissection, Kounis syndrome, and in electrolyte disorders.

Conclusion : In the context of presentation with gastroenterological symptoms but without concurrent chest pain, echocardiography appeared to be useful in distinguishing between "pseudo" myocardial infarction characterised by ST segment elevation in the absence of cardiac disease vs ST segment elevation attributable either to acute myocardial infarction or to Takotsubo cardiomyopathy.

Conclusion (proposition de traduction) : Dans le cadre d'une présentation avec symptômes gastro-entérologiques mais sans douleur thoracique concomitante, l'échocardiographie s'est avérée utile pour distinguer un « pseudo » infarctus du myocarde caractérisé par une élévation du segment ST en l'absence de maladie cardiaque vs une élévation du segment ST attribuable soit à un infarctus aigu du myocarde, soit à une cardiomyopathie de type Takotsubo.

Multisystem inflammatory syndrome in children with COVID-19.
Gottlieb M, Bridwell R, Ravera J, Long B. | Am J Emerg Med. 2021 Nov;49:148-152
DOI: https://doi.org/10.1016/j.ajem.2021.05.076  | Télécharger l'article au format  
Keywords: COVID-19; MIS-C; Pediatrics.

Review article

Introduction : Multisystem inflammatory syndrome in children (MIS-C) is a dangerous pediatric complication of COVID-19.

Méthode : The purpose of this review article is to provide a summary of the diagnosis and management of MIS-C with a focus on management in the acute care setting.

Discussion : MIS-C is an inflammatory syndrome which can affect nearly any organ system. The most common symptoms are fever and gastrointestinal symptoms, though neurologic and dermatologic findings are also well-described. The diagnosis includes a combination of clinical and laboratory testing. Patients with MIS-C will often have elevated inflammatory markers and may have an abnormal electrocardiogram or echocardiogram. Initial treatment involves resuscitation with careful assessment for cardiac versus vasodilatory shock using point-of-care ultrasound. Treatment should include intravenous immunoglobulin, anticoagulation, and consideration of corticosteroids. Interleukin-1 and/or interleukin-6 blockade may be considered for refractory cases. Aspirin is recommended if there is thrombocytosis or Kawasaki disease-like features on echocardiogram. Patients will generally require admission to an intensive care unit.

Conclusion : MIS-C is a condition associated with morbidity and mortality that is increasingly recognized as a potential complication in pediatric patients with COVID-19. It is important for emergency clinicians to know how to diagnose and treat this disorder.

Conclusion (proposition de traduction) : Le MIS-C est une affection associée à la morbidité et à la mortalité qui est de plus en plus reconnue comme une complication potentielle chez les patients pédiatriques atteints de COVID-19. Il est important que les cliniciens d'urgence sachent comment diagnostiquer et traiter ce trouble.

Commentaire : Voir sur le PIMS (syndrome inflammatoire multisystémique pédiatrique ou MIS-C) :
• HAS. Réponse rapide dans le cadre de la COVID-19 : Repérage et prise en charge du syndrome inflammatoire multi-systémique pédiatrique (PIMS) post-infectieux  . Validée par le Collège le 1er juillet 2021.
• Kortz TB, Connolly E, Cohen CL, Cook RE, Jonas JA, Lipnick MS, Kissoon N. Diagnosis and Acute Management of COVID-19 and Multisystem Inflammatory Syndrome in Children. Pediatr Emerg Care. 2021 Oct 1;37(10):519-525  .
• Zhao Y, Patel J, Huang Y, Yin L, Tang L. Cardiac markers of multisystem inflammatory syndrome in children (MIS-C) in COVID-19 patients: A meta-analysis. Am J Emerg Med. 2021 Nov;49:62-70  .

The emergency medicine management of clavicle fractures.
Serpico M, Tomberg S. | Am J Emerg Med. 2021 Nov;49:315-325
DOI: https://doi.org/10.1016/j.ajem.2021.06.011
Keywords: Clavicle; Midshaft; Pediatric; Splinting; Surgery; Ultrasound.

Review article

Introduction : Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

Méthode : To provide an evidence-based review of clavicle fracture management in the emergency department.

Discussion : Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

Conclusion : When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

Conclusion (proposition de traduction) : Lors de la rencontre d'un patient avec une fracture de la clavicule au service des urgences, le schéma de fracture aidera à déterminer si une consultation urgente ou une référence urgente est indiquée. La plupart des patients peuvent sortir en toute sécurité grâce à l'immobilisation du harnais et un suivi ambulatoire approprié.

High flow nasal cannula for adult acute hypoxemic respiratory failure in the ED setting.
Long B, Liang SY, Lentz S. | Am J Emerg Med. 2021 Nov;49:352-359
DOI: https://doi.org/10.1016/j.ajem.2021.06.074  | Télécharger l'article au format  
Keywords: Acute hypoxemic respiratory failure; COVID-19; High-flow nasal cannula; Noninvasive ventilation.

Review article

Introduction : High flow nasal cannula (HFNC) is a noninvasive ventilation (NIV) system that has demonstrated promise in the emergency department (ED) setting.

Méthode : This narrative review evaluates the utility of HFNC in adult patients with acute hypoxemic respiratory failure in the ED setting.

Discussion : HFNC provides warm (37 °C), humidified (100% relative humidity) oxygen at high flows with a reliable fraction of inspired oxygen (FiO2). HFNC can improve oxygenation, reduce airway resistance, provide humidified flow that can flush anatomical dead space, and provide a low amount of positive end expiratory pressure. Recent literature has demonstrated efficacy in acute hypoxemic respiratory failure, including pneumonia, acute respiratory distress syndrome (ARDS), coronavirus disease 2019 (COVID-19), interstitial lung disease, immunocompromised states, the peri-intubation state, and palliative care, with reduced need for intubation, length of stay, and mortality in some of these conditions. Individual patient factors play an important role in infection control risks with respect to the use of HFNC in patients with COVID-19. Appropriate personal protective equipment, adherence to hand hygiene, surgical mask placement over the HFNC device, and environmental controls promoting adequate room ventilation are the foundation for protecting healthcare personnel. Frequent reassessment of the patient placed on HFNC is necessary; those with severe end organ dysfunction, thoracoabdominal asynchrony, significantly increased respiratory rate, poor oxygenation despite HFNC, and tachycardia are at increased risk of HFNC failure and need for further intervention.

Conclusion : HFNC demonstrates promise in several conditions requiring respiratory support. Further randomized trials are needed in the ED setting.

Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit (Optiflow) est prometteuse dans plusieurs conditions nécessitant une assistance respiratoire. D'autres essais randomisés sont nécessaires dans le cadre du service d'urgence.

Incidence of Traumatic Delayed Intracranial Hemorrhage Among Patients Using Direct Oral Anticoagulants.
Valiuddin H, Calice M, Alam A, Millard J, Boehm K, Valiuddin Y, Laforest D, Ricardi R, Kaakaji R, Keyes D. | J Emerg Med. 2021 Nov;61(5):489-498
DOI: https://doi.org/10.1016/j.jemermed.2021.04.017  | Télécharger l'article au format  
Keywords: direct oral anticoagulant; head injury; trauma.

Research article

Introduction : Emergency department visits due to head injury in the United States have increased significantly over the past decade, and parallel the increasing use of direct oral anticoagulants (DOACs).
titre_en_plusx: We investigated the incidence of delayed intracranial hemorrhage (DICH) in patients with head injury who were taking DOACs.

Méthode : We conducted a single-center retrospective study at a level II trauma center. All patients with head injury and using DOACs with an initial negative head computed tomography (HCT) scan from March 1, 2014 to December 31, 2017 were included. DICH was identified as a positive finding on repeat HCT performed within 24 h. Each case of DICH underwent blinded review by two additional neuroradiologists. Demographic data were collected; independent t-tests were used to compare group means and linear regression for variable correlations.

Résultats : Two hundred and eighty-seven patients with mean age of 80 years (interquartile range 14 years) met inclusion criteria. Repeat HCT was performed in 224 study participants (78%). Five (1.7%) resulted in DICH, three of which might have been present on initial HCT, with an incidence rate ranging from 0.7% to 1.7%. Only two initial HCTs were read as negative by all three neuroradiologists; 60% disagreed on the initial read. Independent t-test procedures showed an association between DICH and higher Injury Severity Score (ISS).

Conclusion : We found a DICH incidence rate of 0.7-1.7%. ISS was statistically significant between the two groups. It is possible that in patients with a subjective estimation of low injury severity, a low mechanism of injury and reasonable outpatient follow-up, patients can be discharged home with standard head injury precautions and no repeat HCT, but further prospective studies are needed.

Conclusion (proposition de traduction) : Nous avons trouvé un taux d'incidence d'hémorragie intracrânienne retardée de 0,7 à 1,7 %. Le score de gravité des blessures était statistiquement significatif entre les deux groupes. Il est possible que chez les patients présentant une estimation subjective de la faible gravité des lésions, un mécanisme de lésion peu important et un suivi ambulatoire raisonnable, les patients puissent être renvoyés chez eux avec les précautions habituelles en cas de traumatisme crânien et sans tomodensitométrie crânienne répétée, mais d’autres études prospectives sont nécessaires.

Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department.
Carius BM, Long B, Gottlieb M. | J Emerg Med. 2021 Nov;61(5):499-506
DOI: https://doi.org/10.1016/j.jemermed.2021.07.038  | Télécharger l'article au format  
Keywords: dislocation; neurovascular; orthopedic; shoulder, orthopedics, sternoclavicular dislocation; sternoclavicular dislocation.

Clinical Review

Introduction : Sternoclavicular dislocation (SCD) is a rare injury but can result in hemodynamic and neurovascular complications. Emergency clinicians play an integral role in the evaluation and management of these injuries.

Méthode : This article provides a narrative review of the diagnosis and management of SCD for the emergency clinician.

Discussion : SCD is an infrequent injury and may be misdiagnosed in the emergency department (ED). SCDs may be anterior or posterior. Although anterior SCD is more common, posterior SCD is more dangerous with a risk of pneumothorax or injury to the subclavian artery or vein, esophagus, trachea, or brachial plexus. Most patients present with shoulder and clavicular pain and decreased active range of motion. Clinicians should assess the sternoclavicular joint in patients with shoulder symptoms and consider SCD in traumatic shoulder injuries. Plain radiographs might not identify SCD, and computed tomography is recommended for both the diagnosis of SCD and evaluation of complications. Anterior SCD can be managed in the ED with analgesia, sedation, and closed reduction. If patients with posterior SCDs display airway, hemodynamic, or vascular compromise, emergent reduction is recommended with cardiothoracic consultation. Any complicated anterior SCD, including those with fracture, and all posterior SCDs require emergent orthopedic consultation, with considerations for cardiothoracic or vascular surgery notification.

Conclusion : SCD is an uncommon orthopedic injury but may result in patient morbidity or mortality. Knowledge of SCDs can optimize emergency clinician evaluation and management of this condition.

Conclusion (proposition de traduction) : La luxation sternoclaviculaire est une lésion orthopédique rare mais peut entraîner une morbidité ou une mortalité chez les patients. La connaissance des luxations sternoclaviculaires peut optimiser l'évaluation et la prise en charge par l'urgentiste de cette affection.

Evaluation of Depilatory Agents in the Treatment of Hair-Thread Tourniquet Syndrome.
Kudzinskas A, Reed A, Mahdi M, Tyler M. | J Emerg Med. 2021 Nov;61(5):507-516
DOI: https://doi.org/10.1016/j.jemermed.2021.07.013  | Télécharger l'article au format  
Keywords: Hair-thread tourniquet syndrome; Pediatrics; Plastic surgery; Trauma; Wound management.

Clinical Review

Introduction : Hair-thread tourniquet syndrome (HTTS) is the constriction of an appendage or tissue by a hair thread, which can cause ischemia and necrosis of distal tissues. Depilatory agents have the potential to release the hair tourniquet without exposing the patient to the risks of surgery.
Objectives: This review aims to evaluate the effectiveness, benefits, complications, and contraindications of depilatory agents in HTTS.

Méthode : Relevant terms to HTTS and depilatory agents were used to search for articles on MEDLINE and EMBASE databases using the NHS Healthcare Databases Advanced Search engine.

Résultats : In total, 19 of the 295 articles identified in the primary search were included in the final review. Articles described the benefits of depilatory agents as painless, well tolerated, and non-invasive. Contraindications described include use on mucosal membranes, non-hair tourniquet, and allergy. Sixty-four percent (n = 55) of patients had resolution of their HTTS after one or two cycles of depilatory agent treatment.

Conclusion : The use of depilatory agents has multiple potential benefits. The authors propose a treatment algorithm for the use of depilatory agents in HTTS and recommend that all acute centers should store and train staff in their use.

Conclusion (proposition de traduction) : L'utilisation d'agents dépilatoires présente de multiples avantages potentiels. Les auteurs proposent un algorithme de traitement pour l'utilisation d'agents épilatoires dans le syndrome du cheveu étrangleur et recommandent que tous les centres de soins aigus stockent et forment le personnel à leur utilisation.

Commentaire :  Algorithme de traitement du syndrome du cheveu étrangleur ou du tourniquet


Appendices concernés = orteils (formes fréquentes +++), doigts, OGE (pénis, vulve, petites-grandes lèvres, clitoris), rarement le cou, uvule et langue.
Favorisé par chute de cheveux maternels (telogen effluvium) en post-partum (max 2 à 6 mois) 90 % des femmes.

Claudet I, Pasian N, Maréchal C, Salanne S, Debuisson C, Grouteau E. Syndrome du tourniquet ou cheveu étrangleur [Hair-thread tourniquet syndrome]. Arch Pediatr. 2010 May;17(5):474-9  . French.

Traumatic Pneumothorax: A Review of Current Diagnostic Practices And Evolving Management.
Tran J, Haussner W, Shah K. | J Emerg Med. 2021 Nov;61(5):517-528
DOI: https://doi.org/10.1016/j.jemermed.2021.07.006  | Télécharger l'article au format  
Keywords: CT imaging; pneumothorax; thoracostomy; trauma; ultrasonography.

Clinical Review

Introduction : Pneumothorax (PTX) is defined as air in the pleural space and is classified as spontaneous or nonspontaneous (traumatic). Traumatic PTX is a common pathology identified in the emergency department. Traditional management calls for chest x-ray (CXR) diagnosis and large-bore tube thoracostomy, although recent literature supports the efficacy of lung ultrasound (US) and more conservative approaches. There is a paucity of cohesive literature on how to best manage the traumatic PTX.

Méthode : This review aimed to describe current practices and future directions of traumatic PTX management.

Discussion : Lung US has proven to be a potentially more useful tool in the detection of PTX in the trauma bay compared with CXR, and has the potential to become the new gold standard for diagnosing traumatic PTX. Computed tomography remains the ultimate gold standard, although in the setting of trauma, its utility lies more in confirming the presence and measuring the size of a PTX. The traditional mantra calling for large-bore chest tubes as first-line approaches to traumatic PTX is challenged by recent literature demonstrating pigtail catheters as equally efficacious alternatives. In patients with small or occult PTXs, even observation may be reasonable.

Conclusion : Modern management of the traumatic PTX is shifting toward use of US for diagnosis and more conservative management practices (smaller catheters or observation). Ultimately, this shift is favorable in reducing length of stay, development of complications, and pain in the trauma patient.

Conclusion (proposition de traduction) : La gestion moderne du pneumothorax traumatique évolue vers l'utilisation de l'échographie pour le diagnostic et des pratiques de prise en charge plus conservatrices (cathéters plus petits ou observation). En fin de compte, ce changement est favorable pour réduire la durée du séjour, le développement de complications et la douleur chez le patient traumatisé.

Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms.
Couturaud F, Bertoletti L, Pastre J, Roy PM, Le Mao R, Gagnadoux F, Paleiron N, Schmidt J, Sanchez O, De Magalhaes E, Kamara M, Hoffmann C, Bressollette L, Nonent M, Tromeur C, Salaun PY, Barillot S, Gatineau F, Mismetti P, Girard P, Lacut K, Lemarié CA, Meyer G, Leroyer C; PEP Investigators. | JAMA. 2021 Jan 5;325(1):59-68
DOI: https://doi.org/10.1001/jama.2020.23567  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain.
Objective: To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms.

Méthode : Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017.
Exposures : Acutely worsening respiratory symptoms in patients with COPD.
Main outcomes and measures: The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not.

Résultats : Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P < .001). The prevalence of venous thromboembolism was 11.7% (95% CI, 8.6%-15.9%) among patients in whom pulmonary embolism was suspected (n = 299) and was 4.3% (95% CI, 2.8%-6.6%) among those in whom pulmonary embolism was not suspected (n = 441).

Conclusion : Among patients with chronic obstructive pulmonary disease admitted to the hospital with an acute worsening of respiratory symptoms, pulmonary embolism was detected in 5.9% of patients using a predefined diagnostic algorithm. Further research is needed to understand the possible role of systematic screening for pulmonary embolism in this patient population.

Conclusion (proposition de traduction) : Parmi les patients atteints d'une maladie pulmonaire obstructive chronique admis à l'hôpital avec une aggravation aiguë des symptômes respiratoires, une embolie pulmonaire a été détectée chez 5,9 % des patients à l'aide d'un algorithme de diagnostic prédéfini. Des recherches supplémentaires sont nécessaires pour comprendre le rôle possible du dépistage systématique de l'embolie pulmonaire dans cette population de patients.

The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial.
Kulvatunyou N, Bauman ZM, Zein Edine SB, de Moya M, Krause C, Mukherjee K, Gries L, Tang AL, Joseph B, Rhee P. | J Trauma Acute Care Surg. 2021 Nov 1;91(5):809-813
DOI: https://doi.org/10.1097/ta.0000000000003180
Keywords: Aucun

2021 WTA PODIUM PAPERS

Introduction : The traditional treatment of traumatic hemothorax (HTX) has been an insertion of a large-bore 36- to 40-Fr chest tube. Our previous single-center randomized controlled trial (RCT) had shown that 14-Fr percutaneous catheters (PCs) (pigtail) were equally as effective as chest tube. We performed a multicenter RCT, hypothesizing that PCs are as equally effective as chest tubes in the management of patients with traumatic HTX.

Méthode : We performed a multi-institution prospective RCT comparing 14-Fr PCs with 28- to 32-Fr chest tubes in the management of patients with traumatic HTX from July 2015 to September 2020. We excluded patients who were in extremis and required emergent tube placement and those who refused to participate. The primary outcome was failure rate, defined as a retained HTX requiring a second intervention. Secondary outcomes included daily drainage output, tube days, intensive care unit and hospital length of stay, and insertion perception experience (IPE) score on a scale of 1 to 5 (1, tolerable experience; 5, worst experience). Unpaired Student's t test, χ2, and Wilcoxon rank sum test were used with significance set at p < 0.05.

Résultats : After exclusion, 119 patients participated in the trial, 56 randomized to PCs and 63 to chest tubes. Baseline characteristics between the two groups were similar. The primary outcome, failure rate, was similar between the two groups (11% PCs vs. 13% chest tubes, p = 0.74). All other secondary outcomes were also similar, except PC patients reported lower IPE scores (median, 1: "I can tolerate it"; interquartile range, 1-2) than chest tube patients (median, 3: "It was a bad experience"; interquartile range, 2-5; p < 0.001).

Conclusion : Small caliber 14-Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated.

Conclusion (proposition de traduction) : Les cathéters percutanés de petit calibre 14-Fr sont aussi efficaces que les drains thoraciques de 28 à 32-Fr dans leur capacité à drainer l'hémothorax traumatique sans différence de complications. Les patients ont rapporté de meilleurs scores d'expérience de perception d'insertion avec des cathéters percutanés par rapport aux drains thoraciques, ce qui suggère que les cathéters percutanés sont mieux tolérés.

Ultrasound at the patient's bedside for the diagnosis and prognostication of a renal colic.
Bourcier JE, Gallard E, Redonnet JP, Abillard M, Billaut Q, Fauque L, Jouanolou A, Garnier D. | Ultrasound J. 2021 Nov 22;13(1):45
DOI: https://doi.org/10.1186/s13089-021-00246-2  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : Diagnosing a ureteral colic is sometimes difficult; however, clinicians should not fail to detect a surgical emergency. This is why diagnostic strategies depend on the imaging examinations, especially ultrasound. Prior studies have investigated the accuracy of Point of Care Ultrasound (PoCUS), but there are relatively few. This study aimed to evaluate the performance of the PoCUS in the diagnosis of renal colic. The secondary objective was to evaluate the relationship between the imaging results and the treatment performed.

Méthode : After the clinical evaluation of patients aged > 18 years with suspected ureteral colic, the Emergency Physician (EP) trained in ultrasound performed PoCUS to conclude whether a diagnosis of "renal colic" should be made. A computed tomography (CT) examination was subsequently performed, to determine whether ureteral or bladder lithiasis was present to diagnose a ureteral colic. The patient's management was decided according to the to degree of urinary tract dilatation, presence of perinephric fluid, size, and localization of stones.

Résultats : Of the 12 Eps in our units, seven met the training criteria for the inclusion of patients. A total of 103 patients were analyzed, and the renal colic diagnosis was retained in 85 cases after the CT examination. The accuracy of PoCUS was 91% (86; 95%) for detecting urinary tract dilatation, 83% (76; 90%) for detecting perinephric fluid, and 54% (44; 64%) for detecting lithiasis. Only high urinary tract stones with ≥ 6 mm diameter were surgically managed (p < 0.01). Conversely, distal ureteral stones with a diameter of < 6 mm were managed with medical ambulatory treatment (p < 0.05).

Conclusion : PoCUS is a good diagnostic tool, for renal colic, and could help reduce the requirement for the CT examinations and, hence, reduce induced radiation exposure.

Conclusion (proposition de traduction) : L'échographie au point d'intervention est un bon outil de diagnostic, pour les coliques néphrétiques, et pourrait aider à réduire le besoin d'examens de tomodensitométrie et, par conséquent, à réduire l'exposition aux rayonnements ionisants.

Commentaire :  a- dilatation pyélocalycielle et lithiase proximale, b- dilatation pyélocalycielle, c- liquide périnéphrétique, d- lithiase pelvienne, e- lithiase vésicale et artéfact scintillant en doppler couleur ; et f- lithiase vésicale