Point-of-care echocardiography of the right heart improves acute heart failure risk stratification for low-risk patients: The REED-AHF prospective study.
Harrison NE, Favot MJ, Gowland L, Lenning J, Henry S, Gupta S, Abidov A, Levy P, Ehrman R. | Acad Emerg Med. 2022 Nov;29(11):1306-1319
DOI: https://doi.org/10.1111/acem.14589  | Télécharger l'article au format  
Keywords: cardiology; echocardiography; emergency department; emergency medicine; heart failure; point-of-care ultrasound; risk stratification.

ORIGINAL CONTRIBUTION

Introduction : Validated acute heart failure (AHF) clinical decision instruments (CDI) insufficiently identify low-risk patients meriting consideration of outpatient treatment. While pilot data show that tricuspid annulus plane systolic excursion (TAPSE) is associated with adverse events, no AHF CDI currently incorporates point-of-care echocardiography (POCecho). We evaluated whether TAPSE adds incremental risk stratification value to an existing CDI.

Méthode : Prospectively enrolled patients at two urban-academic EDs had POCechos obtained before or <1 h after first intravenous diuresis, positive pressure ventilation, and/or nitroglycerin. STEMI and cardiogenic shock were excluded. AHF diagnosis was adjudicated by double-blind expert review. TAPSE, with an a priori cutoff of ≥17 mm, was our primary measure. Secondary measures included eight additional right heart and six left heart POCecho parameters. STRATIFY is a validated CDI predicting 30-day death/cardiopulmonary resuscitation, mechanical cardiac support, intubation, new/emergent dialysis, and acute myocardial infarction or coronary revascularization in ED AHF patients. Full (STRATIFY + POCecho variable) and reduced (STRATIFY alone) logistic regression models were fit to calculate adjusted odds ratios (aOR), category-free net reclassification index (NRI_cont), ΔSensitivity (NRI_events), and ΔSpecificity (NRI_nonevents). Random forest assessed variable importance. To benchmark risk prediction to standard of care, ΔSensitivity and ΔSpecificity were evaluated at risk thresholds more conservative/lower than the actual outcome rate in discharged patients.

Résultats : A total of 84/120 enrolled patients met inclusion and diagnostic adjudication criteria. Nineteen percent experiencing the primary outcome had higher STRATIFY scores compared to those event free (233 vs. 212, p = 0.009). Five right heart (TAPSE, TAPSE/PASP, TAPSE/RVDD, RV-FAC, fwRVLS) and no left heart measures improved prediction (p < 0.05) adjusted for STRATIFY. Right heart measures also had higher variable importance. TAPSE ≥ 17 mm plus STRATIFY improved prediction versus STRATIFY alone (aOR 0.24, 95% confidence interval [CI] 0.06-0.91; NRI_cont 0.71, 95% CI 0.22-1.19), and specificity improved by 6%-32% (p < 0.05) at risk thresholds more conservative than the standard-of-care benchmark without missing any additional events.

Conclusion : TAPSE increased detection of low-risk AHF patients, after use of a validated CDI, at risk thresholds more conservative than standard of care.

Conclusion (proposition de traduction) : Mesure du déplacement systolique de l'anneau tricuspide augmente la détection des patients à faible risque souffrant d'insuffisance cardiaque aiguë, après utilisation d'un instrument de décision clinique validé, à des seuils de risque plus bas que la norme de soins.

Effectiveness of Cricoid and Paratracheal Pressures in Occluding the Upper Esophagus Through Induction of Anesthesia and Videolaryngoscopy: A Randomized, Crossover Study.
Kim H, Chang JE, Won D, Lee JM, Kim TK, Kim MJ, Min SW, Hwang JY. | Anesth Analg. 2022 Nov 1;135(5):1064-1072
DOI: https://doi.org/10.1213/ane.0000000000006154  | Télécharger l'article au format  
Keywords: Aucun

Original Clinical Research Report

Introduction : Maneuvers for preventing passive regurgitation of gastric contents are applied to effectively occlude the esophagus throughout rapid sequence induction and intubation. The aim of this randomized, crossover study was to investigate the effectiveness of cricoid and paratracheal pressures in occluding the esophagus through induction of anesthesia and videolaryngoscopy.

Méthode : After the induction of anesthesia in 40 adult patients, the location of the esophageal entrance relative to the glottis and location of the upper esophagus relative to the trachea at the low paratracheal region were assessed using an ultrasonography, and the outer diameter of the esophagus was measured on ultrasound before and during application of cricoid and paratracheal pressures of 30 N. Then, videolaryngoscopy was performed with the application of each pressure. During videolaryngoscopy, location of the esophageal entrance relative to the glottis under cricoid pressure was examined on the screen of videolaryngoscope, and the upper esophagus under paratracheal pressure was evaluated using ultrasound. The occlusion rate of the esophagus, and the best laryngeal view using the percentage of glottic opening scoring system were also assessed during videolaryngsocopy. Esophageal occlusion under each pressure was determined by inserting an esophageal stethoscope into the esophagus. If the esophageal stethoscope could not be advanced into the esophagus under the application of each pressure, the esophagus was regarded to be occluded.

Résultats : During videolaryngoscopy, esophagus was occluded in 40 of 40 (100%) patients with cricoid pressure and 23 of 40 (58%) patients with paratracheal pressure (difference, 42%; 95% confidence interval, 26-58; P < .001). Both cricoid and paratracheal pressures significantly decreased the diameter of the esophagus compared to no intervention in the anesthetized paralyzed state ( P < .001, respectively). Ultrasound revealed that the compressed esophagus by paratracheal pressure in the anesthetized paralyzed state was partially released during videolaryngoscopy in 17 of 40 patients, in whom esophageal occlusion was unsuccessful. The best laryngeal view was not significantly different among the no intervention, cricoid pressure, and paratracheal pressure (77 [29] % vs 79 [30] % vs 76 [31] %, respectively; P = .064).

Conclusion : The occlusion of the upper esophagus defined by inability to pass an esophageal stethoscope was more effective with cricoid pressure than with paratracheal pressure during videolaryngoscopy, although both cricoid and paratracheal pressures reduced the diameter of the esophagus on ultrasound in an anesthetized paralyzed state.

Conclusion (proposition de traduction) : L'occlusion de l'œsophage supérieur définie par l'impossibilité de passer un stéthoscope œsophagien était plus efficace avec la pression cricoïde qu'avec la pression paratrachéale pendant la vidéolaryngoscopie, bien que les pressions cricoïde et paratrachéale aient toutes deux réduit le diamètre de l'œsophage à l'échographie dans un contexte d'anesthésie et de curarisation.

Markarian T | Ann. Fr. Med. Urgence. 2022 Nov;12:375–382
DOI: https://doi.org/10.3166/afmu-2022-0438
Keywords: Emergency care; Acute Kidney Injury; Creatinine; Biomarker

Mise au point

Editorial : L’insuffisance rénale, véritable problème de santé publique, concernerait plus de 82 000 personnes en France. On estime que 5 à 10 % de la population française souffriraient d’une maladie rénale pouvant conduire à une insuffisance rénale avec un taux de mortalité de plus de 10 % par an. À l’inverse de la maladie rénale chronique irréversible, l’insuffisance rénale aiguë est considérée comme un dysfonctionnement transitoire et réversible. Au-delà de l’intérêt de la prévention, le diagnostic précoce de l’insuffisance rénale aiguë permettrait de mettre en place des thérapeutiques adaptées et ciblées afin d’éviter l’évolution vers des lésions rénales irréversibles. Cependant, il demeure un véritable challenge pour le praticien puisque l’on présume que près de 10 % de la population française présenteraient des lésions rénales asymptomatiques. Bien que la définition de l’insuffisance rénale aiguë ait été simplifiée durant ces dernières années, il existe de nombreuses limites. En parallèle, des progrès majeurs ont été réalisés notamment en termes de diagnostic. L’objectif de cette mise au point est de faire un rappel sur l’évolution de l’insuffisance rénale aiguë, les définitions actuelles et de présenter les nouvelles approches diagnostiques en cours de développement.

Conclusion (proposition de traduction) : L’insuffisance rénale aiguë est un véritable problème de santé publique avec un risque d’évolution vers la maladie rénale chronique pourvoyeuse de morbi-mortalité. Son diagnostic précoce, dès l’arrivée dans nos urgences est primordial afin de mettre en oeuvre des thérapeutiques adaptées. Les critères KDIGO sont encore à l’heure actuelle la méthode de référence pour son diagnostic bien que grevés de nombreuses limites. Ainsi, il est fort probable que, dans le futur, l’évolution de nouvelles approches diagnostiques modifie considérablement notre prise en charge.

Commentaire :  Définition et classification de l’insuffisance rénale aiguë (IRA) selon les critères AKI KDIGO
Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179-84  .

Bouzid D, Debray MP, Choquet C,de Montmollin E, Roussel M, Ferré V, Thy M, Le Hingrat Q, Loubet P. | Ann. Fr. Med. Urgence. 2022 Déc;12:383–390
DOI: https://doi.org/10.3166/afmu-2022-0450
Keywords: community-acquired acute pneumonia; respiratory viruses; molecular diagnosis; inflammatory markers; chest CT scan

Mise au point

Editorial : La pandémie actuelle liée à l’émergence du SARSCoV-2 en 2019 a considérablement modifié la perception des médecins de l’impact des virus respiratoires et de leur rôle dans les pneumonies aiguës communautaires (PAC). Alors que plus de 25 % des tableaux de PAC chez l’adulte étaient d’origine virale, les virus respiratoires étaient souvent perçus comme des agents pathogènes peu graves. Devant le défi que représente encore à nos jours la documentation microbiologique d’une PAC, l’instauration d’un traitement empirique par antibiotiques est souvent réalisée aux urgences. La pandémie de COVID-19 a surtout mis en exergue le rôle déterminant de la biologie moléculaire et du scanner thoracique dans l’algorithme diagnostique de la PAC. En effet, un diagnostic rapide et fiable est la clé pour améliorer les mesures de précaution et réduire la prescription inutile d’antibiotiques. Du fait de prises en charges très différentes, il est nécessaire de distinguer l’étiologie virale de la bactérienne d’une PAC.

Conclusion (proposition de traduction) : Le diagnostic de PAC repose donc sur un faisceau d’argu- ments avec à la fois des données cliniques, mais aussi bio- logiques, microbiologiques et radiologiques dont la disponi- bilité reste très variable d’un centre à un autre. La pandémie de Covid-19 et l’essor récent des techniques de biologie moléculaire ont contribué à une prise de conscience de la fréquence des pneumonies d’origine virale et entrainé une modification des prescriptions des tests diagnostiques. En effet, des marqueurs de l’inflammation augmentés ne signi- fient pas systématiquement une PAC d’étiologie bactérienne. Et du fait des faibles performances des hémocultures, de l’antigénurie pneumocoque et de la radiographie de thorax, ainsi que de l’apport limité de la NFS, l’association entre la PCR multiplex sur prélèvement naso-pharyngé, délocalisée aux SU (ou à défaut avec un délai de rendu inférieur à deux heures) et le scanner thoracique rapide paraît être une des approches les plus prometteuses pour le diagnostic d’une PAC aux urgences, avec un effet désormais démontré sur les mesures de précaution. Néanmoins, les contraintes logis- tiques de cette association ainsi que son impact sur la pres- cription d’antibiotiques dans le contexte des SU restent à

Managing Elbow Dislocations.
Gottlieb M | Ann Emerg Med. 2022 Nov;80(5):460-464
DOI: https://doi.org/10.1016/j.annemergmed.2022.04.029
Keywords: Aucun

Trauma

Editorial : Elbow dislocation is one of the most common large-joint dislocations in both adults and children, with an incidence of 5.21 dislocations per 100,000 person-years.1 It occurs across a wide age range but is most common between the ages of 10 and 19 years. The most frequent etiology is related to sports (particularly football, wrestling, basketball, and skating), with the most common mechanism being a fall on an outstretched arm. The majority of elbow dislocations are posterior (ie, olecranon displaced posterior to the humerus) or posterolateral, with only 1.5% being anteriorly displaced (ie, olecranon displaced anterior to the humerus). Fractures are common, occurring in approximately half of the patients, and most commonly involve the coronoid or radial head. Most elbow dislocations can be successfully reduced in the emergency department (ED), although patients may need operative management if there is persistent instability or the inability to reduce at the bedside. Given the frequency with which elbow dislocations can present to the ED, it is important for clinicians to be aware of the approach to the management of these patients. This article is not intended to be a comprehensive review of all the aspects of the evaluation and management of patients with elbow dislocations; instead, this paper seeks to distill key facets of management based on the current literature and years of practice.

Conclusion : Elbow dislocations without evidence of instability or for which the clinician is not able to adequately assess instability can be splinted at 90 degrees with the forearm in a neutral position. Valgus instability is suggestive of medial collateral ligament (also known as the ulnar collateral ligament) injury and would benefit from immobilization with the forearm in supination, whereas varus instability is suggestive of lateral collateral ligament (also known as the radial collateral ligament) injury and would benefit from immobilization with the forearm in pronation.
Elbows with evidence of compartment syndrome or vascular occlusion require orthopedic surgery consultation. Elbows with persistent instability (ie, the elbow can be reduced but continues to redislocate) requiring immobilization beyond 45 degrees of flexion, those with suspected median nerve entrapment, and those with the inability to reduce after several attempts at closed reduction should also prompt orthopedic consultation for possible operative repair. All other dislocations can be immobilized and discharged with orthopedic surgery follow-up within 1 week. Although elbow dislocations were traditionally placed in casts for several weeks, more recent literature recommends early mobility, as longer immobilization has been associated with worse long-term outcomes.

Conclusion (proposition de traduction) : Les luxations du coude sans signe d'instabilité ou pour lesquelles le clinicien n'est pas en mesure d'évaluer correctement l'instabilité peuvent être immobilisées à 90 degrés avec l'avant-bras en position neutre. Une instabilité en valgus évoque une lésion du ligament collatéral médial (également connu sous le nom de ligament collatéral ulnaire) et bénéficierait d'une immobilisation avec l'avant-bras en supination, tandis qu'une instabilité en varus évoque une lésion du ligament collatéral latéral (également connu sous le nom de ligament collatéral radial) et bénéficierait d'une immobilisation avec l'avant-bras en pronation.
Les coudes présentant des signes de syndrome de loge ou de troubles vasculaires nécessitent un avis de chirurgie orthopédique. Les coudes présentant une instabilité persistante (c'est-à-dire que le coude peut être réduit mais continue à se redéplacer) nécessitant une immobilisation au-delà de 45 degrés de flexion, ceux pour lesquels on soupçonne une compression du nerf médian et ceux qui ne peuvent être réduits après plusieurs tentatives de réduction fermée doivent également faire l'objet d'une consultation d'orthopédie en vue d'une éventuelle réparation chirurgicale. Toutes les autres luxations peuvent être immobilisées et sortir de l'hôpital avec un suivi en chirurgie orthopédique dans la semaine. Bien que les luxations du coude aient été traditionnellement placées dans des plâtres pendant plusieurs semaines, la littérature plus récente recommande une mobilité précoce, car une immobilisation plus longue a été associée à de plus mauvais résultats à long terme.

Commentaire : Luxations du coude
Technique de traction-contretraction à deux personnes

Technique de traction et de contre-traction utilisant le bras du le bras du clinicien pour la contre-traction

Technique de traction-contretraction modifiée utilisant la jambe du clinicien pour la contre-traction.

Technique de traction-contretraction modifiée utilisant le corps du patient pour la contre-traction.

Et encore trois autres techniques à découvrir dans l'article…
Technique du levier.
Technique du bras suspendu.
Technique de réduction antérieure.

The effect of time of measurement on the discriminant ability for mortality in trauma of a pre-hospital shock index multiplied by age and divided by the Glasgow Coma Score: a registry study.
Laaksonen M, Björkman J, Iirola T, Raatiniemi L, Nurmi J. | BMC Emerg Med. 2022 Nov 30;22(1):189.
DOI: https://doi.org/10.1186/s12873-022-00749-8  | Télécharger l'article au format  
Keywords: Critical care; Emergency medical services; Shock index.

Research

Introduction : The shock index (SI) and its derivatives have been shown to predict mortality in severely injured patients, both in pre-hospital and in-hospital settings. However, the impact of the time of measurement on the discriminative ability of the pre-hospital SI is unknown. The aim of this study was to evaluate whether the time of measurement influences the discriminative ability of the SI multiplied by age (SIA) and divided by the Glasgow Coma Score (SIA/G).

Méthode : Registry data were obtained from the national helicopter emergency medical services (HEMS) on trauma patients aged ≥ 18 years. The SI values were calculated based on the first measured vitals of the trauma patients by the HEMS unit. The discriminative ability of the SIA/G, with 30-day mortality as the endpoint, was evaluated according to different delay times (0 - 19, 20 - 39 and ≥ 40 min) from the initial incident. Sub-group analyses were performed for trauma patients without a traumatic brain injury (TBI), patients with an isolated TBI and patients with polytrauma, including a TBI.

Résultats : In total, 3,497 patients were included in the study. The SIA/G was higher in non-survivors (median 7.8 [interquartile range 4.7-12.3] vs. 2.4 [1.7-3.6], P < 0.001). The overall area under the receiver operator characteristic curve (AUROC) for the SIA/G was 0.87 (95% CI: 0.85-0.89). The AUROC for the SIA/G was similar in the short (0.88, 95% CI: 0.85-0.91), intermediate (0.86, 95% CI: 0.84-0.89) and long (0.86, 95% CI: 0.82-0.89) measurement delay groups. The findings were similar in the three trauma sub-groups.

Conclusion : The discriminative ability of the SIA/G in predicting 30-day mortality was not significantly affected by the measurement time of the index in the pre-hospital setting. The SIA/G is a simple and reliable tool for assessing the risk of mortality among severely injured patients in the pre-hospital setting.

Conclusion (proposition de traduction) : La capacité discriminante du SIA/G à prédire la mortalité à 30 jours n'était pas significativement affectée par le temps de mesure de l'indice dans le contexte pré-hospitalier. L'indice SIA/G est un outil simple et fiable pour évaluer le risque de mortalité chez les patients gravement blessés dans le contexte préhospitalier.

The application of an age adjusted D-dimer threshold to rule out suspected venous thromboembolism (VTE) in an emergency department setting: a retrospective diagnostic cohort study.
Barrett L, Jones T, Horner D. | BMC Emerg Med. 2022 Nov 23;22(1):186
DOI: https://doi.org/10.1186/s12873-022-00736-z  | Télécharger l'article au format  
Keywords: Compression Ultrasonography; D-dimer; DVT; Emergency medicine; PE; Venous thromboembolism (VTE).

Research

Introduction : Venous Thromboembolic disease (VTE) poses a diagnostic challenge for clinicians in acute care. Over reliance on reference standard investigations can lead to over treatment and potential harm. We sought to evaluate the pragmatic performance and implications of using an age adjusted D-dimer (AADD) strategy to rule out VTE in patients with suspected disease attending an emergency department (ED) setting. We aimed to determine diagnostic test characteristics and assess whether this strategy would result in proportional imaging reduction and potential cost savings.

Méthode : Design: Single centre retrospective diagnostic cohort study. All patients > 50 years old evaluated for possible VTE who presented to the emergency department over a consecutive 12-month period between January and December 2016 with a positive D-dimer result. Clinical assessment records and reference standard imaging results were followed up by multiple independent adjudicators and coded as VTE positive or negative.

Résultats : During the study period, there were 2132 positive D-dimer results. One thousand two hundred thirty-six patients received reference standard investigations. A total increase of 314/1236 (25.1%) results would have been coded as true negatives as opposed to false positive if the AADD cut off point had been applied, with 314 reference standard tests subsequently avoided. The AADD cut off had comparable sensitivity to the current cut off despite this increase in specificity; sensitivities for the diagnosis of DVT were 99.28% (95% CI 96.06-99.98%) and 97.72% for PE (95% CI 91.94% to 97.72). There were 3 false negative results using the AADD strategy.

Conclusion : In patients with suspected VTE with a low or moderate pre-test probability, the application of AADD appears to increase the proportion of patients in which VTE can be excluded without the need for reference standard imaging. This management strategy is likely to be associated with substantial reduction in anticoagulation treatment, investigations and cost/time savings.

Conclusion (proposition de traduction) : Chez les patients présentant une suspicion de thrombophlébite veineuse avec une probabilité pré-test faible ou modérée, l'application d'un seuil de D-dimères ajusté à l'âge semble augmenter la proportion de patients chez lesquels une thrombophlébite veineuse peut être exclue sans avoir besoin d'une imagerie standard de référence. Cette stratégie de gestion est susceptible d'être associée à une réduction substantielle du traitement anticoagulant, des investigations et des économies de coûts/temps.

Can passive leg raise predict the response to fluid resuscitation in ED?.
Elwan MH, Roshdy A, Elsharkawy EM, Eltahan SM, Coats TJ. | BMC Emerg Med. 2022 Oct 26;22(1):172
DOI: https://doi.org/10.1186/s12873-022-00721-6  | Télécharger l'article au format  
Keywords: Bioimpedance; Emergency; Fluid therapy; Haemodynamics; Non-invasive monitoring; Preload responsiveness.

Research article

Introduction : Passive leg raise (PLR) can be used as a reversible preload challenge to stratify patients according to preload response. We aim to evaluate the accuracy of PLR, monitored by a non-invasive cardiac output monitor in predicting to response to fluid resuscitation in emergency department (ED).

Méthode : We recruited adult patients planned to receive a resuscitation fluid bolus. Patients were monitored using a thoracic electrical bioimpedance (TEB) cardiac output monitor (Niccomo, Medis, Germany). A 3-min PLR was carried out before and after fluid infusion. Stroke volume changes (ΔSV) were calculated and a positive response was defined as ≥ 15% increase.

Résultats : We recruited 39 patients, of which 37 were included into the analysis. The median age was 63 (50-77) years and 19 patients were females. 17 patients (46%) were fluid responders compared to 11 (30%) with positive response to PLR1. ΔSV with PLR1 and fluid bolus showed moderate correlation (r = 0.47, 95% confidence interval, CI 0.17-0.69) and 62% concordance rate. For the prediction of the response to a fluid bolus the PLR test had a sensitivity of 41% (95% CI 22-64) and specificity of 80% (95% CI 58-92) with an area under the curve of 0.59 (95% CI 0.41-0.78). None of the standard parameters showed a better predictive ability compared to PLR.

Conclusion : Using TEB, ΔSV with PLR showed a moderate correlation with fluid bolus, with a limited accuracy to predict fluid responsiveness. The PLR test was a better predictor of fluid responsiveness than the parameters commonly used in emergency care (such as heart rate and blood pressure). These data suggest the potential for a clinical trial in sepsis comparing TEB monitored, PLR directed fluid management with standard care.

Conclusion (proposition de traduction) : Grâce à la bio-impédance électrique thoracique, les variations du volume systolique lors de l'élévation passive des jambes ont montré une corrélation modérée avec le bolus de remplissage vasculaire, avec une précision limitée pour prédire la réponse au remplissage vasculaire. Le test d'élévation passive des jambes était un meilleur prédicteur de la réactivité remplissage vasculaire que les paramètres couramment utilisés dans les soins d'urgence (tels que la fréquence cardiaque et la pression artérielle). Ces données suggèrent le potentiel d'un essai clinique dans le sepsis comparant la bioimpédance électrique thoracique surveillée, la gestion du remplissage vasculaire dirigée par le levé passif des jambes avec les soins standard.

Just the facts: How to diagnose and manage acute preschool asthma in the ED.
Burstein B, Turnbull J. | CJEM. 2022 Nov;24(7):688-690
DOI: https://doi.org/10.1007/s43678-022-00376-z
Keywords: Aucun

Just the Facts

Editorial : A 14-month-old girl presents to the emergency department (ED) with signs of respiratory distress and wheeze. The parents report that the child has had fever, cough and nasal congestion for 48 h, with difficulty breathing developing today. She has no significant medical history and immunizations are up to date.

Conclusion : A clinical diagnosis of asthma is made when a child hasexperienced ≥ 2 episodes meeting these criteria. Importantly,among children aged 12–24 months, asthma cannotbe differentiated from bronchiolitis on history and physicalexam alone, therefore initial asthma management can betherapeutic and diagnostic. For children 12–24 months oldwith respiratory tract infection symptoms, wheezing that isnot reversible with a SABA trial is more consistent with adiagnosis of bronchiolitis.

Conclusion (proposition de traduction) : Un diagnostic clinique d'asthme est posé lorsque l'enfant a connu ≥ 2 épisodes répondant à ces critères. Il est important de noter que, chez les enfants âgés de 12 à 24 mois, l'asthme ne peut pas être différencié de la bronchiolite sur la base des antécédents et de l'examen physique uniquement ; par conséquent, la prise en charge initiale de l'asthme peut être thérapeutique et diagnostique. Chez les enfants âgés de 12 à 24 mois présentant des symptômes d'infection des voies respiratoires, une respiration sifflante qui n'est pas réversible avec un essai de ß-agonistes à courte durée d'action est plus compatible avec un diagnostic de bronchiolite.

Commentaire :  Initial management of preschool asthma by severity PRAM score (inset). Source: data drawn from Trottier ED, Chan K, Allain D, Chauvin-Kimoff L. Managing an acute asthma exacerbation in children. Paediatr Child Health. 2021;26(7):438–9.

Pediatric Respiratory Assessment Measure (PRAM) App for Apple   and Android   products.

Alnaji F, Zemek R, Barrowman N, Plint A. PRAM score as predictor of pediatric asthma hospitalization. Acad Emerg Med. 2014 Aug;21(8):872-8  .

Antibiotic prescribing and outcomes for patients with uncomplicated purulent skin and soft tissue infections in the emergency department.
Ibrahim T, Thompson C, Borgundvaag B, McLeod SL. | CJEM. 2022 Nov;24(7):719-724
DOI: https://doi.org/10.1007/s43678-022-00366-1
Keywords: Abscess; Antibiotic; Emergency department; Skin and soft tissue infection.

Brief Original Research

Introduction : Current guidelines suggest adjuvant antibiotics after incision and drainage (I&D) of small, uncomplicated abscesses may improve patient outcomes, minimize pain, and prevent recurrence. The objective was to explore antibiotic prescribing at ED discharge and describe patient outcomes.

Méthode : This was a health records review of adult patients (≥ 18 years) discharged from an academic hospital ED (annual census 65,000) over a 2-year period with diagnosis of an uncomplicated skin abscess. Outcomes included any unplanned return ED visits within 30 days, repeat I&D, and escalation to intravenous (IV) antibiotics.

Résultats : Of 389 ED visits, 85.6% patients underwent I&D, of which 62.2% were prescribed antibiotics at discharge. Of these patients, 36.7% received guideline recommended antibiotics (TMP-SMX or clindamycin). Of all patients who underwent I&D, 13.2% had an unplanned return ED visit within 30 days, 6.9% required repeat I&D, and 0.6% patients were escalated to IV antibiotics. Patients treated with cefalexin were more likely to have an unplanned return ED visit within 30 days (20.0 vs 5.3%; Δ14.7, 95% CI 4.6-24.4), and were more likely to have a repeat I&D within 30 days (13.7 vs 0%; Δ13.7, 95% CI 6.4-22.0), compared to patients prescribed guideline recommended antibiotics. Treatment with guideline recommended antibiotics reduced treatment failure significantly in MRSA positive patients (0.0 vs 44.4%; Δ44.4, 95% CI 13.4-73.3).

Conclusion : Antibiotics were prescribed for most abscesses that underwent I&D. Less than half of the patients received antibiotics that were guideline recommended. Compared to those who received cefalexin, patients prescribed TMP-SMX or clindamycin had fewer return ED visits and were less likely to have a repeat I&D within 30 days. However, adjuvant antibiotic use did not significantly improve outcomes overall, with most patients not requiring a change in management irrespective of antibiotic use.

Conclusion (proposition de traduction) : Des antibiotiques ont été prescrits pour la plupart des abcès ayant fait l'objet d'une incision et d'un drainage. Moins de la moitié des patients ont reçu des antibiotiques recommandés par les lignes directrices. Par rapport à ceux qui ont reçu de la céfalexine, les patients à qui l'on a prescrit du cotrimoxazole ou de la clindamycine ont été moins nombreux à revenir aux urgences et étaient moins susceptibles de subir une nouvelle incision et un nouveau drainage dans les 30 jours. Cependant, l'utilisation d'antibiotiques adjuvants n'a pas amélioré de manière significative les résultats globaux, la plupart des patients ne nécessitant pas de changement de prise en charge indépendamment de l'utilisation d'antibiotiques.

Effect of specialist consultation on emergency department revisits among patients with uncomplicated recent-onset atrial fibrillation or flutter.
Lane DJ, Scheuermeyer FX, Nemnom MJ, Taljaard M, Stiell I. | CJEM. 2022 Nov;24(7):760-769
DOI: https://doi.org/10.1007/s43678-022-00370-5
Keywords: Atrial fibrillation; Atrial flutter; Cardiology; Consultation.

Original Research

Introduction : To examine the association between specialist consultation and risk of 30-day ED revisit in emergency department (ED) patients with recent-onset uncomplicated atrial fibrillation or flutter (AF/AFL).

Méthode : As a secondary analysis of a previously published trial, clinical experts identified predictors of consultation including age and sex, ED sinus conversion, thromboembolic risk, heart rate, rate control medication use, coronary artery disease and anti-platelet use, and chronic obstructive pulmonary disease. These were included in a propensity-matched hierarchical Bayesian model accounting for hospital site as a random effect, with 30-day ED revisit as the primary outcome. We also measured ED length of stay for consulted and non-consulted patients.

Résultats : We analyzed data from 11 sites for 829 ED patients with AF/AFL, of whom 364 (44%) had specialist consultation. A total of 128 patients (15.4%) had an ED revisit, 78 (16.8%) from the no consult group and 50 (13.7%) from the consult group. Consultation rates ranged from 8.8 to 71% between sites. Median length of stay was 591 min (interquartile range [IQR] 359-1024) for consulted patients and 300 min (IQR 212-409) for patients without consultation. After propensity-matching, consulted patients had a 0.6% (IQR - 4 to 3%) lower risk of 30-day revisits than non-consulted patients (probability of lower risk 55%).

Conclusion : In ED patients with uncomplicated AF/AFL, there was substantial between-site variation in specialist consultations; such consultation was unlikely to influence revisits within 30 days while ED length of stay was nearly double. ED specialist consultations may not be necessary for uncomplicated patients.

Conclusion (proposition de traduction) : Chez les patients des urgences souffrant de fibrillation atriale ou de flutter non compliqués, la consultation d'un spécialiste varie considérablement d'un site à l'autre ; il est peu probable que cette consultation ait une influence sur les réadmissions dans les 30 jours, alors que la durée du séjour aux urgences est presque doublée. La consultation d'un spécialiste aux urgences n'est peut-être pas nécessaire pour les patients non compliqués.

NEWS2 in out-of-hospital settings, the ambulance and the emergency department.
Tavaré A, Pullyblank A, Redfern E, Collen A, Barker RO, Gibson A. | Clin Med (Lond). 2022 Nov;22(6):525-529
DOI: https://doi.org/10.7861/clinmed.2022-news-ooh  | Télécharger l'article au format  
Keywords: NEWS2; ambulance; emergency department; out-of-hospital settings.

10 YEARS OF NEWS

Editorial : As more healthcare is provided in non-hospital settings, it is essential to support clinicians in recognising early signs of clinical deterioration to enable prompt intervention and treatment.There are intuitive reasons why the use of the National Early Warning Score 2 (NEWS2) in out-of-hospital settings may enhance the community response to acute illness by using a common language across healthcare. An additional advantage of the use of NEWS2 in community settings is that it is not disease specific and requires no expensive technology or great expertise to take a full set of observations that can be an indicator of clinical acuity.However, concerns have been expressed as NEWS2 was developed in acute hospital settings that it may not be applicable in community settings; this review shares some of the practical ways that NEWS2 can support clinical practice along with the emerging published evidence.

Conclusion : While there is increasing evidence for the value of NEWS2 in clinical practice for both the patient and the clinician, uncertainties remain. The Royal College of General Practitioners supports the use of physiological measurements in a general practice setting for all patients at risk of deterioration but has stopped short of recommending widespread uptake of NEWS2 without more research and evidence.
There are still areas where the practical impact of NEWS2 in pre-hospital settings needs further research and clarification, such as the use of NEWS2 to inform ambulance despatches to ensure decisions be balanced with clinical need. Finnikin et al found that NEWS was poorly related to hospital referral, but these were retrospectively calculated scores with no detail on diagnosis in a system that was not using, or responding to, NEWS in patients outside hospital. The observations were also taken by healthcare assistants and not the admitting clinicians, so NEWS was not used as a tool to support decisions to admit.< br /> The delivery of care in the NHS is also changing to include new models, such as virtual wards and same-day emergency care, delivered in non-hospital settings. Digital technology and the remote monitoring of patient observations underpin many of these pathways, particularly as NEWS2 is often one of the entry criteria as an indicator of clinical acuity. Remote monitoring may be used to support these ‘virtual wards’ and an increased understanding of changes in patient physiology can provide objective evidence of both when the patient deteriorates but also when they improve.
NEWS2 is a common language in the acute sector, it is becoming a more common language in pre-hospital settings, and it has great potential to provide a common language supporting shared decision making with our patients.

Conclusion (proposition de traduction) : Bien qu'il existe de plus en plus de preuves de la pertinence du NEWS2 dans la pratique clinique, tant pour le patient que pour le clinicien, des incertitudes subsistent. Le Royal College of General Practitioners recommande l'utilisation de mesures physiologiques dans un contexte de médecine générale pour tous les patients présentant un risque de détérioration, mais ne recommande pas l'adoption généralisée de NEWS2 sans plus de recherche et de preuves.
Il y a encore des domaines où l'impact pratique de NEWS2 dans les environnements pré-hospitaliers nécessite plus de recherche et de clarification, comme l'utilisation de NEWS2 pour informer les envois d'ambulances afin d'assurer que les décisions soient équilibrées avec les besoins cliniques. Finnikin et al ont trouvé que NEWS était faiblement lié à la direction de l'hôpital, mais il s'agissait de scores calculés rétrospectivement sans aucun détail sur le diagnostic dans un système qui n'utilisait pas, ou ne répondait pas, à NEWS pour les patients en dehors de l'hôpital. Les observations étaient également effectuées par des assistants de santé et non par les cliniciens chargés de l'admission, de sorte que NEWS n'était pas utilisé comme un outil pour étayer les décisions d'admission.
La prestation de soins au sein du NHS évolue également pour inclure de nouveaux modèles, tels que les services virtuels et les soins d'urgence le jour même, dispensés dans des environnements non hospitaliers. La technologie numérique et la surveillance à distance des observations des patients sont à la base de bon nombre de ces parcours, d'autant plus que NEWS2 est souvent l'un des critères d'admission en tant qu'indicateur de la sévérité clinique. La surveillance à distance peut être utilisée pour appuyer ces "salles virtuelles" et une meilleure compréhension des changements dans la physiologie du patient peut fournir des preuves objectives de la détérioration du patient, mais aussi de son amélioration.
NEWS2 est un langage commun dans le secteur des soins aigus, il devient un langage plus commun dans les environnements pré-hospitaliers, et il a un grand potentiel pour fournir un langage commun soutenant la prise de décision partagée avec nos patients.

Using NEWS2: an essential component of reliable clinical assessment.
Welch J, Dean J, Hartin J. | Clin Med (Lond). 2022 Nov;22(6):509-513
DOI: https://doi.org/10.7861/clinmed.2022-0435  | Télécharger l'article au format  
Keywords:

10 YEARS OF NEWS

Editorial : The National Early Warning Score 2 (NEWS2) is the established track and trigger system to assess illness severity and risk of deterioration for patients in acute episodes of care in the UK. It is also increasingly used internationally. In this article, we outline established and recommended practice for initial and ongoing assessment. We also highlight where practice may not meet these standards, how the full context and assessment of the patient is paramount, and opportunities for more accurate assessment in the future.

Conclusion : NEWS2 is a well-established, validated, easy to use track and trigger system for illness severity and the risk of deterioration. While used throughout the NHS, research suggests that it is not always used accurately, and there are risks that less experienced clinicians might place an over reliance on its measures without considering its limitations or the wider clinical context.
Digitisation of measurement and the use of AI give opportunities for more accurate measurement and triggering of response, and also the addition of other measurements that can assess illness severity, deterioration, risk and recovery.
Emphasis should be given to the consistent and accurate use of NEWS2 within and across pathways of care and care settings as part of clinical assessment. Clinical judgement remains paramount. Patient, clinician and family concerns can add significantly to assessment. Other measures that are disease specific should be used alongside NEWS2. The response to a trigger must be a detailed clinical assessment that can determine intervention, ongoing monitoring and escalation requirements for the individual patient, and sometimes palliation with cessation of measuring NEWS2.

Conclusion (proposition de traduction) : NEWS2 est un système de repérage et de détermination de la gravité de la maladie et du risque de détérioration bien établi, validé et facile à utiliser. Bien qu'il soit utilisé dans l'ensemble du NHS, les recherches suggèrent qu'il n'est pas toujours utilisé avec précision, et il existe des risques que des cliniciens moins expérimentés se fient trop à ses mesures sans tenir compte de ses limites ou du contexte clinique plus large.
La numérisation des mesures et l'utilisation de l'IA permettent d'obtenir des mesures plus précises et de déclencher une réponse, mais aussi d'ajouter d'autres mesures permettant d'évaluer la gravité de la maladie, sa détérioration, le risque et la guérison.
Il convient de mettre l'accent sur l'utilisation cohérente et précise de NEWS2 dans le cadre de l'évaluation clinique, à l'intérieur et à travers les filières de soins et les établissements de soins. Le jugement clinique reste primordial. Les préoccupations du patient, du clinicien et de la famille peuvent contribuer de manière significative à l'évaluation. D'autres mesures spécifiques à la maladie doivent être utilisées parallèlement à NEWS2. La réponse à un déclencheur doit être une évaluation clinique détaillée qui peut déterminer l'intervention, la surveillance continue et les exigences d'escalade pour le patient individuel, et parfois la palliation avec l'arrêt de la mesure de NEWS2.

Commentaire : NEWS = National Early Warning Score

Sensitivity of modern multislice CT for subarachnoid haemorrhage at incremental timepoints after headache onset: a 10-year analysis.
Vincent A, Pearson S, Pickering JW, Weaver J, Toney L, Hamill L, Hurrell M, Than M. | Emerg Med J. 2022 Nov;39(11):810-817
DOI: https://doi.org/10.1136/emermed-2020-211068
Keywords: emergency department; headache.

THUNDERCLAP HEADACHE

Introduction : CT performed within 6 hours of headache onset is highly sensitive for the detection of subarachnoid haemorrhage (SAH). Beyond this time frame, if the CT is negative for blood, a lumbar puncture is often performed. Technology improvements in image noise reduction, resolution and motion artefact have enhanced the performance of multislice CT (MSCT) and may have further improved sensitivity. We aimed to describe how the sensitivity to SAH of modern MSCT changes with time from headache onset.

Méthode : This was a retrospective analysis of electronic data collected as part of routine care among all patients presenting to Christchurch Hospital diagnosed with a SAH between 1 January 2008 and 31 December 2017. Patients were imaged with MSCT. The primary outcome was the proportion of patients with spontaneous aneurysmal SAH (identified via coding and confirmed by clinical and radiological records) that had a positive MSCT. The secondary outcome was the proportion of patients with any type of spontaneous SAH that had a positive MSCT.

Résultats : There were 347 patients with an SAH of whom 260 were aneurysmal SAH. MSCT identified 253 (97.3%) of all aneurysmal SAH and 332 (95.7%) of all SAH. The sensitivity of MSCT was 99.6% (95% CI 97.6 to 100) for aneurysmal SAH and 99.0% (95% CI 97.1 to 99.8) for all SAH at 48 hours after headache onset. At 24 hours after headache onset, the sensitivity for aneurysmal SAH was 100% (95% CI 98.3 to 100).

Conclusion : These data suggest that it may be possible to extend the timeframe from headache onset within which modern MSCT can be used to rule out aneurysmal SAH.

Conclusion (proposition de traduction) : Ces données suggèrent qu'il est possible d'étendre le délai à partir de l'apparition de la céphalée dans lequel la tomodensitométrie multibarrettes moderne peut être utilisée pour exclure une hémorragie sous-arachnoïdienne anévrismale.

Commentaire : La sensibilité de la TDM était de 99,6 % (IC 95 % 97,6 à 100) pour les hémorragies sous-arachnoïdiennes anévrismales et de 99,0 % (IC 95 % 97,1 à 99,8) pour toutes les hémorragies sous-arachnoïdiennes 48 heures après le début des céphalées. 24 heures après le début des céphalées, la sensibilité pour l'hémorragie sous-arachnoïdienne anévrismale était de 100 % (IC 95 % 98,3 à 100).

Management of patients presenting to the emergency department with sudden onset severe headache: systematic review of diagnostic accuracy studies.
Walton M, Hodgson R, Eastwood A, Harden M, Storey J, Hassan T, Randall MS, Hassan A, Williams J, Wade R. | Emerg Med J. 2022 Nov;39(11):818-825
DOI: https://doi.org/10.1136/emermed-2021-211900  | Télécharger l'article au format  
Keywords: computed tomography; diagnosis; emergency department; headache.

Systematic review

Introduction : Advances in imaging technologies have precipitated uncertainty and inconsistency in the management of neurologically intact patients presenting to the Emergency Department (ED) with non-traumatic sudden onset severe headache with a clinical suspicion of subarachnoid haemorrhage (SAH). The objective of this systematic review was to evaluate diagnostic strategies in these patients.

Méthode : Studies assessing any decision rule or diagnostic test for evaluating neurologically intact adults with a severe headache, reaching maximum intensity within 1 hour, were eligible. Eighteen databases (including MEDLINE and Embase) were searched. Quality was assessed using QUADAS-2. Where appropriate, hierarchical bivariate meta-analysis was used to synthesise diagnostic accuracy results.

Résultats : Thirty-seven studies were included. Eight studies assessing the Ottawa SAH clinical decision rule were pooled; sensitivity 99.5% (95% CI 90.8 to 100), specificity 24% (95% CI 15.5 to 34.4). Four studies assessing CT within 6 hours of headache onset were pooled; sensitivity 98.7% (95% CI 96.5 to 100), specificity 100% (95% CI 99.7 to 100). The sensitivity of CT beyond 6 hours was considerably lower (≤90%; 2 studies). Three studies assessing lumbar puncture (LP; spectrophotometric analysis) following negative CT were pooled; sensitivity 100% (95% CI 100 to 100), specificity 95% (95% CI 86.0 to 98.5).

Conclusion : The Ottawa SAH Rule rules out further investigation in only a small proportion of patients. CT undertaken within 6 hours (with expertise of a neuroradiologist or radiologist who routinely interprets brain images) is highly accurate and likely to be sufficient to rule out SAH; CT beyond 6 hours is much less sensitive. The CT-LP pathway is highly sensitive for detecting SAH and some alternative diagnoses, although LP results in some false positive results.

Conclusion (proposition de traduction) : La règle de l'hémorragie sous-arachnoïdienne d'Ottawa ne permet d'éviter des examens complémentaires que chez une faible proportion de patients. La tomodensitométrie réalisée dans les 6 heures (avec l'expertise d'un neuroradiologue ou d'un radiologue qui interprète couramment les images cérébrales) est très précise et probablement suffisante pour exclure une hémorragie sous-arachnoïdienne ; la tomodensitométrie réalisée après 6 heures est beaucoup moins sensible. La ponction lombaire après un examen tomodensitométrique négatif est très sensible pour détecter une hémorragie sous-arachnoïdienne et certains diagnostics alternatifs, bien que la ponction lombaire donne quelques résultats faussement positifs.

Cardiac arrest and complications during non-invasive ventilation: a systematic review and meta-analysis with meta-regression.
Rolle A, De Jong A, Vidal E, Molinari N, Azoulay E, Jaber S. | Intensive Care Med. 2022 Nov;48(11):1513-1524
DOI: https://doi.org/10.1007/s00134-022-06821-y  | Télécharger l'article au format  
Keywords: Cardiac arrest; Complications; ICU; Meta-analysis; Non-invasive ventilation.

Content type: Systematic Review

Introduction : The aim of this study was to perform a systematic review and meta-analysis to investigate the incidence rate of cardiac arrest and severe complications occurring under non-invasive ventilation (NIV).

Méthode : We performed a systematic review and meta-analysis of studies between 1981 and 2020 that enrolled adults in whom NIV was used to treat acute respiratory failure (ARF). We generated the pooled incidence and confidence interval (95% CI) of NIV-related cardiac arrest per patient (primary outcome) and performed a meta-regression to assess the association with study characteristics. We also generated the pooled incidences of NIV failure and hospital mortality.

Résultats : Three hundred and eight studies included a total of 7,601,148 participants with 36,326 patients under NIV (8187 in 138 randomized controlled trials, 9783 in 99 prospective observational studies, and 18,356 in 71 retrospective studies). Only 19 (6%) of the analyzed studies reported the rate of NIV-related cardiac arrest. Forty-nine cardiac arrests were reported. The pooled incidence was 0.01% (95% CI 0.00-0.02, I² = 0% (0-15)). NIV failure was reported in 4371 patients, with a pooled incidence of 11.1% (95% CI 9.0-13.3). After meta-regression, NIV failure and the study period (before 2010) were significantly associated with NIV-related cardiac arrest. The hospital mortality pooled incidence was 6.0% (95% CI 4.4-7.9).

Conclusion : Cardiac arrest related to NIV occurred in one per 10,000 patients under NIV for ARF treatment. NIV-related cardiac arrest was associated with NIV failure.

Conclusion (proposition de traduction) : Un arrêt cardiaque lié à la VNI est survenu chez un patient sur 10 000 sous VNI pour le traitement de l'IRA. L'arrêt cardiaque lié à la VNI était associé à l'échec de la VNI.

Vitamin C in sepsis.
Young PJ, Lamontagne F, Fujii T. | Intensive Care Med. 2022 Nov;48(11):1621-1624
DOI: https://doi.org/10.1007/s00134-022-06822-x
Keywords: Aucun

Lasting Legacy in Intensive Care Medicine

Editorial : Vitamin C has a remarkable place in the history of medicine. As sepsis treatment, it has recently been the subject of intense research. The idea that vitamin C might be an efficacious sepsis treatment has a sound biological basis. Humans cannot synthesise vitamin C and plasma levels are often extremely low in critical illness. Vitamin C is a key antioxidant and its deficiency causes oxidative stress. Vitamin C is an essential cofactor to convert dopamine to noradrenaline and for synthesis of vasopressin. It promotes degradation of hypoxia-inducible factor-1α suppressing activation of genes associated with impaired mitochondrial oxygen handling. Vitamin C is present in neutrophils and supports chemotaxis and the oxidative burst.

Conclusion : Despite any uncertainty about role for vitamin C in specific groups of patients with sepsis, in our view, the take home message for clinicians is that any such role should be investigated in RCTs. Until the findings of such RCTs are known, vitamin C should not be used to treat sepsis. Perhaps, the lasting legacy of the vitamin C in sepsis story will be wider realisation that treatments with a strong rationale should be tested in methodologically rigorous multicentre RCTs, and not implemented on the basis of biological plausibility, low-quality studies, and presumed safety.

Conclusion (proposition de traduction) : Malgré l'incertitude quant au rôle de la vitamine C dans des groupes spécifiques de patients atteints de sepsis, nous pensons que le message à retenir pour les cliniciens est que tout rôle de ce type doit être étudié dans le cadre d'essai randomisé contrôlé. Tant que les résultats de ces essai randomisé contrôlé ne sont pas connus, la vitamine C ne doit pas être utilisée pour traiter le sepsis. Peut-être que l'héritage durable de l'histoire de la vitamine C dans le sepsis sera une prise de conscience plus large que les traitements avec une forte justification devraient être testés dans des essai randomisé contrôlé multicentriques méthodologiquement rigoureux, et non pas mis en œuvre sur la base de la plausibilité biologique, des études de faible qualité, et de la sécurité présumée.

Commentaire : 

Protective ventilation.
Juffermans NP, Rocco PRM, Laffey JG. | Intensive Care Med. 2022 Nov;48(11):1629-1631
DOI: https://doi.org/10.1007/s00134-022-06820-z  | Télécharger l'article au format  
Keywords: In silico est un néologisme d'inspiration latine désignant une recherche ou un essai effectué au moyen de calculs complexes informatisés ou de modèles informatiques.

Lasting Legacy in Intensive Care Medicine

Editorial : Following the initial observation in animal models as early as 1967, a key paper in 1974 demonstrating that high inspiratory pressures caused lung injury, crystallized the recognition that mechanical ventilation itself can harm the lung. Experimental models were also instrumental in showing that cyclic lung re-opening and closing creates shear stress with alveolar injury, which could be prevented by the application of positive end-expiratory pressure (PEEP). The use of computed tomography showed the response to PEEP in terms of recruitment of lung volume, giving rise to the ‘baby lung’ concept in acute respiratory distress syndrome (ARDS). Experimental models were also helpful in determining that it was not inspiratory pressure per se, but rather over-distention that caused harm leading to the concept of ‘volutrauma’. These findings led to the ‘open lung’ concept, which argues that a ventilation approach that prioritizes maintenance of lung volume would avoid the lung injury resulting from shear stress. Also, the concept of ‘biotrauma’ was demonstrated in an experimental model, whereby high-stretch ventilation generates the release of inflammatory mediators from the lung, leading to systemic inflammation and distal organ injury, particularly in the presence of zero PEEP. Two years later, these findings were validated clinically in ARDS patients.

Conclusion : As ventilator induced lung injury importantly impacts outcome of mechanically ventilated patients, even in those without lung injury, it follows that those caring for the critically ill should apply protective ventilatory settings to the best of their abilities. This is feasible, without the need for advanced monitoring systems, but by appreciation of the concepts as summarized here. The field of protective ventilation will continue to evolve as we generate new insights in the laboratory and in the clinics. A promising novel innovation is the use of in silico computational models of critically ill acute respiratory distress syndrome patients, which most likely will inform us on how to further refine ventilator settings. In addition, such refinements can potentially be done around the clock, instead of only during ward rounds. Moreover, functional imaging modalities may be useful to help set the ventilator. Although robust data of benefit are still lacking, electrical impedance tomography, for instance, can provide imaging of regional air distribution in the lungs.

Conclusion (proposition de traduction) : Étant donné que les lésions pulmonaires induites par le respirateur ont un impact important sur les résultats des patients sous ventilation mécanique, même chez ceux qui n'ont pas de lésions pulmonaires, il s'ensuit que les soignants des patients gravement malades doivent appliquer des paramètres de ventilation protectrice au mieux de leurs compétences. Cela est possible, sans avoir besoin de systèmes de surveillance avancés, mais en appréciant les concepts résumés ici. Le domaine de la ventilation protectrice continuera d'évoluer au fur et à mesure que de nouvelles connaissances seront acquises en laboratoire et en clinique. Une innovation prometteuse est l'utilisation de modèles informatiques in silico de patients atteints du syndrome de détresse respiratoire aiguë dans un état critique, qui nous renseigneront très probablement sur la manière d'affiner les réglages du ventilateur. De plus, de telles améliorations peuvent potentiellement être effectuées 24 heures sur 24, et non plus seulement pendant les visites des services. De plus, les modalités d'imagerie fonctionnelle peuvent être utiles pour aider à régler le ventilateur. Bien qu'il n'existe pas encore de données solides sur les avantages de cette technique, la tomographie par impédance électrique, par exemple, peut fournir des images de la distribution régionale de l'air dans les poumons.

Commentaire : 

PrEdictive value of coMbined pre-test proBability and blOod gas anaLysis In pulmonary emboliSM-the EMBOLISM study.
Meusel M, Pätz T, Gruber K, Kupp S, Jensch PJ, Saraei R, Fürschke A, Sayk F, Eitel I, Wolfrum S. | Intern Emerg Med. 2022 Nov;17(8):2245-2252
DOI: https://doi.org/10.1007/s11739-022-03075-w  | Télécharger l'article au format  
Keywords: Blood gas analysis; D-dimer; Pre-test probability; Pulmonary embolism; Wells score.

IM - ORIGINAL

Introduction : In patients with suspected pulmonary embolism (PE), the number of unnecessary computed tomography pulmonary angiography (CTPA) scans remains high, especially in patients with low pre-test probability (PTP). So far, no study showed any additional benefit of capillary blood gas analysis (BGA) in diagnostic algorithms for PE.

Méthode : In this retrospective analysis of patients with suspected PE and subsequent CTPA, clinical data, D-dimer levels and BGA parameters (including standardized PaO2) were analyzed. Logistic regression analyses were performed to identify independent predictors for PE and reduce unnecessary CTPA examinations in patients with low PTP according to Wells score.

Résultats : Of 1538 patients, PE was diagnosed in 433 patients (28.2%). The original Wells score (odds ratio: 1.381 [95% CI 1.300-1.467], p < 0.001) and standardized PaO2 (odds ratio: 0.987 [95% CI 0.978-0.996], p = 0.005) were independent predictors for PE. After cohort adjustment for low PTP a D-dimer cut-off < 1.5 mg/L (278 patients (18.1%) with 18 PE (6.5%)) was identified in which a standardized PaO2 > 65 mmHg reduced the number of unnecessary CTPA by 31.9% with a 100% sensitivity.

Conclusion : This approach was further validated in additional 53 patients with low PTP. In this validation group CTPA examinations were reduced by 32.7%. No patient with PE was missed. With our novel algorithm combining BGA testing with low PTP according to Wells score, we were able to increase the D-Dimer threshold to 1.5 mg/L and reduce CTPA examinations by approximately 32%.

Conclusion (proposition de traduction) : Dans ce groupe de validation, les examens d'angiographie pulmonaire par tomodensitométrie ont été réduits de 32,7 %. Aucun patient présentant une embolie pulmonaire n'a été manqué. Grâce à notre nouvel algorithme combinant l'analyse des gaz du sang et la faible probabilité pré-test selon le score de Wells, nous avons pu augmenter le seuil de D-Dimer à 1,5 mg/L et réduire les examens d'angiographie pulmonaire par tomodensitométrie d'environ 32 %.

Efficacy and safety in ketamine-guided prehospital analgesia for abdominal pain.
Häske D, Dorau W, Heinemann N, Eppler F, Schopp T, Schempf B. | Intern Emerg Med. 2022 Nov;17(8):2291-2297
DOI: https://doi.org/10.1007/s11739-022-03091-w
Keywords: EMS; Out-of-hospital; Safety; Treatment.

IM - ORIGINAL

Introduction : Abdominal pain is a common reason for presentation in the emergency department and for calling emergency medical services. The complexity of abdominal pain also influences the analgesia strategy. However, there are almost no data on the use of ketamine for abdominal pain.

Méthode : This study aims to analyze the safety and efficacy of using ketamine as an analgesic for abdominal pain. In a retrospective analysis of prehospital patient data within the framework of quality assurance, all cases with ketamine administered by paramedics as analgesia for abdominal pain were analyzed in terms of pain reduction and patient safety and also compared with other analgesic drugs including fentanyl, morphine, and metamizole.

Résultats : From 01/01/2018 to 11/24/2021, 129 datasets were analyzed. The mean patient age was 50 ± 19 years (19-90 years), with 47.3% (n = 61) women. The application of fentanyl was documented as a monotherapy in 10.9% (n = 14), morphine in 2.3% (n = 3), metamizole in 34.1% (n = 44), and ketamine in 52.7% (n = 68) of cases. The pain relief of fentanyl, metamizole, and ketamine differed significantly from each other (p < 0.001), with fentanyl and ketamine being comparable. Looking at the quality assurance definition of successful analgesia (pain on handover NRS < 5 or pain reduction ≥ 2 points), successful analgesia was shown in 92.9% (n = 13) of cases for fentanyl, in 65.9% (n = 44) for metamizole, and 92.6% (n = 68) for ketamine (p < 0.001). Adverse events were not observed in patients treated with ketamine.

Conclusion : Analgesia is an important goal in the treatment of patients with abdominal pain. With ketamine, analgesia comparable to fentanyl can be achieved. Ketamine appears to be a safe and effective option for the treatment of patients with abdominal pain in emergency medicine.

Conclusion (proposition de traduction) : L'analgésie est un objectif important dans le traitement des patients souffrant de douleurs abdominales. Avec la kétamine, une analgésie comparable à celle du fentanyl peut être obtenue. La kétamine semble être une option sûre et efficace pour le traitement des patients souffrant de douleurs abdominales en médecine d'urgence.

Carli P, Hutin A, Lamhaut I. | J Eur des Urgences et de Reanim. 2022 Nov;34:113—118
DOI: https://doi.org/10.1016/j.jeurea.2022.10.003
Keywords: Out of hospital cardiac arrest OHCA; ECMO

Article original

Editorial : Le débat qui oppose la stratégie du « scoop and run » et de « stay and treat » est bien connu en traumatologie même s’il est peu conclusif. Il prend un relief particulier dans le domaine de l’arrêt cardiorespiratoire (ACR) préhospitalier ou des données récentes suggèrent un avantage conséquent pour la réalisation d’une réanimation cardiopulmonaire spécialisée (RCPS) sur place. Cependant ce résultat est tributaire de la performance globale du système d’urgence qui prend en charge le patient. L’introduction dans la RCPS de l’ECMO comme traitement de deuxième ligne relance ce débat. En effet pour améliorer la survie, l’ECMO doit être mise en place dans l’heure, soit par une équipe préhospitalière soit à la suite d’un transport rapide dans un hôpital en disposant.

Conclusion (proposition de traduction) : Si l’avantage d’une stratégie « stay and treart » sur le « scoop and run » semble acquis pour la réanimation spécialisée des ACR préhospitaliers le développement de l’ECMO introduit un nouveau défi : intégrer l’une ou l’autre de ces stratégies dans un système global de prise en charge des AC permet-tant une assistance cardio-respiratoire extracorporelle dans l’heure qui suit un AC. L’avenir permettra de déterminer si la mise en place préhospitalière de l’ECMO est aussi avantageuse pour le pronostic que l’est la réalisation de la RCP spécialisée sur le terrain.

Okoue Ondoa R, Edjo NkillyG, Matsangab A, Mapalia D, Sagbo Adab V, Igohoa C, Oliveirac S, Nze Obiangd P, Mandji Lawsonc LM, Tchouaa R. | J Eur des Urgences et de Reanim. 2023 Nov:34;173—180
DOI: https://doi.org/10.1016/j.jeurea.2022.11.002
Keywords: Procedural sedation-analgesia; Ketamine; Midazolam; Emergency Room ER

Article original

Introduction : La sédation-analgésie (S-A) pour la réalisation d’actes douloureux devrait occuper une place importante dans nos pays, au vu de la fréquence de la pathologie traumatologique. Nous avons donc décidé de réaliser une étude pour évaluer les connaissances théoriques et la réalisation pratique des procédures des S-A dans les différents CHU de Libreville.

Méthode : Étude transversale multicentrique, prospective, observationnelle sur une période de 3 mois et dans 3 CHU de Libreville. Elle comprenait deux parties, une théorique pour évaluer le niveau de connaissance des médecins exerçant au SAU ; et une autre, pratique, dans laquelle les procédures étaient réalisées et évaluées. Les critères d’inclusion étaient : tout médecin exerçant au SAU dans les CHU de Libreville (partie théorique) ; toute personne âgée de plus de 15 ans, devant bénéficier d’une S-A (partie pratique).

Résultats : Nous avons inclus 44 généralistes (partie théorique) et 40 patients ayant consulté pour une pathologie nécessitant une S-A. Partie théorique : certains médecins généralistes n’avaient jamais recours à la S-A (21 %). La réduction-contention des lésions orthopédiques était l’indication majoritaire. L’association Kétamine-Midazolam était administrée dans la moitié des cas, mais en posologie excessive dans près de 90,3 % des cas. Partie pratique : seul3 % des généralistes surveillaient tous les paramètres vitaux, la durée des sédations étaient trèsélevée, soit environ une demi-heure dans 35 % des cas et plus de 50 min dans 27,5 % des cas. Iln’y avait pas d’effets secondaires majeurs notables, mis à part les hallucinations dans 31,1 %des cas.

Conclusion (proposition de traduction) : Une grande partie des médecins exerc¸ant au SAU n’ont pas la maîtrise desquelques molécules qu’ils administrent pour la S-A de geste douloureux, et, n’appliquent pasles mesures de sécurité élémentaires recommandées par les sociétés savantes. Une formationsur sa pratique, et les mesures de sécurité entourant cette procédure devraient être fourniesaux différents médecins exerc¸ant aux SAU.

Acute and postacute sequelae associated with SARS-CoV-2 reinfection.
Bowe B, Xie Y, Al-Aly Z. | Nat Med. 2022 Nov;28(11):2398-2405
DOI: https://doi.org/10.1038/s41591-022-02051-3  | Télécharger l'article au format  
Keywords: Aucun

Article

Editorial : First infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with increased risk of acute and postacute death and sequelae in various organ systems. Whether reinfection adds to risks incurred after first infection is unclear. Here we used the US Department of Veterans Affairs' national healthcare database to build a cohort of individuals with one SARS-CoV-2 infection (n = 443,588), reinfection (two or more infections, n = 40,947) and a noninfected control (n = 5,334,729). We used inverse probability-weighted survival models to estimate risks and 6-month burdens of death, hospitalization and incident sequelae. Compared to no reinfection, reinfection contributed additional risks of death (hazard ratio (HR) = 2.17, 95% confidence intervals (CI) 1.93-2.45), hospitalization (HR = 3.32, 95% CI 3.13-3.51) and sequelae including pulmonary, cardiovascular, hematological, diabetes, gastrointestinal, kidney, mental health, musculoskeletal and neurological disorders. The risks were evident regardless of vaccination status. The risks were most pronounced in the acute phase but persisted in the postacute phase at 6 months. Compared to noninfected controls, cumulative risks and burdens of repeat infection increased according to the number of infections. Limitations included a cohort of mostly white males. The evidence shows that reinfection further increases risks of death, hospitalization and sequelae in multiple organ systems in the acute and postacute phase. Reducing overall burden of death and disease due to SARS-CoV-2 will require strategies for reinfection prevention.

Conclusion : In sum, in this study of 5,819,264 individuals, we provide evidence that reinfection contributes to additional health risks beyond those incurred in the first infection including all-cause mortality, hospitalization and sequelae in a broad array of organ systems. The risks were evident in the acute and postacute phases of reinfection. The evidence suggests that for people who already had a first infection, prevention of a second infection may protect from additional health risks. Prevention of infection and reinfection with SARS-CoV-2 should continue to be the goal of public health policy.

Conclusion (proposition de traduction) : En résumé, dans cette étude portant sur 5 819 264 patients, nous apportons la preuve que la réinfection contribue à des risques sanitaires supplémentaires par rapport à ceux encourus lors de la première infection, notamment la mortalité toutes causes confondues, l'hospitalisation et les séquelles dans un large éventail de fonctions et organes. Les risques étaient évidents dans les phases aiguës et ultérieures à la réinfection. Les preuves suggèrent que pour les personnes ayant déjà eu une première infection, la prévention d'une seconde infection peut protéger contre des risques supplémentaires pour la société. La prévention de l'infection et de la réinfection par le SRAS-CoV-2 doit rester l'objectif de la politique de santé publique.

Foreign Body Ingestion and Management in Children.
Salman H, Gürsoy Koca T, Dereci S, Akçam M. | Pediatr Emerg Care. 2022 Nov 1;38(11):617-620
DOI: https://doi.org/10.1097/pec.0000000000002856
Keywords: Aucun

Original article

Introduction : The aim of the study is to evaluate of the children who came to our hospital with the complaint of foreign body (FB) ingestion and were treated.

Méthode : A retrospective evaluation was made of the records of children who presented at our institution between January 2014 and August 2021 with the complaint of FB ingestion.

Résultats : Evaluation was made of 297 children, comprising 121 female children (40.7%) with a mean age of 61.1 ± 50.3 months (range, 4-202 months). The ingested FB most frequently was coins (n = 88, 29.6%). The most common complaint on presentation was vomiting in 47 cases (15.8%). Endoscopy was applied to 75 cases (25.3%), and most common FB was removed from the upper esophagus in 31 cases (41.3%). The most frequently removed FB was coins at the rate of 40%. Of the 211 cases left to a spontaneous course, 117 were in the intestines, 22 in the stomach, and in 72 cases localization could not be determined on conventional radiography as the FB was not opaque. In 7 cases with a bolus of food caught in the esophagus, 3 had corrosive esophagus stricture (1 case with colon transposition), 2 had operated esophagus atresia, 1 had eosinophilic esophagitis, and 1 had congenital esophagus stricture.

Conclusion : Although there can be serious outcomes, there is spontaneous expulsion in most cases. However, a significant proportion requires a timely endoscopic procedure. Attention must be paid to underlying diseases when FBs, such as a food bolus, are in the esophagus.

Conclusion (proposition de traduction) : Bien que les conséquences puissent être graves, il y a dans la majorité des cas une expulsion spontanée. Cependant, une proportion importante nécessite une intervention endoscopique rapide. Il convient de prêter attention aux maladies sous-jacentes lorsque des corps étrangers, tels qu'un bol alimentaire, se trouvent dans l'œsophage.

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. 2022 Nov-Dec;26(6):756-763
DOI: https://doi.org/10.1080/10903127.2021.1987597
Keywords: ST-elevation myocardial infarction; epidemiologic factors; signs and symptoms.

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) : Si l'on limitait l'acquisition préhospitalière des ECG à 12 dérivations aux patients présentant des symptômes typiques de STEMI, un patient sur cinq souffrant de STEMI serait reconnu tardivement, ce qui aurait un impact disproportionné sur les patients plus âgés, les femmes et les patients noirs. L'âge, et non le sexe, pourrait être un meilleur prédicteur de la présentation atypique du STEMI.

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. 2022 Nov-Dec;26(6):756-763
DOI: https://doi.org/10.1080/10903127.2021.1987597
Keywords: ST-elevation myocardial infarction; epidemiologic factors; signs and symptoms.

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) : Si l'on limitait l'acquisition préhospitalière des ECG à 12 dérivations aux patients présentant des symptômes typiques de STEMI, un patient sur cinq souffrant de STEMI serait reconnu tardivement, ce qui aurait un impact disproportionné sur les patients plus âgés, les femmes et les patients noirs. L'âge, et non le sexe, pourrait être un meilleur indicateur de la présentation atypique d'un STEMI.

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. 2022 Nov-Dec;26(6):782-791
DOI: https://doi.org/10.1080/10903127.2021.1995799
Keywords: cardiac arrest; dispatch; emergency medical services; number of providers; out-of-hospital cardiac arrest.

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 de sept intervenants préhospitaliers ou plus sur place était associée à des chances significativement plus élevées de survie jusqu'à la sortie de l'hôpital après un arrêt cardiaque extrahospitalier, par rapport à un nombre inférieur d'intervenant sur place.

Family presence during adult resuscitation from cardiac arrest: A systematic review.
Considine J, Eastwood K, Webster H, Smyth M, Nation K, Greif R, Dainty K, Finn J, Bray J; International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams; Basic Life Support; and Advanced Life Support Task Forces. | Resuscitation. 2022 Nov;180:11-23
DOI: https://doi.org/10.1016/j.resuscitation.2022.08.021  | Télécharger l'article au format  
Keywords: Adult; Cardiopulmonary Resuscitation; Family; Family Health; Health Care; Health Personnel; Heart Arrest; Humans; Outcome Assessment; Psychological; Stress; Treatment Outcome.

Review

Introduction : Objective: To conduct a systematic review of the published evidence related to family presence during adult resuscitation from cardiac arrest.

Méthode : This review, registered with PROSPERO (CRD42021242384) and reported according to PRISMA guidelines, included studies of adult cardiac arrest with family presence during resuscitation that reported one or more patient, family or provider outcomes. Three databases (Medline, CINAHL and EMBASE) were searched from inception to 10/05/2022. Two investigators screened the studies, extracted data, and assessed risks of bias using the Mixed Method Appraisal Tool (MMAT). The synthesis approach was guided by Synthesis Without Meta-Analysis (SWiM) reporting guidelines and a narrative synthesis method.

Résultats : The search retrieved 9,459 citations of which 31 were included: 18 quantitative studies (including two RCTs), 12 qualitative studies, and one mixed methods study. The evidence was of very low or low certainty. There were four major findings. High-certainty evidence regarding the effect of family presence during resuscitation on patient outcomes is lacking. Family members had mixed outcomes in terms of depression, anxiety, post-traumatic stress disorder (PTSD) symptoms, and experience of witnessing resuscitation. Provider experience was variable and resuscitation setting, provider education, and provider experience were major influences on family presence during resuscitation. Finally, providers reported that a family support person and organisational guidelines were important for facilitating family presence during resuscitation.

Conclusion : The effect of family presence during resuscitation varies between individuals. There was variability in the effect of family presence during resuscitation on patient outcomes, family and provider outcomes and perceptions.

Conclusion (proposition de traduction) : L'effet de la présence de la famille pendant la réanimation varie d'un individu à l'autre. L'effet de la présence de la famille pendant la réanimation sur les résultats pour le patient, la famille et le personnel soignant, ainsi que sur les perceptions, est variable.

Commentaire : La revue d cela littérature présentée a certes montré la variabilité des pratiques et des résultats de la présence de la famille pendant la réanimation, mais étant donné le souhait élevé de la famille de choisir et les résultats positifs potentiels pour les familles, les lignes directrices internationales en matière de réanimation devraient préconiser le choix de la famille en ce qui concerne sa présence pendant la réanimation.

Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis.
Ramaswamy VV, de Almeida MF, Dawson JA, Trevisanuto D, Nakwa FL, Kamlin CO, Hosono S, Wyckoff MH, Liley HG; International Liaison Committee on Resuscitation Neonatal Life Support Task Force. | Resuscitation. 2022 Nov;180:81-98
DOI: https://doi.org/10.1016/j.resuscitation.2022.09.014  | Télécharger l'article au format  
Keywords: Delivery room; Full-term; Hypothermia; Late-preterm; Newborn.

Review

Introduction : Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥34 weeks' gestation).

Méthode : Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed.

Résultats : 25 RCTs and 10 non-RCTs were included. Room temperature of 23 °C compared to 20 °C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30 °C, 0.23-0.37 °C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes.

Conclusion : Room temperature of 23 °C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation.

Conclusion (proposition de traduction) : Le maintien d'une température ambiante à 23 °C et le maintien du peau à peau peu après la naissance peuvent prévenir l'hypothermie chez les nouveau-nés à la phase tardive de la prématurité et à terme. Bien que le sac en polyéthylène transparent puisse être une intervention complémentaire efficace, le rapport risques-avantages doit faire l'objet d'un examen plus approfondi.

Manual chest compression pause duration for ventilations during prehospital advanced life support – An observational study to explore optimal ventilation pause duration for mechanical chest compression devices.
van Schuppen H, Doeleman LC, Hollmann MW, Koster RW.. | Resuscitation. 2022 Nov;180:24-30
DOI: https://doi.org/10.1016/j.resuscitation.2022.09.001  | Télécharger l'article au format  
Keywords: Advanced life support; Cardiac arrest; Cardiopulmonary resuscitation; Emergency medical services (EMS); Mechanical chest compression devices; Oxygenation; Prehospital care; Ventilation.

Clinical paper

Introduction : Mechanical chest compression devices in the 30:2 mode generally provide a pause of three seconds to give two insufflations without evidence supporting this pause duration. We aimed to explore the optimal pause duration by measuring the time needed for two insufflations, during advanced life support with manual compressions.

Méthode : Prospectively collected data in the AmsteRdam REsuscitation STudies (ARREST) registry were analysed, including thoracic impedance signal and waveform capnography from manual defibrillators of the Amsterdam ambulance service. Compression pauses were analysed for number of insufflations, time interval from start of the compression pause to the end of the second insufflation, chest compression pause duration and ventilation subintervals.

Résultats : During 132 out-of-hospital cardiac arrests, 1619 manual chest compression pauses to ventilate were identified. In 1364 (84%) pauses, two insufflations were given. In 28% of these pauses, giving two insufflations took more than three seconds. The second insufflation is completed within 3.8 seconds in 90% and within 5 seconds in 97.5% of these pauses. An increasing likelihood of achiev

Conclusion : When manual chest compressions are paused to give two ventila- tions, frequently (28%) more than the current 3-second timeframe of mechanical chest compression devices is needed to provide two insufflations. The optimal chest compression pause duration for mechanical chest compression devices appears to be five seconds, which warrants further studies in the context of mechanical chest compression. A 5-second pause will allow providers almost always (97.5%) to be able to provide two insufflations, while still staying within the recommended maximum timeframe of ten seconds. Addi- tionally, a 5-second pause can also be used to perform a rhythm check during Advanced Life Support, which could reduce unneces- sary long chest compressions interruptions. Further research is needed to study ventilation during mechanical chest compression and the impact of this strategy on CPR metrics and outcome.

Conclusion (proposition de traduction) : Lorsque les compressions thoraciques manuelles sont interrompues pour effectuer deux ventilations, il faut souvent (28 !%) plus de temps que le délai actuel de 3 !secondes des appareils de compression thoracique mécanique pour effectuer deux insufflations. La durée optimale de la pause de compression thoracique pour les appareils de compression thoracique mécanique semble être de cinq secondes, ce qui justifie des études supplémentaires dans le contexte de la compression thoracique mécanique. Une pause de cinq secondes permettra aux intervenants d'effectuer presque toujours (97,5 !%) deux insufflations, tout en restant dans le délai maximal recommandé de dix secondes. De plus, une pause de 5 !secondes peut également être utilisée pour effectuer un contrôle du rythme pendant les soins intensifs de réanimation, ce qui pourrait réduire les longues interruptions inutiles des compressions thoraciques. D'autres recherches sont nécessaires pour étudier la ventilation pendant la compression thoracique mécanique et l'impact de cette stratégie sur les paramètres et les résultats de la RCP.

Association of prehospital hypotension depth and dose with survival following out-of-hospital cardiac arrest.
Smida T, Menegazzi JJ, Crowe RP, Weiss LS, Salcido DD. | Resuscitation. 2022 Nov;180:99-107
DOI: https://doi.org/10.1016/j.resuscitation.2022.09.018  | Télécharger l'article au format  
Keywords: Blood pressure; Dopamine; EMS; Emergency medical services; Epinephrine; Hypotension; Hypotension dose; Infusion; Norepinephrine; Out of hospital cardiac arrest; Post ROSC; Post cardiac arrest syndrome; Post resuscitation; Post-ROSC; Prehospital; Push dose pressor; Push dose vasopressor; ROSC; Shock; Vasopressor.

Clinical paper

Introduction : Hypotension following resuscitation from out-of-hospital cardiac arrest (OHCA) may cause harm by exacerbating secondary brain injury; however, limited research has explored this relationship. Our objective was to examine the association between duration and depth of prehospital post return of spontaneous circulation (ROSC) hypotension and survival.

Méthode : We utilized the 2019 and 2020 ESO Data Collaborative public use research data sets for this study (ESO, Austin, TX). Hypotension dose (mmHg*min.), average prehospital systolic blood pressure (SBP), and lowest recorded prehospital SBP were calculated. The association of these measures with survival to home (STH) and rearrest were explored using multivariable logistic regression. Time to hypotension resolution analyses by hypotension management strategy (push dose vasopressors, vasopressor infusion, or fluid only) were conducted using adjusted Cox proportional hazards models.

Résultats : 17,280 OHCA patients met inclusion criteria, of which 3,345 had associated hospital outcome data. Over one-third (37.8%; 6,526/17,280) of all patients had at least one recorded SBP below 90 mmHg. When modeled continuously, average prehospital SBP (1.19 [1.15, 1.23] per 10 mmHg), lowest prehospital SBP (1.20 [1.17, 1.24] per 10 mmHg), and hypotension dose (0.995 [0.993, 0.996] per mmHg*min.) were independently associated with STH. Differences in hypotension management were not associated with differences in survival or time to hypotension resolution.

Conclusion : Severity and duration of hypotension were significantly associated with worse outcomes in this dataset. Defining a threshold for hypotension requiring treatment above the classical SBP threshold of 90 mmHg may be warranted in the setting of prehospital post-resuscitation care.

Conclusion (proposition de traduction) : La gravité et la durée de l'hypotension ont été significativement associées à des résultats plus défavorables dans cet ensemble de données. La définition d'un seuil d'hypotension nécessitant un traitement supérieur au seuil classique de pression artérielle systolique de 90 mmHg peut être justifiée dans le cadre des soins préhospitaliers de post-réanimation.

Intubation first-pass success in a high performing pre-hospital critical care system is not associated with 30-day mortality: a registry study of 4496 intubation attempts.
Ljungqvist H, Pirneskoski J, Saviluoto A, Setälä P, Tommila M, Nurmi J. | Scand J Trauma Resusc Emerg Med. 2022 Nov 21;30(1):61
DOI: https://doi.org/10.1186/s13049-022-01049-7  | Télécharger l'article au format  
Keywords: Air ambulances; Airway management; Critical care; Emergency medical services; First-pass success; Rapid sequence induction and intubation.

Original research

Introduction : Lower intubation first-pass success (FPS) rate is associated with physiological deterioration, and FPS is widely used as a quality indicator of the airway management of a critically ill patient. However, data on FPS's association with survival is limited. We aimed to investigate if the FPS rate is associated with 30-day mortality or physiological complications in a pre-hospital setting. Furthermore, we wanted to describe the FPS rate in Finnish helicopter emergency medical services.

Méthode : This was a retrospective observational study. Data on drug-facilitated intubation attempts by helicopter emergency medical services were gathered from a national database and analysed. Multivariate logistic regression, including known prognostic factors, was performed to assess the association between FPS and 30-day mortality, collected from population registry data.

Résultats : Of 4496 intubation attempts, 4082 (91%) succeeded on the first attempt. The mortality rates in FPS and non-FPS patients were 34% and 38% (P = 0.21), respectively. The adjusted odds ratio of FPS for 30-day mortality was 0.88 (95% CI 0.66-1.16). Hypoxia after intubation and at the time of handover was more frequent in the non-FPS group (12% vs. 5%, P < 0.001, and 5% vs. 3%, P = 0.01, respectively), but no significant differences were observed regarding other complications.

Conclusion : FPS is not associated with 30-day mortality in pre-hospital critical care delivered by advanced providers. It should therefore be seen more as a process quality indicator instead of a risk factor of poor outcome, at least considering the current limitations of the parameter.

Conclusion (proposition de traduction) : La réussite du premier essai d'intubation n'est pas associée à la mortalité à 30 jours dans les soins intensifs préhospitaliers dispensés par des prestataires de soins avancés. Il devrait donc être considéré comme un indicateur de la qualité du processus plutôt que comme un facteur de risque de mauvais résultats, du moins si l'on tient compte des limites actuelles du paramètre.

Transient synovitis of the hip: Current practice and risk of misdiagnosis.
Lipshaw MJ, Walsh PS. | Am J Emerg Med. 2022 Nov;61:1-6
DOI: https://doi.org/10.1016/j.ajem.2022.08.022
Keywords: Orthopedics; Pediatrics; Septic arthritis; Transient synovitis.

Original Contribution

Introduction : Transient synovitis (TS) is a common and benign cause of hip pain in children, but must be distinguished from more serious entities such as septic arthritis, osteomyelitis, and pyomyositis. Our objectives were to determine the risk of missed bacterial musculoskeletal infection and rates of diagnostic testing in children diagnosed with TS.

Méthode : We performed a cohort study using the Pediatric Heath Information System of children 1-10 years diagnosed with TS in the ED. We determined rates of missed bacterial musculoskeletal infection (defined as a new diagnosis of septic arthritis, osteomyelitis, or pyomyositis within 14 days of initial ED visit). We described the initial diagnostic evaluation and ED management of children diagnosed with TS and variability between sites.

Résultats : We analyzed 6419 encounters from 37 hospitals. 62 (1.0%, 95%CI: 0.7-1.2%) children were diagnosed with a missed bacterial musculoskeletal infection. Children with missed infection were younger than those without (median age 2.6 vs. 4.6 years, p < 0.01). Serum laboratory testing was performed in 76% of encounters with minimal variation across sites. There was significant variation in the rates of hip ultrasound by site (2 to 92%), which has increased in use over time (from 42% in 2016 to 62% in 2021).

Conclusion : In this large observational study, missed bacterial musculoskeletal infection in children diagnosed with TS was rare but more common in younger children. The optimal combination of bloodwork and radiographic testing, especially ultrasound, to distinguish TS from more serious disease remains unclear.

Conclusion (proposition de traduction) : Dans cette vaste étude observationnelle, le risque de passer à côté d'une infection musculo-squelettique bactérienne chez les enfants diagnostiqués avec une synovite aigüe transitoire était rare, mais plus fréquent chez les jeunes enfants. La combinaison optimale d'analyses sanguines et de tests radiographiques, en particulier l'échographie, pour distinguer une synovite aigüe transitoire d'une maladie plus grave, n'est toujours pas claire.

Early predictors of brain injury in patients with acute carbon monoxide poisoning and the neuroprotection of mild hypothermia.
Zhang JJ, Bi WK, Cheng YM, Yue AC, Song HP, Zhou XD, Bi MJ, Han W, Li Q. | Am J Emerg Med. 2022 Nov;61:18-28
DOI: https://doi.org/10.1016/j.ajem.2022.08.016
Keywords: Acute severe CO poisoning; BIS index; G-P scores; Mild hypothermia therapy; NSE; O(2)UCc.

Original Contribution

Introduction : Carbon monoxide (CO) poisoning can cause serious neurological sequelae. However, there is neither effective treatment strategy nor reliable indicators to determine the prognosis of patients with CO poisoning. The present study aimed to observe the changes of neurological function score, disease severity score, cerebral oxygen utilization (O2UCc), bispectral (BIS) index and neuron-specific enolase (NSE) concentration, and to elucidate the clinical significance of these potential indicators and the neuroprotective effect of mild hypothermia on brain injury in patients with severe acute CO poisoning.

Méthode : A total of 277 patients with acute severe CO poisoning from 2013 to 2018 were enrolled in our hospital. Patients were divided into three groups according to their body temperature on the day of admission and their willingness to treat: a fever group (n = 78), a normal temperature group (NT group, n = 113), and a mild hypothermia group (MH group, n = 86). All patients were given hyperbaric oxygen therapy, while those in the MH group received additional mild hypothermia treatment. The severity of the disease, the neurobehavioral status, the incidence of delayed encephalopathy after acute carbon monoxide poisoning (DEACMP), and other indicators including BIS, O₂UCc, NSE were further evaluated in all patients at given time-points.

Résultats : Mild hypothermia therapy improved the prognosis of patients with CO poisoning, significantly decreased the value of O₂UCc and NSE, and up-regulated BIS. The incidence of DEACMP at 6 months was 27% in the fever group, 23% in the NT group, and 8% in the MH group. The values of Glasgow-Pittsburgh coma scale (G-P score), BIS index and NSE were closely related to the occurrence of DEACMP, the cutoff values were 12.41, 52.17 and 35.20 ng/mL, and the sensitivity and specificity were 79.3%, 77.6%, 79.3% and 67.6%, 89.5%, 88.6% in the receiver operating characteristic curve (ROC), respectively.

Conclusion : Early mild hypothermia treatment could significantly reduce the severity of brain injury after CO poisoning, and might be further popularized in clinic. G-P scores, NSE and BIS index can be regarded as the prediction indicators in the occurrence and development of DEACMP.

Conclusion (proposition de traduction) : Un traitement précoce par hypothermie légère pourrait réduire de manière significative la gravité des lésions cérébrales après une intoxication au CO, et pourrait être popularisé en clinique. Les scores G-P (Glasgow-Pittsburgh coma scale), la NSE (neuron-specific enolase) et l'indice BIS peuvent être considérés comme des indicateurs de prédiction de l'apparition et du développement d'une encéphalopathie tardive après une intoxication aiguë au monoxyde de carbone.

Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation.
Foster M, Self M, Gelber A, Kennis B, Lasoff DR, Hayden SR, Wardi G. | Am J Emerg Med. 2022 Nov;61:131-136
DOI: https://doi.org/10.1016/j.ajem.2022.08.054
Keywords: Etomidate; Ketamine; Post-intubation hypotension; Rapid sequence intubation; Shock index.

Original contribution

Introduction : Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate.

Méthode : A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension.

Résultats : A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension.

Conclusion : In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.

Conclusion (proposition de traduction) : Dans notre cohorte de patients bénéficiant d'une intubation trachéale en urgence, la kétamine était plus souvent utilisée pour les patients présentant un indice de choc élevé. Nous n'avons pas identifié d'association entre l'incidence de l'hypotension post-intubation et l'agent d'induction entre la kétamine et l'étomidate. Les patients présentant un indice de choc élevé avaient un risque plus élevé de collapsus cardiovasculaire, quel que soit le choix de la kétamine ou de l'étomidate.

Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial.
Yang P, Song L, Zhang Y, Zhang X, Chen X, Li Y, Sun L, Wan Y, Billot L, Li Q, Ren X, Shen H, Zhang L, Li Z, Xing P, Zhang Y, Zhang P, Hua W, Shen F, Zhou Y, Tian B, Chen W, Han H, Zhang L, Xu C, Li T, Peng Y, Yue X, Chen S, Wen C, Wan S, Yin C, Wei M, Shu H, Nan G, Liu S, Liu W, Cai Y, Sui Y, Chen M, Zhou Y, Zuo Q, Dai D, Zhao R, Li Q, Huang Q, Xu Y, Deng B, Wu T, Lu J, Wang X, Parsons MW, Butcher K, Campbell B, Robinson TG, Goyal M, Dippel D, Roos Y, M. | Lancet. 2022 Nov 5;400(10363):1585-1596
DOI: https://doi.org/10.1016/s0140-6736(22)01882-7
Keywords: Aucun

Article

Introduction : The optimum systolic blood pressure after endovascular thrombectomy for acute ischaemic stroke is uncertain. We aimed to compare the safety and efficacy of blood pressure lowering treatment according to more intensive versus less intensive treatment targets in patients with elevated blood pressure after reperfusion with endovascular treatment.

Méthode : We conducted an open-label, blinded-endpoint, randomised controlled trial at 44 tertiary-level hospitals in China. Eligible patients (aged ≥18 years) had persistently elevated systolic blood pressure (≥140 mm Hg for >10 min) following successful reperfusion with endovascular thrombectomy for acute ischaemic stroke from any intracranial large-vessel occlusion. Patients were randomly assigned (1:1, by a central, web-based program with a minimisation algorithm) to more intensive treatment (systolic blood pressure target <120 mm Hg) or less intensive treatment (target 140-180 mm Hg) to be achieved within 1 h and sustained for 72 h. The primary efficacy outcome was functional recovery, assessed according to the distribution in scores on the modified Rankin scale (range 0 [no symptoms] to 6 [death]) at 90 days. Analyses were done according to the modified intention-to-treat principle. Efficacy analyses were performed with proportional odds logistic regression with adjustment for treatment allocation as a fixed effect, site as a random effect, and baseline prognostic factors, and included all randomly assigned patients who provided consent and had available data for the primary outcome. The safety analysis included all randomly assigned patients. The treatment effects were expressed as odds ratios (ORs).

Résultats : Between July 20, 2020, and March 7, 2022, 821 patients were randomly assigned. The trial was stopped after review of the outcome data on June 22, 2022, due to persistent efficacy and safety concerns. 407 participants were assigned to the more intensive treatment group and 409 to the less intensive treatment group, of whom 404 patients in the more intensive treatment group and 406 patients in the less intensive treatment group had primary outcome data available. The likelihood of poor functional outcome was greater in the more intensive treatment group than the less intensive treatment group (common OR 1·37 [95% CI 1·07-1·76]). Compared with the less intensive treatment group, the more intensive treatment group had more early neurological deterioration (common OR 1·53 [95% 1·18-1·97]) and major disability at 90 days (OR 2·07 [95% CI 1·47-2·93]) but there were no significant differences in symptomatic intracerebral haemorrhage. There were no significant differences in serious adverse events or mortality between groups.

Conclusion : Intensive control of systolic blood pressure to lower than 120 mm Hg should be avoided to prevent compromising the functional recovery of patients who have received endovascular thrombectomy for acute ischaemic stroke due to intracranial large-vessel occlusion.

Conclusion (proposition de traduction) : Le contrôle intensif de la pression artérielle systolique à moins de 120 mm Hg doit être évité pour ne pas compromettre la récupération fonctionnelle des patients ayant subi une thrombectomie endovasculaire pour un accident vasculaire cérébral ischémique aigu dû à une occlusion intracrânienne des gros vaisseaux.

Defibrillation Strategies for Refractory Ventricular Fibrillation.
Cheskes S, Verbeek PR, Drennan IR, McLeod SL, Turner L, Pinto R, Feldman M, Davis M, Vaillancourt C, Morrison LJ, Dorian P, Scales DC. | N Engl J Med. 2022 Nov 24;387(21):1947-1956
DOI: https://doi.org/10.1056/nejmoa2207304
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Despite advances in defibrillation technology, shock-refractory ventricular fibrillation remains common during out-of-hospital cardiac arrest. Double sequential external defibrillation (DSED; rapid sequential shocks from two defibrillators) and vector-change (VC) defibrillation (switching defibrillation pads to an anterior-posterior position) have been proposed as defibrillation strategies to improve outcomes in patients with refractory ventricular fibrillation.

Méthode : We conducted a cluster-randomized trial with crossover among six Canadian paramedic services to evaluate DSED and VC defibrillation as compared with standard defibrillation in adult patients with refractory ventricular fibrillation during out-of-hospital cardiac arrest. Patients were treated with one of these three techniques according to the strategy that was randomly assigned to the paramedic service. The primary outcome was survival to hospital discharge. Secondary outcomes included termination of ventricular fibrillation, return of spontaneous circulation, and a good neurologic outcome, defined as a modified Rankin scale score of 2 or lower (indicating no symptoms to slight disability) at hospital discharge.

Résultats : A total of 405 patients were enrolled before the data and safety monitoring board stopped the trial because of the coronavirus disease 2019 pandemic. A total of 136 patients (33.6%) were assigned to receive standard defibrillation, 144 (35.6%) to receive VC defibrillation, and 125 (30.9%) to receive DSED. Survival to hospital discharge was more common in the DSED group than in the standard group (30.4% vs. 13.3%; relative risk, 2.21; 95% confidence interval [CI], 1.33 to 3.67) and more common in the VC group than in the standard group (21.7% vs. 13.3%; relative risk, 1.71; 95% CI, 1.01 to 2.88). DSED but not VC defibrillation was associated with a higher percentage of patients having a good neurologic outcome than standard defibrillation (relative risk, 2.21 [95% CI, 1.26 to 3.88] and 1.48 [95% CI, 0.81 to 2.71], respectively).

Conclusion : Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation.

Conclusion (proposition de traduction) : Parmi les patients présentant une fibrillation ventriculaire réfractaire, la survie jusqu'à la sortie de l'hôpital était plus fréquente chez ceux qui avaient bénéficié d'une défibrillation externe double séquentielle (Double défibrillation) ou d'une défibrillation par changement de vecteur que chez ceux qui avaient reçu une défibrillation standard.

Commentaire :  Le positionnement des électrodes pour la défibrillation standard, la défibrillation par changement de vecteur (VC), et la défibrillation externe séquentielle double (DSED) est illustré. Dans le panneau inférieur, les électrodes de défibrillation 2A et 2B sont celles du second défibrillateur, avec les électrodes placées dans les positions postérieure et antérieure. Pour toutes les Dans le panneau inférieur, les électrodes de défibrillation 2A et 2B sont celles du second défibrillateur, avec les électrodes placées dans les positions postérieure et antérieure. Pour toutes les stratégies stratégies, les trois premiers chocs ont eu lieu avec les électrodes placées dans la configuration utilisée pour la défibrillation standard.