Severe and traumatic injuries associated with home trampoline use in children and adolescents: A systematic review.
Eslick GD, Nunez C, Elliott EJ. | Acad Emerg Med. 2023 Mar;30(3):209-213
DOI: https://doi.org/10.1111/acem.14594
Keywords: accidental injury, childhood injury, public health, systematic review, trampoline injury

SYSTEMATIC REVIEW

Editorial : Trampolining is a popular form of recreation and trampolines are among the most common gifts to school age children and preadolescents. However, trampolining poses a significant risk of injury, which accounts annually for nearly 100,000 pediatric emergency visits in the United States. A recent meta-analysis of 11 studies with 1,386,843 trampoline injuries compared the type and site of injury sustained at trampoline centers and on home trampolines. The study identified that musculoskeletal and/or orthopedic injuries, lower-extremity injury, sprains, or a need for surgery were more likely to result from injuries sustained at trampoline centers rather than on home trampolines. Conversely, upper-extremity in-jury (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.05–4.00), concussion (OR 2.08, 95% CI 1.54–2.86), and lacerations (OR 2.17, 95% CI 1.69–2.86) were more likely to occur in the home compared to trampoline centers.

Conclusion : Our study highlights that severe and traumatic injuries can result from children and adolescents using home trampolines but is an underestimate of the true number of severe cases that present to hospital emergency departments. These reports suggest that severe and traumatic trampoline injuries do occur on home trampolines and not just in trampoline centers. There is an urgent need for educa-tion of children and parents/caregivers about the dangers associated with home trampolines. Simple measures could reduce the number of severe and traumatic injuries on home trampolines. These include making sure that any purchased trampoline meets industry safety standards; having adult supervision at all times; preventing children under 6 years of age from using the trampoline; having only one person on the trampoline at a time; making sure the trampoline's bars, springs, and surrounding landing surfaces are covered with protective padding; and prohibiting high-risk maneuvers such as somersaults. In addition, some of these children had a delayed presentation to hospital, which has the potential to affect long-term outcomes. It would be of value for parents and caregivers to have completed a first aid course and follow the advice “if in doubt, have it checked out!” immediately no matter how minor the symptoms may appear after an accident on a trampoline.

Conclusion (proposition de traduction) : Notre étude souligne que des blessures graves et traumatiques peuvent résulter de l'utilisation de trampolines domestiques par des enfants et des adolescents, mais qu'elle sous-estime le nombre réel de cas graves qui se présentent aux services d'urgence des hôpitaux. Ces rapports suggèrent que des blessures graves et traumatiques se produisent sur les trampolines à domicile et pas seulement dans les centres de trampolines. Il est urgent d'éduquer les enfants et les parents/soignants sur les dangers associés aux trampolines domestiques. Des mesures simples pourraient réduire le nombre de blessures graves et traumatiques sur les trampolines domestiques. Il s'agit notamment de s'assurer que le trampoline acheté répond aux normes de sécurité de l'industrie, d'assurer la surveillance d'un adulte à tout moment, d'empêcher les enfants de moins de 6 ans d'utiliser le trampoline, de ne faire monter qu'une seule personne à la fois sur le trampoline, de s'assurer que les barres, les ressorts et les surfaces d'atterrissage du trampoline sont recouverts d'un rembourrage de protection et d'interdire les manœuvres à haut risque telles que les sauts périlleux. En outre, certains de ces enfants se sont présentés tardivement à l'hôpital, ce qui peut avoir une incidence sur les résultats à long terme. Il serait utile que les parents et les soignants aient suivi un cours de premiers secours et suivent le conseil "en cas de doute, faites-vous examiner" immédiatement, même si les symptômes semblent mineurs après un accident sur un trampoline.

Age-Stratified Propofol Dosage for Pediatric Procedural Sedation and Analgesia.
van Dijk H, Hendriks MP, van Eck-Smaling MM, van Wolfswinkel L, van Loon K. | Anesth Analg. 2023 Mar 1;136(3):551-558
DOI: https://doi.org/10.1213/ane.0000000000006196  | Télécharger l'article au format  
Keywords: Aucun

OrigiNal CliNiCal researCh repOrt

Introduction : Procedural sedation and analgesia (PSA) for diagnostic and minimally invasive therapeutic procedures has become common practice in children of all ages. Based on our clinical experience, we suspected an inverse relation between age and dosage. However, a schedule for age-stratified propofol induction and maintenance dosage for PSA was not available and could be helpful to many anesthesiologists as a reference.

Méthode : We performed a retrospective cohort study of children who received procedural sedation at the Wilhelmina Children's Hospital (WKZ), a tertiary pediatric hospital part of the University Medical Center Utrecht (UMCU), between June 2007 and December 2020. We studied whether the induction (mg·kg -1 ) and maintenance (mg·kg -1 ·h -1 ) dosage is age-dependent using linear regression models.

Résultats : A total of 6438 pediatric procedures were retrieved from Anesthesia Information Management Systems (AIMS). A total of 5567 records were available for induction dose analysis and 5420 records for analysis of the maintenance dose. After adjustment for sex, American Society of Anesthesiologists (ASA) physical status classification, opioid administration, and diagnostic or interventional, we obtained a coefficient of -0.11 (95% confidence interval [CI], -0.12 to -0.11) for age (years) from a multivariable linear regression model for propofol induction dosage (mg·kg -1 ) and a coefficient of -0.36 (95% CI, -0.39 to -0.34) for age (years) for propofol maintenance dosage.

Conclusion : We found a noteworthy inverse age-effect on propofol dosage for both induction and maintenance of pediatric procedural sedation. Furthermore, our study revealed that remarkably higher propofol sedation doses were needed for infants and toddlers than previously expected and reported.

Conclusion (proposition de traduction) : Nous avons constaté un effet inverse de l'âge sur la dose de propofol pour l'induction et le maintien de la sédation procédurale pédiatrique. En outre, notre étude a révélé que des doses de sédation au propofol remarquablement plus élevées que celles prévues et rapportées précédemment étaient nécessaires pour les nourrissons et les enfants en bas âge.

Effect of Different Early Oxygenation Levels on Clinical Outcomes of Patients Presenting in the Emergency Department With Severe Traumatic Brain Injury.
Kotanidou A, Siempos II. | Ann Emerg Med. 2023 Mar;81(3):273-281
DOI: https://doi.org/10.1016/j.annemergmed.2022.09.026  | Télécharger l'article au format  
Keywords: Aucun

Trauma

Introduction : Despite the almost universal administration of supplemental oxygen in patients presenting in the emergency department (ED) with severe traumatic brain injury, optimal early oxygenation levels are unknown. Therefore, we aimed to examine the effect of different early oxygenation levels on the clinical outcomes of patients presenting in the emergency department with severe traumatic brain injury.

Méthode : We performed a secondary analysis of the Resuscitation Outcomes Consortium Traumatic Brain Injury Hypertonic Saline randomized controlled trial by including patients with Glasgow Coma Scale ≤8. Early oxygenation levels were assessed by the worst value of arterial partial pressure of oxygen (PaO2) during the first 4 hours of presentation in the emergency department. The primary outcome was 6-month neurologic status, as assessed by the Extended Glasgow Outcome Scale. A binary logistic regression was utilized, and an odds ratio (OR) with 95% (95% confidence intervals) was calculated.

Résultats : A total of 910 patients were included. In unadjusted (crude) analysis, a PaO2 of 101 to 250 mmHg (OR, 0.59 [0.38 to 0.91]), or 251 to 400 mmHg (OR, 0.53 [0.34 to 0.83]) or ≥401 mmHg (OR, 0.31 [0.20 to 0.49]) was less likely to be associated with poor neurologic status when compared with a PaO2 of ≤100 mmHg. This was also the case for adjusted analyses (including age, pupillary reactivity, and Revised Trauma Score).

Conclusion : High oxygenation levels as early as the first 4 hours of presentation in the emergency department may not be adversely associated with the long-term neurologic status of patients with severe traumatic brain injury. Therefore, during the early phase of trauma, clinicians may focus on stabilizing patients while giving low priority to the titration of oxygenation levels.

Conclusion (proposition de traduction) : Des niveaux d'oxygénation élevés au cours des 4 premières heures de l'arrivée aux urgences peuvent ne pas être associés à des effets négatifs sur l'état neurologique à long terme des patients souffrant de lésions cérébrales traumatiques sévères. Par conséquent, pendant la phase initiale du traumatisme, les médecins peuvent se concentrer sur la stabilisation des patients tout en accordant une faible priorité à la titration des niveaux d'oxygénation.

Final Study Report of Andexanet Alfa for Major Bleeding With Factor Xa Inhibitors.
Milling TJ Jr, Middeldorp S, Xu L, Koch B, Demchuk A, Eikelboom JW, Verhamme P, Cohen AT, Beyer-Westendorf J, Gibson CM, Lopez-Sendon J, Crowther M, Shoamanesh A, Coppens M, Schmidt J, Albaladejo P, Connolly SJ; ANNEXA-4 Investigators. | Circulation. 2023 Mar 28;147(13):1026-1038
DOI: https://doi.org/10.1161/circulationaha.121.057844
Keywords: clinical trials; cohort studies; factor Xa inhibitors; gastrointestinal hemorrhage; intracranial hemorrhage.

Original Research Article

Introduction : Andexanet alfa is a modified recombinant inactive factor Xa (FXa) designed to reverse FXa inhibitors. ANNEXA-4 (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) was a multicenter, prospective, phase-3b/4, single-group cohort study that evaluated andexanet alfa in patients with acute major bleeding. The results of the final analyses are presented.

Méthode : Patients with acute major bleeding within 18 hours of FXa inhibitor administration were enrolled. Co-primary end points were anti-FXa activity change from baseline during andexanet alfa treatment and excellent or good hemostatic efficacy, defined by a scale used in previous reversal studies, at 12 hours. The efficacy population included patients with baseline anti-FXa activity levels above predefined thresholds (≥75 ng/mL for apixaban and rivaroxaban, ≥40 ng/mL for edoxaban, and ≥0.25 IU/mL for enoxaparin; reported in the same units used for calibrators) who were adjudicated as meeting major bleeding criteria (modified International Society on Thrombosis and Haemostasis definition). The safety population included all patients. Major bleeding criteria, hemostatic efficacy, thrombotic events (stratified by occurring before or after restart of either prophylactic [ie, a lower dose, for prevention rather than treatment] or full-dose oral anticoagulation), and deaths were assessed by an independent adjudication committee. Median endogenous thrombin potential at baseline and across the follow-up period was a secondary outcome.

Résultats : There were 479 patients enrolled (mean age, 78 years; 54% male; 86% White); 81% were anticoagulated for atrial fibrillation, and the median time was 11.4 hours since last dose, with 245 (51%) on apixaban, 176 (37%) on rivaroxaban, 36 (8%) on edoxaban, and 22 (5%) on enoxaparin. Bleeding was predominantly intracranial (n=331 [69%]) or gastrointestinal (n=109 [23%]). In evaluable apixaban patients (n=172), median anti-FXa activity decreased from 146.9 ng/mL to 10.0 ng/mL (reduction, 93% [95% CI, 94-93]); in rivaroxaban patients (n=132), it decreased from 214.6 ng/mL to 10.8 ng/mL (94% [95% CI, 95-93]); in edoxaban patients (n=28), it decreased from 121.1 ng/mL to 24.4 ng/mL (71% [95% CI, 82-65); and in enoxaparin patients (n=17), it decreased from 0.48 IU/mL to 0.11 IU/mL (75% [95% CI, 79-67]). Excellent or good hemostasis occurred in 274 of 342 evaluable patients (80% [95% CI, 75-84]). In the safety population, thrombotic events occurred in 50 (10%) patients; in 16 patients, these occurred during treatment with prophylactic anticoagulation that began after the bleeding event. No thrombotic episodes occurred after oral anticoagulation restart. Specific to certain populations, reduction of anti-FXa activity from baseline to nadir significantly predicted hemostatic efficacy in patients with intracranial hemorrhage (area under the receiver operating characteristic curve, 0.62 [95% CI, 0.54-0.70]) and correlated with lower mortality in patients <75 years of age (adjusted P=0.022; unadjusted P=0.003). Median endogenous thrombin potential was within the normal range by the end of andexanet alfa bolus through 24 hours for all FXa inhibitors.

Conclusion : In patients with major bleeding associated with the use of FXa inhibitors, treatment with andexanet alfa reduced anti-FXa activity and was associated with good or excellent hemostatic efficacy in 80% of patients.

Conclusion (proposition de traduction) : Chez les patients présentant une hémorragie majeure associée à l'utilisation d'inhibiteurs du Facteur Xa, le traitement par andexanet alfa a réduit l'activité anti-Facteur Xa et a été associé à une efficacité hémostatique bonne ou excellente chez 80 % des patients.

Commentaire : Deux classes d'AOD :
• inhibiteurs directs du facteur Xa : rivaroxaban [XARELTO], apixaban [ELIQUIS], edoxaban [LIXIANA] ;
• inhibiteur direct de la thrombine (anti-IIa) : dabigatran [PRADAXA] (neutralisation de l’effet anticoagulant spécifique par l'idarucizumab [PRAXBIND]).

Fluids and vasopressors in septic shock: basic knowledge for a firstapproach in the emergency department.
Coen D | Emerg Care J. 2023 Mar;19:10810
DOI: https://doi.org/10.4081/ecj.2023.10810  | Télécharger l'article au format  
Keywords: fluid resuscitation; vasopressors; septic shock; preload; stressed volume; emergency department.

REVIEW

Editorial : Much research, both pathophysiological and clinical, has been produced on septic shock during the last 20 years. Nevertheless, many aspects of treatment are still controversial, among these the approach to the administration of fluids and vasopressors. Moreover, most clinical research on septic shock was produced in the ICU setting on mechanically ventilated and invasively monitored patients, a situation hardly comparable to that of most emergency rooms throughout the world. In this non-systematic review, the basic pathophysiological concepts and the most important messages from clinical studies will be summarized, with the aim to identify the baseline skills and knowledge necessary for a first approach to septic shock patients in the emergency room.

Conclusion : Noradrenaline is the vasopressor of choice and, when necessary, it can be first administered in a peripheral vein. The addition of other vasopressors (adrenaline or vasopressin) is acceptable in patients who do not respond to noradrenaline. The use of inotropic drugs has a rationale in case of left ventricular insufficiency and an inadequate response to fluids and noradrenaline, although it is not supported by appropriate clinical trials. Echocardiography may help identify patients that could better respond to inotropes. This treatment, as well as the administration of adrenaline, should be constantly monitored and reserved for patients followed in an intensive care setting. Since an early and appropriate antimicrobial treatment has the best correlation with prognosis, ED physicians should pay the utmost attention to identifying and possibly removing the source of infection. Early cultures and initiation of antibiotic treatment are also of paramount importance. Finally, the very frail patients in whom sepsis is the final event of advanced chronic disease should be spared unnecessary clinical aggressiveness and be started on palliative care early.

Conclusion (proposition de traduction) : La noradrénaline est le vasopresseur de choix et, si nécessaire, elle peut être administrée en premier lieu par voie veineuse périphérique. L'ajout d'autres vasopresseurs (adrénaline ou vasopressine) est acceptable chez les patients qui ne répondent pas à la noradrénaline. L'utilisation de médicaments inotropes est justifiée en cas d'insuffisance ventriculaire gauche et de réponse inadéquate au remplissage vasculaire et à la noradrénaline, bien qu'elle ne soit pas étayée par des essais cliniques suffisants. L'échocardiographie peut aider à identifier les patients qui pourraient mieux répondre aux inotropes. Ce traitement, ainsi que l'administration d'adrénaline, doit faire l'objet d'une surveillance constante et être réservé aux patients suivis dans un environnement de soins intensifs. Étant donné qu'un traitement antibiotique précoce et approprié présente la meilleure corrélation avec le pronostic, les urgentistes doivent accorder la plus grande attention à l'identification et à l'élimination éventuelle de la source d'infection. Des hémocultures précoces et l'instauration d'un traitement antibiotique sont également d'une importance essentielle. Enfin, les patients très fragiles chez qui le sepsis est l'événement final d'une maladie chronique avancée doivent être épargnés d'une escalade clinique inutile et bénéficier de soins palliatifs précoces.

Diagnostic performance of S100B as a rule-out test for intracranial pathology in head-injured patients presenting to the emergency department who meet NICE Head Injury Guideline criteria for CT-head scan.
Rogan A, Sik A, Dickinson E, Patel V, Peckler B, McQuade D, Larsen PD; Endorsed by ACEM Emergency Department Epidemiology Network. | Emerg Med J. 2023 Mar;40(3):159-166
DOI: https://doi.org/10.1136/emermed-2022-212549  | Télécharger l'article au format  
Keywords: Computed tomography; Diagnostic Tests; craniocerebral trauma; management.

Original research

Introduction : Traumatic brain injury is a common ED presentation. CT-head utilisation is escalating, exacerbating resource pressure in the ED. The biomarker S100B could assist clinicians with CT-head decisions by excluding intracranial pathology. Diagnostic performance of S100B was assessed in patients meeting National Institute of Health and Clinical Excellence Head Injury Guideline (NICE HIG) criteria for CT-head within 6 and 24 hours of injury.

Méthode : This multicentre prospective observational study included adult patients presenting to the ED with head injuries between May 2020 and June 2021. Informed consent was obtained from patients meeting NICE HIG CT-head criteria. A venous blood sample was collected and serum was tested for S100B using a Cobas Elecsys-S100 module; >0.1 µg/mL was the threshold used to indicate a positive test. Intracranial pathology reported on CT-head scan by the duty radiologist was used as the reference standard to review diagnostic performance.

Résultats : This study included 265 patients of whom 35 (13.2%) had positive CT-head findings. Within 6 hours of injury, sensitivity of S100B was 93.8% (95% CI 69.8% to 99.8%) and specificity was 30.8% (22.6% to 40.0%). Negative predictive value (NPV) was 97.3% (95% CI 84.2% to 99.6%) and area under the curve (AUC) was 0.73 (95% CI 0.61 to 0.85; p=0.003). Within 24 hours of injury, sensitivity was 82.9% (95% CI 66.4% to 93.44%) and specificity was 43.0% (95% CI 36.6% to 49.7%). NPV was 94.29% (95% CI 88.7% to 97.2%) and AUC was 0.65 (95% CI 0.56 to 0.74; p=0.046). Theoretically, use of S100B as a rule-out test would have reduced CT-head scans by 27.1% (95% CI 18.9% to 36.8%) within 6 hours and 37.4% (95% CI 32.0% to 47.2%) within 24 hours. The risk of missing a significant injury with this approach would have been 0.75% (95% CI 0.0% to 2.2%) within 6 hours and 2.3% (95% CI 0.5% to 4.1%) within 24 hours.

Conclusion : Within 6 hours of injury, S100B performed well as a diagnostic test to exclude significant intracranial pathology in low-risk patients presenting with head injury. In theory, if used in addition to NICE HIGs, CT-head rates could reduce by one-quarter with a potential miss rate of <1%.

Conclusion (proposition de traduction) : Dans les 6 heures suivant le traumatisme, la S100B a donné de bons résultats en tant que test diagnostique permettant d'exclure une pathologie intracrânienne significative chez les patients à faible risque se présentant avec un traumatisme crânien. En théorie, s'il est utilisé en complément des lignes directrices du National Institute of Health and Clinical Excellence sur les traumatismes crâniens, les taux de tomodensitométrie crânienne pourraient être réduits d'un quart, avec un taux d'échec potentiel de moins de 1 %.

Prevalence of secondary insults and outcomes of patients with traumatic brain injury intubated in the prehospital setting: a retrospective cohort study.
Butterfield M, Bodnar D, Williamson F, Parker L, Ryan G. | Emerg Med J. 2023 Mar;40(3):167-174
DOI: https://doi.org/10.1136/emermed-2022-212513  | Télécharger l'article au format  
Keywords: RSI; Rapid Sequence Induction and Intubation; craniocerebral trauma; pre-hospital; pre-hospital care.

Original research

Introduction : Prehospital neuroprotective strategies aim to prevent secondary insults (SIs) in traumatic brain injury (TBI). This includes haemodynamic optimisation in addition to oxygenation and ventilation targets achieved through rapid sequence intubation (RSI).The primary aim was to report the incidence and prevalence of SIs (prolonged hypotension, prolonged hypoxia and hyperventilation) and outcomes of patients with TBI who were intubated in the prehospital setting.

Méthode : A retrospective cohort study of adult patients with TBI who underwent RSI by a metropolitan road-based service in South-East Queensland, Australia between 1 January 2017 and 31 December 2020. Patients were divided into two cohorts based on the presence or absence of any SI sustained. Prolonged SIs were defined as occurring for ≥5 min. The association between SIs and mortality was examined in multivariable logistic regression and reported with adjusted ORs (aORs) and 95% CIs.

Résultats : 277 patients were included for analysis. Median 'Head' Abbreviated Injury Scale and Injury Severity Score were 4 (IQR: 3-5) and 26 (IQR: 17-34), respectively. Most episodes of prolonged hypotension and prolonged hypoxia were detected with the first patient contact on scene. Overall, 28-day mortality was 26%. Patients who sustained any SI had a higher mortality than those sustaining no SI (34.9% vs 14.7%, p<0.001). Prolonged hypoxia was an independent predictor of mortality (aOR 4.86 (95% CI 1.65 to 15.61)) but not prolonged hypotension (aOR 1.45 (95% CI 0.5 to 4.25)) or an end-tidal carbon dioxide <30 mm Hg on hospital arrival (aOR 1.28 (95% CI 0.5 to 3.21)).

Conclusion : SIs were common in the early phase of prehospital care. The association of prolonged hypoxia and mortality in TBI is potentially more significant than previously recognised, and if corrected early, may improve outcomes. There may be a greater role for bystander intervention in prevention of early hypoxic insult in TBI.

Conclusion (proposition de traduction) : Les lésions secondaires sont fréquentes dans la phase initiale des soins préhospitaliers. L'association entre l'hypoxie prolongée et la mortalité dans les cas de lésions cérébrales traumatiques est potentiellement plus importante qu'on ne le pensait auparavant et, si elle est corrigée rapidement, elle peut améliorer les résultats. L'intervention des témoins pourrait jouer un rôle plus important dans la prévention des lésions hypoxiques précoces en cas de traumatisme crânien.

Does pre-injury clopidogrel use increase the risk of intracranial haemorrhage post head injury in adult patients? A systematic review and meta-analysis.
Moffatt S, Venturini S, Vulliamy P. | Emerg Med J. 2023 Mar;40(3):175-181
DOI: https://doi.org/10.1136/emermed-2021-212225
Keywords: Computed Tomography; craniocerebral trauma; emergency department.

Systematic review

Introduction : Several current guidelines do not include antiplatelet use as an explicit indication for CT scan of the head following head injury. The impact of individual antiplatelet agent use on rates of intracranial haemorrhage is unclear. The primary objective of this systematic review was to assess if clopidogrel monotherapy was associated with traumatic intracranial haemorrhage (tICH) on CT of the head within 24 hours of presentation following head trauma compared with no antithrombotic controls.

Méthode : Eligible studies were non-randomised studies with participants aged ≥18 years old with head injury. Studies had to have conducted CT of the head within 24 hours of presentation and contain a no antithrombotic control group and a clopidogrel monotherapy group.Eight databases were searched from inception to December 2020. Assessment of identified studies against inclusion criteria and data extraction were carried out independently and in duplicate by two authors.Quality assessment and risk of bias (ROB) were assessed using the Newcastle-Ottawa Quality Assessment tool and Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. Meta-analysis was conducted using a random-effects model and reported as an OR and 95% CI.

Résultats : Seven studies were eligible for inclusion with a total of 21 898 participants that were incorporated into the meta-analysis. Five studies were retrospective. Clopidogrel monotherapy was not significantly associated with an increase in risk of tICH compared with no antithrombotic controls (OR 0.97, 95% CI 0.54 to 1.75). Heterogeneity was high with an I² of 75%. Sensitivity analysis produced an I² of 21% and did not show a significant association between clopidogrel monotherapy and risk of tICH (OR 1.16, 95% CI 0.87 to 1.55). All studies scored for moderate to serious ROB on categories in the ROBINS-I tool.

Conclusion : Included studies were vulnerable to confounding and several were small-scale studies. The results should be interpreted with caution given the ROB identified. This study does not provide statistically significant evidence that clopidogrel monotherapy patients are at increased risk of tICH after head injury compared with no antithrombotic controls.

Conclusion (proposition de traduction) : Les études incluses étaient sujettes à des facteurs de confusion et plusieurs d'entre elles étaient des études à petite échelle. Les résultats doivent être interprétés avec prudence compte tenu du risque de biais identifié. Cette étude ne fournit pas de preuves statistiquement significatives que les patients traités par clopidogrel en monothérapie courent un risque accru d'hémorragie intracrânienne traumatique après un traumatisme crânien, par rapport aux témoins ne prenant pas d'antithrombotique.

Paediatric acute non-traumatic limp presenting to the emergency department: a retrospective observational study.
Tu J, Haines M, Gowdie P, Craig S. | Emerg Med J. 2023 Mar;40(3):182-188
DOI: https://doi.org/10.1136/emermed-2022-212624
Keywords: epidemiology; pediatric emergency medicine.

Original research

Introduction : Acute non-traumatic limp in children has many causes, ranging from common benign and self-limiting disease to serious time-sensitive emergencies such as septic arthritis. We aimed to (1) describe the epidemiology and workup of paediatric acute non-traumatic limp presentation in three Australian EDs and (2) compare investigations and treatment between a tertiary paediatric centre and two non-tertiary centres.

Méthode : A retrospective chart review of children aged 0-16 years, with an initial presentation of non-traumatic limp to three EDs in Melbourne, Australia. Data on presentation, management and outcomes was systematically collected on all eligible patients.

Résultats : Of 63 941 presentations over a 12-month period, 475 (0.7%) met inclusion criteria. The median (IQR) age of presentation was 5 (3-8) years, with a male predominance (61%). Blood tests and imaging were performed in 39% and 51%, respectively. 34% of presentations had no investigations. The most frequent ED diagnoses were transient synovitis (37%) and viral myositis (16%). 84% were discharged home after ED evaluation. Compared with the two non-tertiary hospitals, children who presented to the tertiary centre were less likely to have any investigation performed (OR=0.41, 95% CI: 0.27 to 0.62, p<0.001) and more likely to be discharged home after evaluation (OR=4.67, 95% CI: 2.79 to 7.81, p<0.001).

Conclusion : Although mostly due to benign disorders, an important number of limping children who presented to the ED had serious disease, with approximately one-third of these not diagnosed at the initial ED visit. There is large variation in workup including blood test, imaging and decisions regarding ED disposition.

Conclusion (proposition de traduction) : Bien que la plupart du temps due à des pathologies bénignes, un nombre important d'enfants qui boitent et qui se présentent aux urgences souffre d'une maladie grave, dont environ un tiers n'est pas diagnostiqué lors de la première visite aux urgences. Il y a une grande variation dans le bilan, y compris les examens de sang, l'imagerie et les décisions concernant la prise en charge aux urgences.

Machine learning to predict in-hospital cardiac arrest from patients presenting to the emergency department.
Lu TC, Wang CH, Chou FY, Sun JT, Chou EH, Huang EP, Tsai CL, Ma MH, Fang CC, Huang CH. | Intern Emerg Med. 2023 Mar;18(2):595-605
DOI: https://doi.org/10.1007/s11739-022-03143-1
Keywords: Cardiopulmonary resuscitation; Emergency department; In-hospital cardiac arrest; Machine learning.

EM - ORIGINAL

Introduction : In-hospital cardiac arrest (IHCA) in the emergency department (ED) is not uncommon but often fatal. Using the machine learning (ML) approach, we sought to predict ED-based IHCA (EDCA) in patients presenting to the ED based on triage data. We retrieved 733,398 ED records from a tertiary teaching hospital over a 7 year period (Jan. 1, 2009-Dec. 31, 2015).

Méthode : We included only adult patients (≥ 18 y) and excluded cases presenting as out-of-hospital cardiac arrest. Primary outcome (EDCA) was identified via a resuscitation code. Patient demographics, triage data, and structured chief complaints (CCs), were extracted. Stratified split was used to divide the dataset into the training and testing cohort at a 3-to-1 ratio.

Résultats : Three supervised ML models were trained and performances were evaluated and compared to the National Early Warning Score 2 (NEWS2) and logistic regression (LR) model by the area under the receiver operating characteristic curve (AUC). We included 316,465 adult ED records for analysis. Of them, 636 (0.2%) developed EDCA. Of the constructed ML models, Random Forest outperformed the others with the best AUC result (0.931, 95% CI 0.911-0.949), followed by Gradient Boosting (0.930, 95% CI 0.909-0.948) and Extra Trees classifier (0.915, 95% CI 0.892-0.936). Although the differences between each of ML models and LR (AUC: 0.905, 95% CI 0.882-0.926) were not significant, all constructed ML models performed significantly better than using the NEWS2 scoring system (AUC 0.678, 95% CI 0.635-0.722).

Conclusion : Our ML models showed excellent discriminatory performance to identify EDCA based only on the triage information. This ML approach has the potential to reduce unexpected resuscitation events if successfully implemented in the ED information system.

Conclusion (proposition de traduction) : Nos modèles d'apprentissage automatique ont montré d'excellentes performances discriminatoires pour identifier les arrêts cardiaques à l'hôpital à partir des seules informations de triage. Cette approche d'apprentissage automatique a le potentiel de réduire les événements inattendus de mort subite si elle est mise en œuvre avec succès dans le système d'information du service des urgences.

Point-of-care ultrasound improves clinical outcomes in patients with acute onset dyspnea: a systematic review and meta-analysis.
Szabó GV, Szigetváry C, Szabó L, Dembrovszky F, Rottler M, Ocskay K, Madzsar S, Hegyi P, Molnár Z. | Intern Emerg Med. 2023 Mar;18(2):639-653
DOI: https://doi.org/10.1007/s11739-022-03126-2  | Télécharger l'article au format  
Keywords: Acute-onset dyspnea; Clinical outcomes; Point-of-care ultrasound.

CE-SYSTEMATIC REVIEWS AND META-ANALYSIS

Introduction : The early, appropriate management of acute onset dyspnea is important but often challenging. The aim of this study was to investigate the effects of the use of Point-of-Care Ultrasound (PoCUS) versus conventional management on clinical outcomes in patients with acute onset dyspnea. The Cochrane Library, MEDLINE, EMBASE and reference lists were searched to identify eligible trials (inception to October 14, 2021). There were no language restrictions. Randomized controlled trials (RCTs), and prospective and retrospective cohort studies that compared PoCUS with conventional diagnostic modalities (controls) in patients with acute onset dyspnea were included. Two independent reviewers extracted data and assessed the risk of bias. Disagreements were resolved by consensus.

Méthode : The primary study outcomes were time to diagnosis, time to treatment, and length of stay (LOS). Secondary outcomes included rate of appropriate treatment, 30-day re-admission rate, and mortality. We included eight RCTs and six observational studies with a total of 5393 participants. Heterogeneity across studies was variable (from low to considerable), with overall low or moderate study quality and low or moderate risk of bias (except one article with serious risk of bias).

Résultats : Time to diagnosis (mean difference [MD], - 63 min; 95% CI, - 115 to - 11 min] and time to treatment (MD, - 27 min; 95% CI - 43 to - 11 min) were significantly shorter in the PoCUS group. In-hospital LOS showed no differences between the two groups, but LOS in the Intensive Care Unit (MD, - 1.27 days; - 1.94 to - 0.61 days) was significantly shorter in the PoCUS group. Patients in the PoCUS group showed significantly higher odds of receiving appropriate therapy compared to controls (odds ratio [OR], 2.31; 95% CI, 1.61-3.32), but there was no significant effect on 30-day re-admission rate and in-hospital or 30-day mortality.

Conclusion : Our results indicate that PoCUS use contributes to early diagnosis and better outcomes compared to conventional methods in patients admitted with acute onset dyspnea.

Conclusion (proposition de traduction) : Nos résultats indiquent que l'utilisation de l'échographie au point d'intervention contribue à un diagnostic précoce et à de meilleurs résultats que les méthodes conventionnelles chez les patients admis pour une dyspnée aiguë.

Commentaire : 

A Prospective Observational Crossover Study Comparing Intubation by Pediatric Residents Using Video Laryngoscopy and Direct Laryngoscopy on a Pierre Robin Simulation Manikin.
Shaylor R, Weiniger CF, Rachman E, Sela Y, Kohn A, Lahat S, Rimon A, Capua T. | Pediatr Emerg Care. 2023 Mar 1;39(3):159-161
DOI: https://doi.org/10.1097/pec.0000000000002923
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Video laryngoscopy (VL) has been proposed to increase the likelihood of successful intubation in patients with predicted difficult airways such as those with Pierre Robin sequence (PRS). Prior studies have focused on the performance of anesthesiologists, who are generally considered airway experts. Our primary aim was to investigate the success rate of intubation using VL compared with direct laryngoscopy (DL) when attempted by pediatric residents on a PRS model.

Méthode : Participants were administered a 5-minute refresher video on 2 VL techniques (CMAC, conventional geometry VL, and McGrath, unconventional geometry VL) and DL. The participants were asked to intubate the AirSim PRS infant manikin. The order of VL and DL use was randomly selected. All intubations were video recorded, and the recordings were analyzed by 3 anesthesiologists blinded to the participant's identity and previous experience.

Résultats : Seventeen of 23 residents succeeded in intubating the PRS model using DL. Only 9 residents succeeded in intubating the PRS model using VL (conventional or unconventional geometry). Intubation success rate was higher when comparing DL with VL ( P = 0.04) and similar when comparing VL devices ( P = 0.69).

Conclusion : Contrary to expectation, the intubation success rate was lower using VL than with DL among pediatric residents. This should be considered when designing residency training and in real-life resuscitation.

Conclusion (proposition de traduction) : Contrairement aux prévisions, le taux de réussite de l'intubation était plus faible en utilisant la vidéolaryngoscopie qu'en utilisant la laryngoscopie directe chez les internes de pédiatrie. Ceci devrait être pris en compte lors de la conception de la formation des résidents et lors de la réanimation en situation réelle.

Management of the Difficult Airway.
Miller KA, Goldman MP, Nagler J. | Pediatr Emerg Care. 2023 Mar 1;39(3):192-200
DOI: https://doi.org/10.1097/pec.0000000000002916
Keywords: airway management; endotracheal intubation; difficult airway; supraglottic airways; bag-mask ventilation; surgical airway

REVIEWARTICLE

Editorial : Airway management is a fundamental component of care during resuscitation of critically ill and injured children. In addition to predicted anatomic and physiologic differences in children compared with adults, certain conditions can predict potential difficulty during pediatric airway management. This review presents approaches to identifying pediatric patients in whom airway management is more likely to be difficult, and discusses strategies to address such challenges. These strategies include optimization of effective bag-mask ventilation, alternative approaches to laryngoscopy, use of adjunct airway devices, modifications to rapid sequence intubation, and performance of surgical airways in children. The importance of considering systems of care in preparing for potentially difficult pediatric airways is also discussed.

Conclusion : In addition to differences in pediatric anatomy and physiology, some pediatric patients have specific risk factors for difficult airways. Universal strategies including optimizing preoxygenation and BMV should be coupled with a focus on identifying patients at risk for difficulties and implementing patient-specific strategies. Providers should also familiarize themselves with rescue methods such as supraglottic airways and approaches tomedication administration beyond RSI. Finally, optimizing planning can ensure that the appropriate equipment, personnel, and systems are easy to access in these critical situations.

Conclusion (proposition de traduction) : Outre les différences anatomiques et physiologiques en pédiatrie, certains enfants présentent des facteurs de risque spécifiques de difficultés respiratoires. Les stratégies universelles, notamment l'optimisation de la préoxygénation et la ventilation au BAVU, doivent être associées à la recherche des patients présentant un risque de voies respiratoires difficiles et à la mise en œuvre de stratégies spécifiques à chaque patient. Les médecins doivent également se familiariser avec les méthodes de secours telles que les voies aériennes supraglottiques et les procédures d'administration de médicaments autres que l'intubation en séquence rapide. Enfin, l'optimisation de la préparation permet de s'assurer que l'équipement, le personnel et les systèmes appropriés sont facilement accessibles dans ces situations critiques.

Prehospital Intranasal Glucagon for Hypoglycemia.
Haamid A, Christian E, Tataris K, Markul E, Zaidi HQ, Mycyk MB, Weber JM. | Prehosp Emerg Care. 2023;27(3):356-359
DOI: https://doi.org/10.1080/10903127.2022.2045406
Keywords: Aucun

FOCUS ON PHARMACOLOGY

Introduction : Prehospital hypoglycemia is usually treated with oral or intravenous (IV) dextrose in a variety of concentrations. In the absence of vascular access, intramuscular (IM) glucagon is commonly administered. Occupational needle-stick injury remains a significant risk while attempting to obtain vascular access or administer medications intramuscularly in the prehospital setting. We sought to determine if intranasal (IN) glucagon is effective in the prehospital treatment of hypoglycemia.

Méthode : We performed a retrospective analysis of all consecutive cases where recombinant glucagon was administered IN by paramedics from January 1, 2015 through December 31, 2020. Excluded were cases without pre or post administration blood glucose documentation, and cases where another form of treatment for hypoglycemia was administered at any time during the EMS encounter. The primary outcome was clinical response to IN glucagon documented by paramedics; secondary outcomes included pre and post administration blood glucose values.

Résultats : Out of 44 cases that met study inclusion criteria, 14 patients (32%) had substantial improvement, 13 patients (30%) had slight improvement, and 17 patients (38%) had no improvement in mental status after administration of IN glucagon. In cases with substantial improvement (n = 14), the mean pre administration blood glucose was 33.8 mg/dl and the mean post administration blood glucose was 87.1 mg/dl (mean increase 53.3 mg/dl, 95% CI: 21.5 to 85.1). In cases with slight improvement (n = 13), the mean pre administration blood glucose was 23.9 mg/dl and the mean post administration blood glucose was 53.8 mg/dl (mean increase 29.9 mg/dl, 95% CI = 2.9 to 56.9). In case with no improvement (n = 17) the mean pre administration blood glucose was 30.1 mg/dl and the mean post administration glucose was 33.1 mg/dl (mean difference 3.1 mg/dl, 95% CI: -10.1 to 3.9).

Conclusion : Intranasal administration of recombinant glucagon for hypoglycemia resulted in a clinically significant improvement in mental status and a corresponding increase in blood glucose levels in select cases in the prehospital setting.

Conclusion (proposition de traduction) : L'administration intranasale de glucagon recombinant pour traiter l'hypoglycémie a permis une amélioration cliniquement significative de l'état mental et une augmentation correspondante de la glycémie dans certains cas en milieu préhospitalier.

Prehospital Ketamine Use in Pediatrics.
Goyal A, Frawley J, Gappy R, Sandoval S, Chen NW, Crowe R, Swor R. | Prehosp Emerg Care. 2023;27(3):360-365
DOI: https://doi.org/10.1080/10903127.2022.2096161
Keywords: Aucun

Focus on Pharmacology

Introduction : Information regarding prehospital ketamine use in the pediatric population is limited as existing literature focuses primarily on critical care and air transport. Our objective was to describe patient characteristics among pediatric EMS patients who received ketamine. Secondarily, we assessed effectiveness, deviation from recommended dosing, and adverse outcomes of pediatric EMS patients who received ketamine.

Méthode : We conducted a retrospective data review of records from the ESO Data Collaborative for all 9-1-1 transports of pediatric patients (≤ 18 years of age) who received ketamine from 2019-2020. We categorized EMS primary impressions as a proxy for medication indication. We defined effectiveness as paramedic-identified clinical improvement, and pain relief as decrease in pain score ≥2 points between initial and final recording. Descriptive statistics were used to summarize clinical characteristics. Non-parametric Wilcoxon signed-rank test was used to assess change in pain score.

Résultats : Out of 422,968 ground-ambulance pediatric patients, 1,291 received ketamine. They were predominately male (842, 65.2%), teenagers (median age 16, IQR: 13-17), Caucasian (810, 62.7%), and from urban areas (1,041, 80.6%). The most common EMS impressions were related to injuries (810, 62.7%) and behavior disorders (281, 21.8%). Only 980/1,291 (75.9%) had weights and identifiable routes recorded. Most patients (960, 74.4%) received single doses of ketamine, with EMS clinicians reporting improvement in 855 (89.1%) of 960 patients. Among non-behavioral emergency patients, 727/1,010 (72.0%) had pain scores recorded. Pain scores decreased significantly from a median of 8 (IQR: 4-10) to 2 (IQR: 0-6) (p < 0.001) with 59% (429) of 727 patients reporting pain score reductions of 2 or more points. Desaturation (<90% SpO₂) events were noted to be minimal (1.8%). A small number (28, 2.2%) received positive pressure ventilation without advanced airway placement. No prehospital deaths were documented.

Conclusion : In this large review of pediatric prehospital ketamine use, ketamine was primarily used for analgesia, but was frequently used for other indications. Most patients were observed to improve after ketamine use, with most injured patients reporting decreases in pain scores. We observed few significant adverse events related to ketamine use in this population.

Conclusion (proposition de traduction) : Dans cette large revue de l'utilisation de la kétamine en préhospitalier pédiatrique, la kétamine a été principalement utilisée pour l'analgésie, mais a été fréquemment utilisée pour d'autres indications. L'état de la plupart des patients s'est amélioré après l'utilisation de la kétamine, la plupart des patients blessés signalant une diminution des scores de douleur. Nous avons observé peu d'effets indésirables significatifs liés à l'utilisation de la kétamine dans cette population.

Methods for calculating ventilation rates during resuscitation from out-of-hospital cardiac arrest.
Wang HE, Jaureguibeitia X, Aramendi E, Nassal M, Panchal A, Alonso E, Nichol G, Aufderheide T, Daya MR, Carlson J, Idris A. | Resuscitation. Resuscitation.
DOI: https://doi.org/10.1016/j.resuscitation.2022.109679  | Télécharger l'article au format  
Keywords: Airway management; Cardiopulmonary arrest; Emergency medical services; Intubation; Ventilation.

Research article

Introduction : Ventilation control is important during resuscitation from out-of-hospital cardiac arrest (OHCA). We compared different methods for calculating ventilation rates (VR) during OHCA.

Méthode : We analyzed data from the Pragmatic Airway Resuscitation Trial, identifying ventilations through capnogram recordings. We determined VR by: 1) counting the number of breaths within a time epoch ("counted" VR), and 2) calculating the mean of the inverse of measured time between breaths within a time epoch ("measured" VR). We repeated the VR estimates using different time epochs (10, 20, 30, 60 sec). We defined hypo- and hyperventilation as VR <6 and >12 breaths/min, respectively. We assessed differences in estimated hypo- and hyperventilation with each VR measurement technique.

Résultats : Of 3,004 patients, data were available for 1,010. With the counted method, total hypoventilation increased with longer time epochs ([10-s epoch: 75 sec hypoventilation] to [60-s epoch: 97 sec hypoventilation]). However, with the measured method, total hypoventilation decreased with longer time epochs ([10-s epoch: 223 sec hypoventilation] to [60-s epoch: 150 sec hypoventilation]). With the counted method, the total duration of hyperventilation decreased with longer time epochs ([10-s epochs: 35 sec hyperventilation] to [60-s epoch: 0 sec hyperventilation]). With the measured method, total hyperventilation decreased with longer time epochs ([10-s epoch: 78 sec hyperventilation] to [60-s epoch: 0 sec hyperventilation]). Differences between the measured and counted estimates were smallest with a 60-s time epoch.

Conclusion : Quantifications of hypo- and hyperventilation vary with the applied measurement methods. Measurement methods are important when characterizing ventilation rates in OHCA.

Conclusion (proposition de traduction) : Les quantifications de l'hypo- et de l'hyperventilation varient en fonction des méthodes de mesure utilisées. Les méthodes de mesure sont importantes pour caractériser les taux de ventilation dans les cas d'OHCA.

Characteristics of patients resuscitated after burn related out-of-hospital cardiac arrest.
Hoshino T, Enomoto Y, Inoue Y. | Resuscitation. 2023 Mar;184:109692
DOI: https://doi.org/10.1016/j.resuscitation.2023.109692
Keywords: Burn; Electrical injury; OHCA; Out-of-hospital cardiac arrest.

Clinical Paper

Introduction : This study's objective was to describe the characteristics of burn injury patients who were resuscitated after burn related out-of-hospital cardiac arrest (OHCA).

Méthode : We conducted a retrospective cohort study and examined characteristics of burn related OHCA using data from a Japanese nationwide burn registry that was collected between April 1, 2011 and March 31, 2020. First, we compared the characteristics of burn patients with and without OHCA. Second, among burn patients with OHCA, we compared the characteristics of survivors with non-survivors.

Résultats : In the database, there were 16,995 hospitalised burn patients and 256 burn related OHCA. Thirty-two of the 256 burn patients (13%) survived after admission. Among patients with burns who also had OHCA, flames were the most common injury mechanism (74%); in comparison to all other injury mechanisms, the rate of flame burn was significantly higher in burn patients with OHCA than in burn patients without OHCA. The most common cause of death for burn related OHCA is carbon-monoxide poisoning (46%). Compared with survivors, non-survivors had a larger burn area, greater age and more complications. such as inhalation injuries and perineal burn injuries. Compared to other mechanisms of burn injury, electrical burn injuries were more common among survivors. In twelve patients with electrical burns, eight patients survived (67%) OHCA; of those eight patients, six (50%) could be discharged home.

Conclusion : Patients with burn related OHCA have a poor prognosis; however, patients who sustain electrical shock injuries may do better.

Conclusion (proposition de traduction) : Les patients qui présentent un arrêt cardiaque extrahospitalier occasionné par des brûlures ont un mauvais pronostic ; cependant, les patients qui présentent des lésions dues à un choc électrique peuvent s'en sortir mieux.

Association between prehospital airway type and oxygenation and ventilation in out-of-hospital cardiac arrest.
Song SR, Kim KH, Park JH, Song KJ, Shin SD. | Am J Emerg Med. 2023 Mar;65:24-30
DOI: https://doi.org/10.1016/j.ajem.2022.12.021  | Télécharger l'article au format  
Keywords: Airway management; Blood gas analysis; Emergency medical services; Out-of-hospital cardiac arrest.

Original contribution

Introduction : This study aimed to evaluate the association between prehospital airway type and oxygenation and ventilation in out-of-hospital cardiac arrest (OHCA).

Méthode : This retrospective observational study included OHCA patients who visited the emergency departments (EDs) between October 2015 and June 2021. The study groups were categorized according to the prehospital airway type: endotracheal intubation (ETI), supraglottic airway (SGA), or bag-valve-mask ventilation (BVM). The primary outcome was good oxygenation: partial pressure of oxygen (PaO2) ≥ 60 mmHg on the first arterial blood gas (ABG) test. The secondary outcome was good ventilation: partial pressure of carbon dioxide (PaCO2) ≤ 45 mmHg. Multivariate logistic regression was conducted to calculate the adjusted odds ratio (AOR) and 95% confidence interval (CI).

Résultats : A total of 7,372 patients were enrolled during the study period: 1,819 patients treated with BVM, 706 with ETI, and 4,847 who underwent SGA. In multivariable logistic regression analysis for good oxygenation outcomes, the ETI group showed a higher AOR than the BVM group (AOR [95% CIs]: 1.30 [1.06-1.59] in ETI and 1.05 [0.93-1.20] in SGA groups). Regarding good ventilation, the ETI group showed a higher AOR, and the SGA group showed a lower AOR compared to the BVM group (AOR [95% CIs] 1.33 [1.02-1.74] in the ETI and 0.83 (0.70-0.99) in the SGA groups). There was no significant difference in survival to discharge.

Conclusion : ETI was significantly associated with good oxygenation and good ventilation compared to BVM in patients with OHCA, particularly during longer transports. This should be taken into consideration when deciding the prehospital advanced airway management in patients with OHCA.

Conclusion (proposition de traduction) : L'intubation endotrachéale était significativement associée à une meilleure oxygénation et à une meilleure ventilation par rapport à la ventilation au ballon autoremplisseur à valve unidirectionnelle chez les patients ayant une ventilation au ballon autoremplisseur à valve unidirectionnelle, en particulier lors des transports les plus longs. Cet élément doit être pris en considération lors de la prise de décision concernant la gestion préhospitalière des voies aériennes avancées chez les patients bénéficiant d'une ventilation à l'aide d'un ballon autoremplisseur à valve unidirectionnelle.

Correlation between prehospital and in-hospital hypotension and outcomes after traumatic brain injury.
Rice AD, Hu C, Spaite DW, Barnhart BJ, Chikani V, Gaither JB, Denninghoff KR, Bradley GH, Howard JT, Keim SM, Bobrow BJ. | Am J Emerg Med. 2023 Mar;65:95-103
DOI: https://doi.org/10.1016/j.ajem.2022.12.015  | Télécharger l'article au format  
Keywords: Blood pressure; Hypotension; Prehospital; Traumatic brain injury.

Original contribution

Introduction : Hypotension has a powerful effect on patient outcome after traumatic brain injury (TBI). The relative impact of hypotension occurring in the field versus during early hospital resuscitation is unknown. We evaluated the association between hypotension and mortality and non-mortality outcomes in four cohorts defined by where the hypotension occurred [neither prehospital nor hospital, prehospital only, hospital only, both prehospital and hospital].

Méthode : Subjects ≥10 years with major TBI were included. Standard statistics were used for unadjusted analyses. We used logistic regression, controlling for significant confounders, to determine the adjusted odds (aOR) for outcomes in each of the three cohorts.

Résultats : Included were 12,582 subjects (69.8% male; median age 44 (IQR 26-61). Mortality by hypotension status: No hypotension: 9.2% (95%CI: 8.7-9.8%); EMS hypotension only: 27.8% (24.6-31.2%); hospital hypotension only: 45.6% (39.1-52.1%); combined EMS/hospital hypotension 57.6% (50.0-65.0%); (p < 0.0001). The aOR for death reflected the same progression: 1.0 (reference-no hypotension), 1.8 (1.39-2.33), 2.61 (1.73-3.94), and 4.36 (2.78-6.84), respectively. The proportion of subjects having hospital hypotension was 19.0% (16.5-21.7%) in those with EMS hypotension compared to 2.0% (1.8-2.3%) for those without (p < 0.0001). Additionally, the proportion of patients with TC hypotension was increased even with EMS "near hypotension" up to an SBP of 120 mmHg [(aOR 3.78 (2.97, 4.82)].

Conclusion : While patients with hypotension in the field or on arrival at the trauma center had markedly increased risk of death compared to those with no hypotension, those with prehospital hypotension that was not resolved before hospital arrival had, by far, the highest odds of death. Furthermore, TBI patients who had prehospital hypotension were five times more likely to arrive hypotensive at the trauma center than those who did not. Finally, even "near-hypotension" in the field was strongly and independently associated the risk of a hypotensive hospital arrival (<90 mmHg). These findings are supportive of the prehospital guidelines that recommend aggressive prevention and treatment of hypotension in major TBI.

Conclusion (proposition de traduction) : Alors que les patients souffrant d'hypotension sur le lieu de l'accident ou à leur arrivée au centre de traumatologie présentaient un risque de décès nettement plus élevé que ceux ne souffrant pas d'hypotension, les patients souffrant d'hypotension préhospitalière non résolue avant leur arrivée à l'hôpital présentaient, de loin, le risque de décès le plus élevé. En outre, les patients victimes d'un traumatisme crânien qui présentaient une hypotension préhospitalière étaient cinq fois plus susceptibles d'arriver en état d'hypotension au centre de traumatologie que ceux qui n'en présentaient pas. Enfin, même une « quasi-hypotension » sur le lieu de l'accident était fortement et indépendamment associée au risque d'hypotension à l'arrivée à l'hôpital (< 90 mmHg). Ces résultats confirment les recommandations préhospitalières qui recommandent une prévention et un traitement agressifs de l'hypotension en cas de traumatisme crânien majeur.

Low- versus high-dose nitroglycerin infusion in the management of acute pulmonary edema.
Kelly GS, Branstetter LA, Moran TP, Hanzelka N, Cooper CD. | Am J Emerg Med. 2023 Mar;65:71-75
DOI: https://doi.org/10.1016/j.ajem.2022.12.022  | Télécharger l'article au format  
Keywords: Acute heart failure; Hypertension; Nitroglycerin; Pulmonary edema.

Brief Report

Introduction : Nitroglycerin (NTG) is commonly used for the management of pulmonary edema in acute heart failure presentations. Although commonly initiated at low infusion rates, higher infusion rates have favorable pharmacodynamic properties and may improve outcomes in the management of acute pulmonary edema.
Objectives: To characterize the clinical outcomes including the time to resolution of severe hypertension when using an initial low dose (<100 μg/min) versus high-dose (≥100 μg/min) strategy.

Méthode : This was a retrospective study performed at a single, tertiary academic emergency department in Atlanta, GA. We describe the blood pressure effects and key safety outcomes (intubation, hypotension, intensive care unit admissions) during the first hour of treatment of acute pulmonary edema.

Résultats : 41 patients were included in the final sample. 27 (66%) received low dose NTG and 14 (34%) received high dose NTG. The high dose group reached their blood pressure faster on average (hazard ratio = 3.5, 95% CI: 1.2-10.1). 8/14 (57%) of patients in the high dose group reached their BP target within the first hour of treatment, compared to 6/27 (22%) in the low dose group. Observed incidence of safety outcomes were similar between the two groups.

Conclusion : Higher initial NTG doses may be an effective way to decrease times to achieve blood pressure targets and should be the focus of future trials.

Conclusion (proposition de traduction) : Des doses initiales plus élevées de nitroglycérine peuvent être un moyen efficace de réduire le temps nécessaire pour atteindre les objectifs de pression artérielle et devraient faire l'objet d'essais futurs.

High risk and low prevalence diseases: Adult bacterial meningitis.
Pajor MJ, Long B, Koyfman A, Liang SY. | Am J Emerg Med. 2023 Mar;65:76-83
DOI: https://doi.org/10.1016/j.ajem.2022.12.042  | Télécharger l'article au format  
Keywords: Infectious disease; Meningitis; Neurology.

Review article

Introduction : Acute bacterial meningitis in adults is a rare but serious condition that carries a high rate of morbidity.

Méthode : This review highlights pearls and pitfalls of acute bacterial meningitis in adults, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

Discussion : Meningitis encompasses a broad spectrum of disease involving inflammation of the meninges and subarachnoid space. It classically presents with fever, nuchal rigidity, and altered mental status, but this triad is not present in all cases. Up to 95% of patients will have at least two of the following four cardinal symptoms: fever, nuchal rigidity, altered mental status, and headache. The most common bacterial etiologies are S. pneumoniae and N. meningitidis. Cerebrospinal fluid testing obtained by lumbar puncture remains the gold standard in diagnosis. Head computed tomography prior to lumbar puncture may not be necessary in most patients. Empiric treatment consists of vancomycin, ceftriaxone, and dexamethasone. Elevated intracranial pressure should be managed using established neurocritical care strategies.

Conclusion : Meningitis is a broad spectrum of disease that involves inflammation of the meninges and subarachnoid space. Due to widespread immunization against the most common pathogens, the incidence of bacterial meningitis has decreased over the past several decades, making this a rare albeit severe disease. The condition classically presents with the triad of fever, nuchal rigidity, and altered mental status. The range of disease may range from a relatively mild, self-limited viral illness to life-threatening bacterial infections. The most common etiologies for bacterial meningitis include Streptococcus pneumoniae (Pneumococcus) and Neisseria meningitidis (Meningococcus), which should be treated with broad-spectrum antibiotics and steroids. The gold standard in diagnosis is a lumbar puncture; however, treatment with antibiotics and steroids should not be delayed to obtain neuroimaging or a CSF sample. Emergency clinicians should consider this diagnosis in any patient presenting to the ED with flu-like symptoms and have a low threshold for pursuing additional workup and treatment.

Conclusion (proposition de traduction) : La méningite est une maladie à large spectre qui implique une inflammation des méninges et de l'espace sous-arachnoïdien. Grâce à la vaccination généralisée contre les agents pathogènes les plus courants, l'incidence de la méningite bactérienne a diminué au cours des dernières décennies, ce qui en fait une maladie rare mais grave. La maladie se présente classiquement sous la forme d'une triade : fièvre, rigidité nucale et altération de l'état mental. La maladie peut aller d'une maladie virale relativement bénigne et spontanément résolutive à des infections bactériennes mettant en jeu le pronostic vital. Les étiologies les plus courantes de la méningite bactérienne sont Streptococcus pneumoniae (pneumocoque) et Neisseria meningitidis (méningocoque), qui doivent être traités par des antibiotiques à large spectre et des stéroïdes. L'étalon-or du diagnostic est la ponction lombaire ; cependant, le traitement par antibiotiques et stéroïdes ne doit pas être retardé pour obtenir une neuro-imagerie ou un échantillon de LCR. Les médecins urgentistes doivent envisager ce diagnostic chez tout patient se présentant aux urgences avec des symptômes pseudo-grippaux et ne doivent pas hésiter à poursuivre les examens complémentaires et le traitement.

Airway management in out-of-hospital cardiac arrest: A systematic review and network meta-analysis.
Lou J, Tian S, Kang X, Lian H, Liu H, Zhang W, Peran D, Zhang J. | Am J Emerg Med. 2023 Mar;65:130-138
DOI: https://doi.org/10.1016/j.ajem.2022.12.029  | Télécharger l'article au format  
Keywords: Airway management; Cardiac arrest; Network meta-analysis; Out-of-hospital.

Review article

Introduction : Airway management during cardiopulmonary resuscitation is particularly important for patients with out-of-hospital cardiac arrest (OHCA). This study was performed to compare the efficacy of the most commonly used out-of-hospital airway management methods in increasing the survival to discharge in patients with OHCA.

Méthode : We screened all relevant literature from database inception to 21st January 2019 in PubMed, Web of Science, Embase, and the Cochrane Library. We included all randomized controlled trials (RCTs) of airway management for OHCA in adults (≥16 years of age) with no limitations on publication status, publication date, or language. The primary outcome was survival to discharge. The secondary outcomes were the overall airway technique success rate, return of spontaneous circulation, and survival to hospital admission.

Résultats : Overall, from 1986 to 2018, 9 RCTs involving 13,949 patients were included in the network meta-analysis, and the efficacy of six airway management methods for patients with OHCA were compared. However, none of the results were statistically significant.

Conclusion : As the gold standard of airway management for patients with out-of-hospital cardiac arrest in most countries, endotracheal intubation (ETI) has been widely used for many years. However, our systematic review and network meta-analysis showed that ETI is no better than other methods in increasing the survival to discharge. This is not directly proportional to the various preparations required before ETI. Additional randomized controlled trials are needed to identify more effective methods and improve patients' outcome.

Conclusion (proposition de traduction) : Dans la plupart des pays, l'intubation endotrachéale est la méthode de référence pour la gestion des voies aériennes chez les patients victimes d'un arrêt cardiaque extrahospitalier, et elle est largement utilisée depuis de nombreuses années. Cependant, notre étude systématique et notre méta-analyse en réseau ont montré que l'intubation endotrachéale n'est pas plus efficace que d'autres méthodes pour augmenter le taux de survie jusqu'à la sortie de l'hôpital. Ce résultat n'est pas directement proportionnel aux diverses formations requises avant l'intubation endotrachéale. D'autres essais contrôlés randomisés sont nécessaires pour identifier des méthodes plus efficaces et améliorer les résultats pour les patients.

Comparison of Intubation Conditions Between Airtraq, McGrath Video Laryngoscopes, and Macintosh Under Conditions of Simulated Trauma Airway and Rapid Sequence Induction Intubation.
Maremanda KR, Jayaram K, Durga P. | J Emerg Med. 2023 Mar;64(3):271-281
DOI: https://doi.org/10.1016/j.jemermed.2022.12.014
Keywords: Cervical immobilization; Cervical vertebrae; Cricoid pressure; Laryngoscopy; Rapid sequence induction and intubation; Respiratory aspiration of gastric contents; Rigid collar; Simulation training.

Original Contribution

Introduction : Patients arriving at the emergency department with a potential cervical spine injury and immobilized in a rigid cervical collar often require emergency airway management and rapid sequence induction intubation (RSII). There have been several advances in airway management with the advent of channeled (AirtraqⓇ; Prodol Meditec) and nonchanneled (McGrathⓇ; Meditronics) video laryngoscopes, which enable intubation without the removal of the cervical collar, but their efficacy and superiority over conventional laryngoscopy (Macintosh) in the presence of a rigid cervical collar and cricoid pressure have not been evaluated.
Objective: Our aim was to compare the channeled (Airtraq [group A]) and nonchanneled (McGrath [Group M]) video laryngoscopes with a conventional laryngoscope (Macintosh [Group C]) in a simulated trauma airway.

Méthode : A prospective randomized controlled study was conducted in a tertiary care center. Participants were 300 patients requiring general anesthesia (American Society of Anesthesiologists class I or II), of both sexes, and aged 18-60 years. Airway management was simulated without removal of a rigid cervical collar and using cricoid pressure during intubation. After RSI, patients were intubated with one of the study techniques according to randomization. Intubation time and intubation difficulty scale (IDS) score were noted.

Résultats : Mean intubation time was 42.2 s in group C, 35.7 s in group M, and 21.8 s in group A (p = 0.001). Intubation was easy in group M and group A (median IDS score of 0; interquartile range [IQR] 0-1 for group M and median IDS score of 1; IQR 0-2 for group A and group C; p < 0.001). A higher proportion (95.1%) of patients had an IDS score of < 1 in group A.

Conclusion : The performance of RSII with cricoid pressure in the presence of a cervical collar was easier and more rapid with channeled video laryngoscope than with other techniques.

Conclusion (proposition de traduction) : L'intubation par induction en séquence rapide avec pression cricoïdienne en présence d'un collier cervical était plus facile et plus rapide avec le laryngoscope vidéo canalisé qu'avec les autres techniques.

Droperidol Use in the Emergency Department: A Clinical Review.
Siegel RB, Motov SM, Marcolini EG. | J Emerg Med. 2023 Mar;64(3):289-294
DOI: https://doi.org/10.1016/j.jemermed.2022.12.012
Keywords: analgesic; antiemetic; anxiolytic; boxed warning; droperidol; neuroleptanalgesia.

Clinical Review

Introduction : Droperidol is a butyrophenone, with antiemetic, sedative, anxiolytic, and analgesic properties. Although droperidol was once widely used in both emergency and perioperative settings, use of the medication declined rapidly after a 2001 U.S. Food and Drug Administration (FDA) boxed warning called the medication's safety into question.

Méthode : The purpose of this clinical review was to provide evidence-based answers to questions about droperidol's safety and to examine its efficacy in its various clinical indications.

Discussion : Droperidol is an effective sedative, anxiolytic, analgesic, and antiemetic medication. As a sedative, when compared with haloperidol, droperidol has faster onset, as well as greater efficacy, in patients experiencing acute psychosis, with no increase in adverse events. As an antiemetic, droperidol has been found to have equal or greater efficacy in reducing nausea and vomiting than ondansetron and metoclopramide, with similar adverse effects and the added effect of reducing the need for rescue analgesia in these patients. As an analgesic, droperidol is effective for migraines and has opioid-sparing effects when used to treat abdominal pain. Droperidol is a particularly useful adjunct in patients who are opioid-tolerant, whose pain is often difficulty to manage adequately.

Conclusion : Droperidol seems to be effective and safe, despite the boxed warning issued by the FDA. Droperidol is a powerful antiemetic, sedative, anxiolytic, antimigraine, and adjuvant to opioid analgesia and does not require routine screening with electrocardiography when used in low doses in otherwise healthy patients before administration in the emergency department.

Conclusion (proposition de traduction) : Le dropéridol semble être efficace et sûr, malgré l'avertissement émis par la FDA. Le dropéridol est un puissant antiémétique, sédatif, anxiolytique, antimigraineux et adjuvant de l'analgésie morphinique. Il ne nécessite pas de dépistage systématique par électrocardiographie lorsqu'il est utilisé à faibles doses chez des patients par ailleurs en bonne santé avant d'être administré dans le service des urgences.

Comparison of Rigid and Articulating Video Stylets During Simulated Endotracheal Intubation With Hyperangulated Video Laryngoscopy.
Nikolla DA, Boulet S, Carlson JN. | J Emerg Med. 2023 Mar;64(3):315-320
DOI: https://doi.org/10.1016/j.jemermed.2023.01.007
Keywords: Airway management; Endotracheal intubation; Laryngoscope.

Brief Report

Introduction : Endotracheal tube delivery through the vocal cords can be challenging with hyperangulated video laryngoscopy due to the acute angle around the tongue and surrounding airway structures. Articulating video stylets may mitigate this issue by equipping an endotracheal tube stylet with an operator-controlled articulating end that has an additional camera at the tip.
Objectives: We compared operator-reported ease of intubation between the traditional rigid stylet (GlideRite^Ⓡ Rigid Stylet, Verathon Inc., Bothell, WA) and the articulating video stylet (ProVu™ Video Stylet, Flexicare Inc., Irvine, CA) with a hyperangulated video laryngoscope (GlideScope^Ⓡ, Verathon Inc., Bothell, WA).

Méthode : Participants performed simulated intubation using a hyperangulated video laryngoscope with both stylets in random order. We compared operator-reported ease of intubation on a 0-100 visual analogue scale (VAS), best percentage of glottic opening (POGO), and time to intubation. We compared outcomes using a paired t-test or the asymptotic Wilcoxon-Pratt signed-rank test dependent on normality.

Résultats : We enrolled a convenience sample of 16 emergency department attendings, residents, and physician assistant postgraduate trainees. The median operator-reported ease of intubation on VAS was 20 (interquartile range 9, 30) for the rigid stylet and 20 (10, 30) for the articulating video stylet (p = 0.832). However, the rigid stylet had a slightly shorter mean time to intubation compared with the articulating video stylet, 6.9 (standard deviation 2.5) vs. 10.3 (4.1) s, respectively (p = 0.017). POGO was similar between groups.

Conclusion : During simulated endotracheal intubation, the rigid and articulating video stylets had similar operator-reported ease of intubation.

Conclusion (proposition de traduction) : Lors d'une intubation endotrachéale simulée, les stylets vidéo rigides et souples présentaient une facilité d'intubation similaire selon l'opérateur.

The "Syringe Hickey": An Alternative Skin Marking Method for Lumbar Puncture.
Issa EC, Ware PJ, Bitange P, Cooper GJ, Galea T, Bengiamin DI, Young TP. | J Emerg Med. 2023 Mar;64(3):400-404
DOI: https://doi.org/10.1016/j.jemermed.2023.01.013
Keywords: Fitzpatrick scale; lumbar puncture; skin marker; sterile technique; syringe hickey.

Research article

Introduction : Lumbar puncture is a procedure that is commonly performed in emergency departments. Despite their absence from procedure kits, emergency physicians often use skin markers to delineate landmarks for a lumbar puncture. We prefer to create a temporary indentation in the skin using the suction of a syringe. This "syringe hickey" eliminates the need for a skin marker.

Discussion : We created a photo demonstration comparing the syringe hickey to a skin marker for site marking. The syringe hickey was created using a 10-mL syringe aspirated to 5 mL on the forearm for 1 min. The syringe hickey lasted over 30 min on a range of skin tones across the Fitzpatrick Scale. The skin marker faded but the syringe hickey maintained its definition after application of ultrasound gel and sterilization with either chlorhexidine or betadine.

Conclusion : The syringe hickey is a simple skin marking technique that is resistant to antiseptic agents and ultrasound gel. The syringe hickey may be useful for other procedures that require puncture site marking.

Conclusion (proposition de traduction) : Le suçon à la seringue est une technique simple de marquage de la peau qui résiste aux agents antiseptiques et au gel à ultrasons. Le suçon à la seringue peut être utile pour d'autres procédures nécessitant un marquage du site de ponction.

Successful Glenohumeral Shoulder Reduction With Combined Suprascapular and Axillary Nerve Block.
Fredericks AC, Jackson M, Oswald J. | J Emerg Med. 2023 Mar;64(3):405-408
DOI: https://doi.org/10.1016/j.jemermed.2023.01.009  | Télécharger l'article au format  
Keywords: Axillary nerve; Dislocation reduction; Nerve block; Shoulder reduction; Subluxation; Suprascapular nerve; Ultrasound.

Ultrasound in Emergency Medicine

Introduction : Anterior glenohumeral dislocation is a common injury seen in the emergency department (ED) that sometimes requires procedural sedation for manual reduction. When compared with procedural sedation for dislocation reductions, peripheral nerve blocks provide similar patient satisfaction scores but have shorter ED length of stays. In this case report, we describe the first addition of an ultrasound-guided axillary nerve block to a suprascapular nerve block for reduction of an anterior shoulder dislocation in the ED.

Conclusion : Procedural sedation for reduction of anterior shoulder dis- locations is time consuming, resource intensive, and can be risky in some populations. The addition of an axil- lary nerve block to a suprascapular nerve block allows for more complete muscle relaxation to successfully reduce a shoulder dislocation without procedural sedation.

Conclusion (proposition de traduction) : La sédation procédurale pour la réduction des luxations antérieures de l'épaule prend du temps, nécessite beaucoup de ressources et peut être risquée dans certaines populations. L'ajout d'un bloc du nerf axillaire à un bloc du nerf suprascapulaire permet une relaxation musculaire plus complète pour réduire avec succès une luxation de l'épaule sans sédation procédurale.

Comparison of Intubation Conditions Between Airtraq, McGrath Video Laryngoscopes, and Macintosh Under Conditions of Simulated Trauma Airway and Rapid Sequence Induction Intubation.
Maremanda KR, Jayaram K, Durga P. | J Emerg Med. 2023 Mar;64(3):271-281
DOI: https://doi.org/10.1016/j.jemermed.2022.12.014
Keywords: Cervical immobilization; Cervical vertebrae; Cricoid pressure; Laryngoscopy; Rapid sequence induction and intubation; Respiratory aspiration of gastric contents; Rigid collar; Simulation training.

Original Contribution

Introduction : Patients arriving at the emergency department with a potential cervical spine injury and immobilized in a rigid cervical collar often require emergency airway management and rapid sequence induction intubation (RSII). There have been several advances in airway management with the advent of channeled (Airtraq^Ⓡ; Prodol Meditec) and nonchanneled (McGrath^Ⓡ; Meditronics) video laryngoscopes, which enable intubation without the removal of the cervical collar, but their efficacy and superiority over conventional laryngoscopy (Macintosh) in the presence of a rigid cervical collar and cricoid pressure have not been evaluated.
Objective: Our aim was to compare the channeled (Airtraq [group A]) and nonchanneled (McGrath [Group M]) video laryngoscopes with a conventional laryngoscope (Macintosh [Group C]) in a simulated trauma airway.

Méthode : A prospective randomized controlled study was conducted in a tertiary care center. Participants were 300 patients requiring general anesthesia (American Society of Anesthesiologists class I or II), of both sexes, and aged 18-60 years. Airway management was simulated without removal of a rigid cervical collar and using cricoid pressure during intubation. After RSI, patients were intubated with one of the study techniques according to randomization. Intubation time and intubation difficulty scale (IDS) score were noted.

Résultats : Mean intubation time was 42.2 s in group C, 35.7 s in group M, and 21.8 s in group A (p = 0.001). Intubation was easy in group M and group A (median IDS score of 0; interquartile range [IQR] 0-1 for group M and median IDS score of 1; IQR 0-2 for group A and group C; p < 0.001). A higher proportion (95.1%) of patients had an IDS score of < 1 in group A.

Conclusion : The performance of RSII with cricoid pressure in the presence of a cervical collar was easier and more rapid with channeled video laryngoscope than with other techniques.

Conclusion (proposition de traduction) : L'intubation par induction en séquence rapide avec pression cricoïdienne en présence d'un collier cervical était plus facile et plus rapide avec le vidéolaryngoscope avec canal de guidage (Airtraq^Ⓡ) qu'avec les autres techniques.