The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study.
Gibbons RC, Smith D, Feig R, Mulflur M, Costantino TG. | Acad Emerg Med. 2024 Feb;31(2):112-118
DOI: https://doi.org/10.1111/acem.14839  | Télécharger l'article au format  
Keywords: aortic dissection; point-of-care ultrasound.

Original article

Introduction : An aortic dissection (AoD) is a potentially life-threatening emergency with mortality rates exceeding 50%. While computed tomography angiography remains the diagnostic standard, patients may be too unstable to leave the emergency department. Investigators developed a point-of-care ultrasound (POCUS) protocol combining transthoracic echocardiography (TTE) and the abdominal aorta. The study objective was to determine the test characteristics of this protocol.

Méthode : This was an institutional review board-approved, multicenter, prospective, observational, cohort study of a convenience sample of adult patients. Patients suspected of having an AoD received a TTE and abdominal aorta POCUS. Three sonographic signs suggested AoD: a pericardial effusion, an intimal flap, or an aortic outflow track diameter measuring more than 35 mm. Investigators present continuous and categorical data as medians with interquartile ranges or proportions with 95% confidence intervals (CIs) and utilized standard 2 × 2 tables on MedCalc (Version 19.1.6) to calculate test characteristics with 95% CI.

Résultats : Investigators performed 1314 POCUS examinations, diagnosing 21 Stanford type A and 23 Stanford type B AoD. Forty-one of the 44 cases had at least one of the aforementioned sonographic findings. The protocol has a sensitivity of 93.2% (95% CI 81.3-98.6), specificity of 90.9 (95% CI 89.2-92.5), positive and negative predictive values of 26.3% (95% CI 19.6-33.9) and 99.7% (95% CI 99.2-100), respectively, and an accuracy of 91% (95% CI 89.3-92.5).

Conclusion : The SPEED protocol has an overall sensitivity of 93.2% for AoD.

Conclusion (proposition de traduction) : Le protocole SPEED a une sensibilité globale de 93,2 % pour les dissections aortiques.

Commentaire :  Il existe deux types d'artefacts :
Artéfact du lobe latéral : échodensité curviligne le long d'un arc sectoriel qui n'est pas ondulatoire. Il est causé par la calcification de la racine aortique, de la valve aortique et de la jonction sinotubulaire.
Artéfact de réverbération : il s'agit de la duplication d'un signal d'écho linéaire le long du trajet du faisceau ultrasonore. Il peut provenir de la paroi auriculaire gauche, de l'artère pulmonaire droite. Les artefacts linéaires sont plus fréquents lorsque le diamètre de la racine aortique est > à l'oreillette gauche (Acute Aortic Syndromes  ).

Hypertension in the emergency department: A missed opportunity to screen for primary aldosteronism?.
Graven RD, Lee I, Ren J, Yang J, Egerton-Warburton D. | Acad Emerg Med. 2024 Feb;31(2):156-163
DOI: https://doi.org/10.1111/acem.14830  | Télécharger l'article au format  
Keywords: emergency department; hypertension; primary aldosteronism; screening guidelines.

ORIGINAL ARTICLE

Introduction : Primary aldosteronism (PA) is a common but underdiagnosed secondary cause of hypertension. Emergency departments (EDs) often assess patients with severe hypertension or its sequelae, some of whom have underlying PA. We aimed to determine the proportion of patients presenting to the ED with hypertension who meet the Endocrine Society criteria for PA testing and the proportion who were screened.

Méthode : We performed a structured retrospective chart review of adults who presented to three EDs in an Australian tertiary health network between August 2019 and February 2020, with a coded presenting complaint of hypertension. Clinical parameters to determine whether the patients met the criteria for PA testing were extracted from electronic medical records.

Résultats : Of the 418 patients who presented to the EDs with documented elevated blood pressure (BP), 181 patients (43.3%) fulfilled PA screening criteria and nine patients (2.2%) underwent PA testing. Individuals who fulfilled screening criteria were older; had higher prevalence of Type 2 diabetes, coronary artery disease, and congestive heart failure; took more antihypertensive medications; and had lower estimated glomerular filtration rate. Individuals who were tested for PA were younger and had higher BP on presentation. Screening for PA was more frequent in patients who were referred to medical teams.

Conclusion : As far as we are aware, our study is the first to evaluate PA testing in hypertensive patients who present to ED. More than 40% of adults presenting to the EDs with hypertension met the current criteria for testing for PA but only few were tested. These results emphasize that increased awareness of PA in the ED is needed to encourage opportunistic testing, referral, and treatment, especially in patients who present with hypertensive emergencies. Prospective studies are required to determine the feasibility and effectiveness of this.

Conclusion (proposition de traduction) : À notre connaissance, notre étude est la première à évaluer le dépistage de l'aldostéronisme primaire chez les patients hypertendus qui se présentent aux urgences. Plus de 40 % des adultes se présentant aux urgences avec une hypertension répondent aux critères actuels de dépistage de l'aldostéronisme primaire, mais peu d'entre eux ont été testés. Ces résultats soulignent la nécessité d'une sensibilisation accrue à l'aldostéronisme primaire dans les services d'urgence afin d'encourager les tests opportunistes, l'orientation et le traitement, en particulier chez les patients qui se présentent pour des urgences hypertendues. Des études prospectives sont nécessaires pour déterminer la faisabilité et l'efficacité de cette démarche.

Commentaire : Le diagnostic de l'hyperaldostéronisme primaire passe par le dosage de l'aldostérone plasmatique et de l'activité de la rénine plasmatique et le calcul du rapport aldostérone/rénine. En présence d'un taux d'aldostérone élevé et d'un rapport élevé aldostérone/rénine, il faut suspecter un hyperaldostéronisme primaire.

Outcome prediction in comatose cardiac arrest patients with initial shockable and non-shockable rhythms.
Wimmer H, Stensønes SH, Benth JŠ, Lundqvist C, Andersen GØ, Draegni T, Sunde K, Nakstad ER. | Acta Anaesthesiol Scand. 2024 Feb;68(2):263-273
DOI: https://doi.org/10.1111/aas.14337  | Télécharger l'article au format  
Keywords: hypoxic-ischemic brain injury; late awakening; non-shockable rhythm; out-of-hospital cardiac arrest; prognostication; resuscitation guidelines; withrawal of life sustaining therapy.

RESEARCH ARTICLE

Introduction : Prognosis after out-of-hospital cardiac arrest (OHCA) is presumed poorer in patients with non-shockable than shockable rhythms, frequently leading to treatment withdrawal. Multimodal outcome prediction is recommended 72 h post-arrest in still comatose patients, not considering initial rhythms. We investigated accuracy of outcome predictors in all comatose OHCA survivors, with a particular focus on shockable vs. non-shockable rhythms.

Méthode : In this observational NORCAST sub-study, patients still comatose 72 h post-arrest were stratified by shockable vs. non-shockable rhythms for outcome prediction analyzes. Good outcome was defined as cerebral performance category 1-2 within 6 months. False positive rate (FPR) was used for poor and sensitivity for good outcome prediction accuracy.

Résultats : Overall, 72/128 (56%) patients with shockable and 12/50 (24%) with non-shockable rhythms had good outcome (p < .001). For poor outcome prediction, absent pupillary light reflexes (PLR) and corneal reflexes (clinical predictors) 72 h after sedation withdrawal, PLR 96 h post-arrest, and somatosensory evoked potentials (SSEP), all had FPR <0.1% in both groups. Unreactive EEG and neuron-specific enolase (NSE) >60 μg/L 24-72 h post-arrest had better precision in shockable patients. For good outcome, the clinical predictors, SSEP and CT, had 86%-100% sensitivity in both groups. For NSE, sensitivity varied from 22% to 69% 24-72 h post-arrest. The outcome predictors indicated severe brain injury proportionally more often in patients with non-shockable than with shockable rhythms. For all patients, clinical predictors, CT, and SSEP, predicted poor and good outcome with high accuracy.

Conclusion : Outcome prediction accuracy was comparable for shockable and non-shockable rhythms. PLR and corneal reflexes had best precision 72 h after sedation withdrawal and 96 h post-arrest.

Conclusion (proposition de traduction) : La précision de la prédiction du résultat était comparable pour les rythmes choquables et non choquables. Les réflexes pupillaires à la lumière et les réflexes cornéens présentaient la meilleure précision 72 heures après le retrait de la sédation et 96 heures après l'arrêt.

Relationship between extravascular leakage and clinical outcome on computed tomography of isolated traumatic brain injury.
Ito H, Nakamura Y, Togami Y, Onishi S, Nakao S, Ogura H, Oda J. | Acute Med Surg. 2024 Feb 20;11(1):e931
DOI: https://doi.org/10.1002/ams2.931  | Télécharger l'article au format  
Keywords: contrast extravasation; head injury; mortality; surgery.

Original article

Introduction : This study investigated whether contrast extravasation on computed tomography (CT) angiography in patients with traumatic brain injury (TBI) is associated with death or surgical procedures.

Méthode : Patients over 18 years old, directly brought in by ambulance with an isolated head injury and confirmed to have acute intracranial hemorrhage on a CT scan upon admission between 2010 and 2020, were included. The primary outcome was mortality, and the secondary outcome was neurosurgical procedures performed from admission to discharge from the intensive care unit. Multivariable logistic regression analyses were performed to evaluate the association between these outcomes and contrast extravasation.

Résultats : The analysis included 188 patients with a median age of 65 years, 123 men (65.4%), 34 deaths (18.1%), and 91 surgeries (48.4%). Among the 66 patients with contrast extravasation, 22 (33.3%) died and 47 (71.2%) required surgery. Among the 122 patients with no contrast extravasation, 12 (9.8%) died, and 44 (36.1%) required surgery. The presence or absence of extravascular leakage was associated with death (odds ratio, 3.6 [95% CI: 1.2-12.2]) and surgery (odds ratio, 7.6 [95% CI: 2.5-22.7]).

Conclusion : Contrast extravasation was associated with mortality and performance of surgery in patients with an isolated head injury.

Conclusion (proposition de traduction) : L'extravasation de produit de contraste a été associée à la mortalité et à la chirurgie chez les patients présentant un traumatisme crânien isolé.

Teaching when time is short: Applying the one-minute preceptor model to the emergency department setting.
Yang T, Natesan Q, Corbo S, Gottlieb M. | AEM Educ Train. 2024 Jan 16;8(1):10.1002/aet2.10927
DOI: https://login.research4life.org/tacsgr1doi_org/10.1002/aet2.10927
Keywords: Aucun

EDUCATIONAL DOWNLOAD

Introduction : As emergency medicine faculty, it is our job to provide excellent patient care, while also training a wide range of learners through clinical teaching. Faculty are often faced with the challenge of balancing between teaching and feedback efforts during busy shifts involving variable acuity and volume of patients. Therefore, it is important to have strategies for teaching that can adapt to the unpredictable emergency department (ED) setting.
In 1992, Neher and colleagues described the one-minute preceptor (OMP) method. Although this was first utilized for outpatient family medicine, other specialties (including internal medicine, psychiatry, obstetrics/gynecology, and anesthesiology) have described its use. The OMP model involves a framework composed of five microskills for learner-centered clinical teaching.
There are several advantages to the OMP teaching model. First, the tool is efficient and effective in both acute and non–acute care settings. Second, both facilitators and learners preferred the OMP method over the traditional teaching method. Lastly, facilitators have reported that the OMP method is easy to implement with the ability to provide more information to the learner in less time. As such, this would be well suited for faculty wanting to provide succinct teaching and feedback in the busy ED.

Conclusion : As we explore options to teach learners during clinical shifts better, the OMP model can be an effective five-step strategy to implement in a busy ED. It is quick, easy to learn, easy to use by clinical educa-tors, and well received by learners.

Conclusion (proposition de traduction) : Alors que nous explorons des options pour mieux enseigner aux étudiants pendant les gardes cliniques, le modèle « one-minute preceptor » peut être une stratégie efficace en cinq étapes à mettre en œuvre dans un service d'urgence très sollicité. Il est rapide, facile à apprendre, facile à utiliser par les enseignants cliniciens et bien accueilli par les étudiants.

Commentaire :  Les micro-compétences du « one-minute preceptor ».

Les 5 étapes du « One-minute preceptor ».
Référence : Farrell S, et al. What’s the evidence: a review of the one-minute preceptor model of clinical teaching and implications for teaching inthe emergency department. J Emerg Med. 2016 Sep;51(3):278-83  .

Performing Accurate Standard 12 Lead ECGs on patients with Burns to the Chest.
Gard KE, Dries D, House C. | Air Med J. 2024 Jan-Feb;43(1):8-10
DOI: https://doi.org/10.1016/j.amj.2023.11.001  | Télécharger l'article au format  
Keywords: Aucun

Critical Care Update

Editorial : The use of the electrocardiogram (ECG) in critical care settings is a long-established cardiovascular monitoring tool. The effectiveness of the routine 12-lead ECG relies on accurate lead placement that is consistent and replicable. Improper lead placement may display erroneous ECG patterns and affect patient management decisions. In the setting of an acute injury, such as a torso burn to the ventral surface, accurate lead placement may be compromised or impossible. The regional burn center, which is part of our organization, sees approximately 500 patients per year. Of those patients, burns to the chest accounted for 21% of admissions during 2020 and 2021. This significant fraction of burn injury patients requires modification of our standard approach to provide an accurate ECG. Baseline ECGs are routinely acquired on the burn unit per protocol and for monitoring of patient response to numerous pharmaceutical therapies.

Conclusion : By developing a standard approach to these uncommon and complex monitoring scenarios, a consistent and reliable method of ECG acquisition can be achieved on which to base treatment. This protocol should be incorporated into the training of hospital ECG technicians and emergency medical services and burn center staff as part of their ongoing competency training. Collaboration with the care team to determine the optimal ECG based on patient clinical presentation and safe wound access is a key point in ensuring those who know the patient best are supporting the staff who understand ECG acquisition to provide reproducible and reliable ECG tracing. It is important that consistent review of the literature and hospital practices provides opportunities to improve this process. This practice is not static and must be open to ongoing scrutiny and updates with the focus on the patient.

Conclusion (proposition de traduction) : En développant une approche standard pour ces scénarios de surveillance complexes et peu courants, on peut obtenir une méthode cohérente et fiable d'acquisition de l'ECG sur laquelle baser le traitement. Ce protocole doit être intégré à la formation des techniciens ECG des hôpitaux, des services médicaux d'urgence et du personnel des centres de traitement des brûlures dans le cadre de leur formation continue. La collaboration avec l'équipe soignante pour déterminer l'ECG optimal en fonction de la présentation clinique du patient et de la sécurité de l'accès à la plaie est un point clé pour s'assurer que ceux qui connaissent le mieux le patient soutiennent le personnel qui comprend l'acquisition de l'ECG pour fournir un tracé ECG reproductible et fiable. Il est important que l'examen régulier de la littérature et des pratiques hospitalières permette d'améliorer ce processus. Cette pratique n'est pas statique et doit faire l'objet d'un examen et d'une mise à jour continus, l'accent étant mis sur le patient.

Does the Location of Endotracheal Intubation Affect the Success of Airway Management in a Helicopter Air Ambulance Service? A Simulation Study.
Krebs W, Newmyer A, Dzurik A, Burgard K, Scaff T, Waltmire J, Wilson T, Kimmett C, Stausmire J, Buderer N. | Air Med J. 2024 Jan-Feb;43(1):19-22
DOI: https://doi.org/10.1016/j.amj.2023.09.002  | Télécharger l'article au format  
Keywords: Aucun

Feature Article

Introduction : Airway management is a cornerstone of helicopter air ambulance patient management. The purpose of this study was to evaluate the overall quality of airway management of critical care crews in 3 common locations for intubation.

Méthode : This was a prospective observational simulation study assessing the overall airway management of critical care providers managing simulated patients in an emergency department, helicopter, and ambulance. Composite scores were obtained and compared with respect to physical environment and provider certification level.

Résultats : Fifty-four participants completed the simulations. The median score for the emergency department was 100; for ambulance, it was 80; and for helicopter, it was 80. Ambulance scores were significantly lower than emergency department scores (median difference = -5 points, P = .002) as were helicopter scores (median difference = -10 points, P < .001). The small sample size limited the statistical power to detect differences in provider type, and no statistically significant differences were found in these groups.

Conclusion : In this study, the physical location of airway management negatively impacted the overall airway management success as determined by a standardized composite score. This suggests that airway management may have the highest rate of success in an emergency department as opposed to ground ambulance or helicopter air ambulance settings.

Conclusion (proposition de traduction) : Dans cette étude, le lieu géographique de la prise en charge des voies aériennes a eu un impact négatif sur la réussite globale de la prise en charge des voies aériennes, déterminée par un score composite standardisé. Cela suggère que la prise en charge des voies aériennes peut avoir le taux de succès le plus important dans un service d'urgence par rapport à une ambulance au sol ou à un service d'ambulance héliportée.

Commentaire : Le score composite calculé pour chaque membre de l'équipe de soins intensifs pour chacun des trois environnements physiques (urgence, ambulance terrestre ou HAA) à l'aide de la liste de contrôle suivante, élaborée par l'organisation. Les scores peuvent varier de 0 à 100.
• Éviter la chute de la pression artérielle pendant l'intubation en séquence rapide < 90 de pression artérielle systolique (10 points)
• Éviter les tentatives de plus de 30 minutes (10 points)
• Arrêt de la tentative avant l'hypoxie (10 points)
• Maintien du rachis cervical (10 points)
• Pas d'intubation pulmonaire sélective (10 points)
• Succès (1 des éléments suivants ou 0 point si aucun)
   ° Première tentative (50 points)
   ° Deuxième tentative (40 points)
   ° Tentative suivante (30 points)
   ° Utilisation des voies aériennes de secours (25 points)

Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis.
von Hellmann R, Fuhr N, Ward A Maia I, Gerberi D, Pedrollo D, Bellolio F, Oliveira J E Silva L. | Ann Emerg Med. 2024 Feb;83(2):132-144
DOI: https://doi.org/10.1016/j.annemergmed.2023.08.484  | Télécharger l'article au format  
Keywords: Aucun

Research article

Introduction : The use of a bougie, a flexible endotracheal tube introducer, has been proposed to optimize first-attempt success in emergency department intubations. We aimed to evaluate the available evidence on the association of bougie use in the first attempt and success in tracheal intubations. This was a systematic review and meta-analysis of studies that evaluated first-attempt success between adults intubated with a bougie versus without a bougie (usually with a stylet) in all settings. Manikin and cadaver studies were excluded.

Méthode : A medical librarian searched Ovid Cochrane Central, Ovid Embase, Ovid Medline, Scopus, and Web of Science for randomized controlled trials and comparative observational studies from inception to June 2023. Study selection and data extraction were done in duplicate by 2 independent reviewers. We conducted a meta-analysis with random-effects models, and we used GRADE to assess the certainty of evidence at the outcome level.

Résultats : We screened a total of 2,699 studies, and 133 were selected for full-text review. A total of 18 studies, including 12 randomized controlled trials, underwent quantitative analysis. In the meta-analysis of 18 studies (9,151 patients), bougie use was associated with increased first-attempt intubation success (pooled risk ratio [RR] 1.11, 95% confidence interval [CI] 1.06 to 1.17, low certainty evidence). Bougie use was associated with increased first-attempt success across all analyzed subgroups with similar effect estimates, including in emergency intubations (9 studies; 8,070 patients; RR 1.11, 95% CI 1.05 to 1.16, low certainty). The highest point estimate favoring the use of a bougie was in the subgroup of patients with Cormack-Lehane III or IV (5 studies, 585 patients, RR 1.60, 95% CI 1.40 to 1.84, moderate certainty).

Conclusion : In this meta-analysis, the bougie as an aid in the first intubation attempt was associated with increased success. Despite the certainty of evidence being low, these data suggest that a bougie should probably be used first and not as a rescue device in emergency intubations.

Conclusion (proposition de traduction) : Dans cette méta-analyse, l'utilisation d'un mandrin long béquillé lors de la première tentative d'intubation a été associée à une plus grande réussite. Bien que la certitude des preuves soit faible, ces données suggèrent qu'un mandrin long béquillé devrait probablement être utilisée en premier lieu et non comme dispositif de secours dans les intubations d'urgence.

Commentaire : Cette méta-analyse corrobore l’essai monocentrique BEAM qui avait montré une amélioration de la réussite lors de la première tentative lorsqu’un mandrin long béquillé était utilisé systématiquement. L’essai randomisé contrôlé BOUGIE (Bougie Or stylet in patients UnderGoing Intubation Emergently) quant à lui n’avait retrouvé aucune différence entre l’utilisation d’un mandrin long béquillé et la sonde armée d’un mandrin souple malléable en ce qui concerne le taux de réussite au premier passage.
En conclusion, en laryngoscopie directe, il semble que l’utilisation d’un mandrin (long béquillé ou souple malléable) soit nettement à envisager dès le premier essai.
Toutefois, l’utilisation du vidéolaryngoscope (N Engl J Med. 2023 Aug 3;389(5):418-429  ) pourrait être la solution pour améliorer définitivement le taux de réussite au premier essai mais sous réserve que, si le passage de la laryngoscopie directe à la vidéolaryngoscopie pouvait améliorer les résultats de la gestion des voies aériennes, la dépendance à l'égard de la vidéolaryngoscopie pourrait dégrader d'autres compétences cliniques importantes au moment où elles sont le plus nécessaires : en effet, si la vidéolaryngoscopie était adaptée comme technique de référence, les médecins prenant en charge les voies aériennes risqueraient de ne plus pratiquer et de ne plus conserver leurs compétences dans d'autres techniques de gestion des voies aériennes qui pourraient être nécessaires en cas d'échec de la vidéolaryngoscopie.
A lire sur le sujet :
• Driver BE and al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189  .
• Driver BE and al.; BOUGIE Investigators and the Pragmatic Critical Care Research Group. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2021 Dec 28;326(24):2488-2497  .

Prolonged versus intermittent β-lactam infusion in sepsis: a systematic review and meta-analysis of randomized controlled trials.
Zhao Y, Zang B, Wang Q. | Ann Intensive Care. 2024 Feb 18;14(1):30
DOI: https://doi.org/10.1186/s13613-024-01263-9  | Télécharger l'article au format  
Keywords: Antibiotics; Carbapenems; Cephalosporins; Penicillin; Pharmacodynamics; Pharmacokinetics; Sepsis.

Review

Introduction : The two latest studies on prolonged versus intermittent use of β-lactam antibiotics in patients with sepsis did not reach consistent conclusions, further contributing to the controversy surrounding the effectiveness of the prolonged β-lactam antibiotics infusion strategy. We conducted a systemic review and meta-analysis to evaluate the efficacy and safety of prolonged and intermittent β-lactam infusion in adult patients with sepsis.

Méthode : We systematically searched PubMed, EMBASE, and Cochrane Library databases for original randomized controlled trials comparing prolonged and intermittent β-lactam infusion in sepsis patients. A random-effects model was used to evaluate mortality, clinical success, microbiological success, and adverse events. We also conducted subgroup analyses to explore the impact of various factors on the mortality rates. Relative risk (RR) and corresponding 95% confidence intervals (CIs) were used to calculate the overall effect sizes for dichotomous outcomes.

Résultats : We assessed 15 studies involving 2130 patients. In our comprehensive assessment, we found a significant reduction in all-cause mortality (RR, 0.83; 95% CI 0.72-0.97; P = 0.02) and a notable improvement in clinical success (RR, 1.16; 95% CI 1.03-1.31; P = 0.02) in the prolonged infusion group compared to the intermittent infusion group, whereas microbiological success did not yield statistically significant results (RR, 1.10; 95% CI 0.98-1.23; P = 0.11). No significant differences in adverse events were observed between the two groups (RR, 0.91; 95% CI 0.64-1.29; P = 0.60). Additionally, remarkable conclusions were drawn from subgroup analyses including studies with sample sizes exceeding 20 individuals per group (RR, 0.84; 95%CI 0.72-0.98; P = 0.03), research conducted post-2010 (RR, 0.84; 95%CI 0.72-0.98; P = 0.03), cases involving infections predominantly caused by Gram-negative bacteria (RR, 0.81; 95%CI 0.68-0.96; P = 0.02), as well as the administration of a loading dose (RR, 0.84; 95% CI 0.72-0.97; P = 0.02) and the use of penicillin (RR, 0.61; 95% CI 0.38-0.98; P = 0.04).

Conclusion : Compared to intermittent infusion, prolonged infusion of β-lactam antibiotics significantly decreases all-cause mortality among patients with sepsis and enhances clinical success without increasing adverse events.

Conclusion (proposition de traduction) : Comparée à la perfusion intermittente, la perfusion continue de β-lactamines diminue significativement la mortalité toutes causes confondues chez les patients présentant un sepsis et améliore le résultat clinique sans augmenter les effets indésirables.

Earthquake victims in focus: a cross-sectional examination of trauma and management in intensive care unit.
Aydin K, Ozel Yesilyurt A, Cetinkaya F, Gok MG, Dogan O, Ozcengiz D. | BMC Emerg Med. 2024 Feb 20;24(1):30
DOI: https://doi.org/10.1186/s12873-024-00949-4  | Télécharger l'article au format  
Keywords: CRAMS score; Earthquake; Intensive care unit; Intra-abdominal pressure; Mortality; Victims.

Research

Introduction : fter the Kahramanmaras earthquake of February 6, 2023, the disaster of the century, a significant number of victims were admitted to intensive care units (ICUs). In this study, we aimed to share the characteristics and management of critical earthquake victims and shed light on our experiences as intensivists in future earthquakes.

Méthode : The study included 62 earthquake victims in two tertiary ICUs. Demographic characteristics, laboratory findings, clinical characteristics, trauma and disease severity scores, treatments administered to patients, and the clinical course of the patients were recorded retrospectively. The patients were divided into two groups, survivors and nonsurvivors, according to 7-day mortality and into two groups according to the duration of their stay under the rubble: those who remained under the rubble for 72 hours or less and those who remained under the rubble for more than 72 hours. A receiver operating characteristic (ROC) curve analysis was used to determine the best cutoff value for the 'Circulation, Respiration, Abdomen, Motor, and Speech' (CRAMS) score.

Résultats : The median age of the 62 patients included in the study was 35.5 (23-53) years. The median length of stay under the rubble for the patients was 30.5 (12-64.5) hours. The patient was transferred to the ward with a maximum duration of 222 hours under the rubble. The limb (75.8%) was the most common location of trauma in patients admitted to the ICU. Crush syndrome developed in 96.8% of the patients. There was a positive correlation between the development of acute kidney injury (AKI) and myoglobin, serum lactate, and uric acid levels (r = 0.372, p = 0.003; r = 0.307, p = 0.016; r = 0.428, p = 0.001, respectively). The best cutoff of the CRAMS score to predict in-7-day mortality was < 4.5 with 0.94 area under the curve (AUC); application of this threshold resulted in 75% sensitivity and 96.3% specificity.

Conclusion : Search and rescue operations should continue for at least ten days after an earthquake. The CRAMS score can be used to assess trauma severity and predict mortality in critically ill earthquake victims.

Conclusion (proposition de traduction) : Les opérations de recherche et de sauvetage doivent se poursuivre pendant au moins dix jours après un tremblement de terre. Le score CRAMS peut être utilisé pour évaluer la gravité des traumatismes et prédire la mortalité chez les victimes de tremblements de terre gravement malades.

Commentaire : CRAMS Score  
CRAMS est l’acronyme de « Circulation, Respiration, Abdomen, Motor, Speech ». Il s’agit d’un score physiologique. Il comprend 5 paramètres évalués chacun sur une échelle de 0 à 2. Le score s’échelonne de 0 (décès) à 10 (pas de signe de sévérité). Un score CRAMS < 9 indique un traumatisme sévère. Cependant, il ne peut prédire le recours à la chirurgie.
Score de triage CRAMS

Effect of wet clothing removal on skin temperature in subjects exposed to cold and wrapped in a vapor barrier: a human, randomized, crossover field study.
Hagen LT, Brattebø G, Dipl-Math JA, Wiggen Ø, Østerås Ø, Mydske S, Thomassen Ø. | BMC Emerg Med. 2024 Jan 25;24(1):18
DOI: https://doi.org/10.1186/s12873-024-00937-8  | Télécharger l'article au format  
Keywords: Accidental hypothermia; Active external rewarming; Clinical trial; Crossover; Emergency medicine; Field study; Human; Mountain medicine; Vapor barrier; Wet clothing.

Research

Introduction : Prehospital care for cold-stressed and hypothermic patients focuses on effective insulation and rewarming. When encountering patients wearing wet clothing, rescuers can either remove the wet clothing before isolating the patient or isolate the patient using a vapor barrier. Wet clothing removal increases skin exposure but avoids the need to heat the wet clothing during rewarming. Leaving wet clothing on will avoid skin exposure but is likely to increase heat loss during rewarming. This study aimed to evaluate the effect of wet clothing removal compared to containing the moisture using a vapor barrier on skin temperature in a prehospital setting.

Méthode : This randomized crossover experimental field study was conducted in a snow cave in Hemsedal, Norway. After an initial cooling phase of 30 min while wearing wet clothes, the participants were subjected to one of two rewarming scenarios: (1) wet clothing removal and wrapping in a vapor barrier, insulating blankets, and windproof outer shell (dry group) or (2) wrapping in a vapor barrier, insulating blankets, and windproof outer shell (wet group). The mean skin temperature was the primary outcome whereas subjective scores for both thermal comfort and degree of shivering were secondary outcomes. Primary outcome data were analyzed using the analysis of covariance (ANCOVA).

Résultats : After an initial decrease in temperature during the exposure phase, the dry group had a higher mean skin temperature compared to the wet group after only 2 min. The skin-rewarming rate was highest in the initial rewarming stages for both groups, but increased in the dry group as compared to the wet group in the first 10 min. Return to baseline temperature occurred significantly faster in the dry group (mean 12.5 min [dry] vs. 28.1 min [wet]). No intergroup differences in the subjective thermal comfort or shivering were observed.

Conclusion : Removal of wet clothing in combination with a vapor barrier increases skin rewarming rate compared to encasing the wet clothing in a vapor barrier, in mild cold and environments without wind.

Conclusion (proposition de traduction) : Le retrait des vêtements mouillés en combinaison avec une couverture de survie augmente le taux de réchauffement de la peau par rapport à celui obtenu en enfermant avec les vêtements mouillés dans une couverture de survie, dans des conditions de froid léger et dans des environnements sans vent.

Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis.
Fuchs A, Koepp G, Huber M, Aebli J, Afshari A, Bonfiglio R, Greif R, Lusardi AC, Romero CS, von Gernler M, Disma N, Riva T. | Br J Anaesth. 2024 Feb;132(2):392-406
DOI: https://doi.org/10.1016/j.bja.2023.10.039  | Télécharger l'article au format  
Keywords: airway; apnoea; apnoeic oxygenation; paediatric anaesthesia; supplemental oxygen; tracheal intubation.

RESPIRATION AND THE AIRWAY

Introduction : Supplemental oxygen administration by apnoeic oxygenation during laryngoscopy for tracheal intubation is intended to prolong safe apnoea time, reduce the risk of hypoxaemia, and increase the success rate of first-attempt tracheal intubation under general anaesthesia. This systematic review examined the efficacy and effectiveness of apnoeic oxygenation during tracheal intubation in children.

Méthode : This systematic review and meta-analysis included randomised controlled trials and non-randomised studies in paediatric patients requiring tracheal intubation, evaluating apnoeic oxygenation by any method compared with patients without apnoeic oxygenation. Searched databases were MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), Scopus, and Web of Science from inception to March 22, 2023. Data extraction and risk of bias assessment followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) recommendation.

Résultats : After initial selection of 40 708 articles, 15 studies summarising 9802 children were included (10 randomised controlled trials, four pre-post studies, one prospective observational study) published between 1988 and 2023. Eight randomised controlled trials were included for meta-analysis (n=1070 children; 803 from operating theatres, 267 from neonatal intensive care units). Apnoeic oxygenation increased intubation first-pass success with no physiological instability (risk ratio [RR] 1.27, 95% confidence interval [CI] 1.03-1.57, P=0.04, I2=0), higher oxygen saturation during intubation (mean difference 3.6%, 95% CI 0.8-6.5%, P=0.02, I2=63%), and decreased incidence of hypoxaemia (RR 0.24, 95% CI 0.17-0.33, P<0.01, I2=51%) compared with no supplementary oxygen administration.

Conclusion : This systematic review with meta-analysis confirms that apnoeic oxygenation during tracheal intubation of children significantly increases first-pass intubation success rate. Furthermore, apnoeic oxygenation enables stable physiological conditions by maintaining oxygen saturation within the normal range.

Conclusion (proposition de traduction) : Cette revue systématique avec méta-analyse confirme que l'oxygénation apnéique pendant l'intubation trachéale des enfants augmente significativement le taux de réussite de l'intubation au premier essai. De plus, l'oxygénation apnéique permet d'obtenir des conditions physiologiques stables en maintenant la saturation en oxygène dans la plage normale.

Evaluation of hydroxocobalamin use for the treatment of suspected cyanide toxicity secondary to smoke inhalation.
Kamta J, Maynard K, Schult RF, Bell DE, Jones CMC, Acquisto NM. | Burns. 2024 Feb;50(1):157-166
DOI: https://doi.org/10.1016/j.burns.2023.08.020
Keywords: Antidotes; Cyanides; Humans; Hydroxocobalamin; Smoke inhalation injury.

Research article

Introduction : Hydroxocobalamin is used for cyanide toxicity after smoke inhalation, but diagnosis is challenging. Retrospective studies have associated hydroxocobalamin with acute kidney injury (AKI).

Méthode : This is a retrospective analysis of patients receiving hydroxocobalamin for suspected cyanide toxicity. The primary outcome was the proportion of patients meeting predefined appropriate use criteria defined as ≥1 of the following: serum lactate ≥8 mmol/L, systolic blood pressure (SBP) <90 mmHg, new-onset seizure, cardiac arrest, or respiratory arrest. Secondary outcomes included incidence of AKI, pneumonia, resolution of initial neurologic symptoms, and in-hospital mortality.

Résultats : Forty-six patients were included; 35 (76%) met the primary outcome. All met appropriate use criteria due to respiratory arrest, 15 (43%) for lactate, 14 (40%) for SBP, 12 (34%) for cardiac arrest. AKI, pneumonia, and resolution of neurologic symptoms occurred in 30%, 21%, and 49% of patients, respectively. In-hospital mortality was higher in patients meeting criteria, 49% vs. 9% (95% CI 0.16, 0.64). When appropriate use criteria were modified to exclude respiratory arrest in a post-hoc analysis, differences were maintained, suggesting respiratory arrest alone is not a critical component to determine hydroxocobalamin administration.

Conclusion : Predefined appropriate use criteria identify severely ill smoke inhalation victims and provides hydroxocobalamin treatment guidance.

Conclusion (proposition de traduction) : Des critères d'utilisation appropriés prédéfinis permettent d'identifier les victimes d'inhalation de fumée gravement malades et d'orienter le traitement à l'hydroxocobalamine.

Completeness and accuracy of digital charting vs paper charting in simulated pediatric cardiac arrest: a randomized controlled trial.
St-Onge-St-Hilaire A, Cheng A, Davidson J, Wan B, Lin Y. | CJEM. 2024 Feb;26(2):94-102
DOI: https://doi.org/10.1007/s43678-023-00624-w
Keywords: Cardiopulmonary arrest; Charting; Digital; Simulation.

Original Research

Introduction : To determine if data collected through digital charting are more complete and more accurate compared to traditional paper-based charting during simulated pediatric cardiac arrest.

Méthode : We performed a single-center simulation-based randomized controlled trial. Participants were randomized to a novel handheld digital charting device (intervention group) or to the standard resuscitation paper chart (control group). Participants documented two 15-min simulated pediatric cardiac arrest scenarios. We compared the charting completeness between the two groups. Completeness score (primary outcome) was established by calculating a completeness score for each group based on a list of pre-determined critical tasks. Charting accuracy (secondary outcome) was compared between the two groups, defined as the time interval between the real-time task performance and charted time.

Résultats : Charting data from 34 simulated cardiac arrest events were included in the analysis (n = 18 intervention; n = 16 control). The paper charting group had a higher completeness score (median (IQR) paper vs digital: 72.0% (66.4-76.9%) vs 65.0% (58.5-66.4%), p = 0.015). For accuracy, the digital charting group was superior to the paper charting group for all pre-established critical tasks.

Conclusion : Compared to paper-based charting, digital charting group captured more critical tasks during pediatric simulated resuscitation and was more accurate in the time intervals between real-time tasks performance and charted time. For tasks charted, paper-based charting was significantly more complete and more detailed during simulated pediatric cardiac arrest.

Conclusion (proposition de traduction) : Comparé à la tenue de dossiers sur papier, le groupe des dossiers informatisés a saisi plus de gestes critiques au cours d'une simulation de réanimation pédiatrique et s'est avéré plus précis dans les intervalles de temps entre l'exécution des gestes en temps réel et le moment où ils ont été consignés. En ce qui concerne les données sur les pratiques, les dossiers papier étaient significativement plus complets et plus détaillés pendant la simulation d'un arrêt cardiaque pédiatrique.

Hypotension and respiratory events related to electrical cardioversion for atrial fibrillation or atrial flutter in the emergency department.
Liu S, Stiell I, Eagles D, Borgundvaag B, Grewal K. | CJEM. 2024 Feb;26(2):103-110
DOI: https://doi.org/10.1007/s43678-023-00621-z
Keywords: Adverse events; Atrial fibrillation; Emergency department.

Original Research

Introduction : Electrical cardioversion for atrial fibrillation/atrial flutter (AF/AFL) is common in the ED. Our previous work showed that hypotension and respiratory events were important adverse events that occurred in patients undergoing electrical cardioversion for AF/AFL. The purpose of this study was to examine if (1) beta-blockers or calcium channel blocker use prior to ECV were associated with hypotension and (2) medications used for procedural sedation were associated with respiratory events.

Méthode : This was a secondary analysis of pooled study data from four previous multicentred studies on AF/AFL. We conducted a multivariable logistic regression to examine predictors of hypotension and respiratory adverse events.

Résultats : There were 1736 patients who received ECV. A hypotensive event occurred in 62 (3.6%) patients. There was no significant difference in the odds of a hypotensive event in patients who received a beta-blocker or calcium channel blocker in the ED compared to no rate control. Procedural sedation with fentanyl (OR 2.01 95% CI 1.15-3.51) and home beta-blocker use (OR 1.92, 95% CI 1.14-3.21) were significantly associated with hypotensive events. A respiratory event occurred in 179 (10.3%) patients. Older age (OR 2.02, 95% CI 1.30- 3.15) and receiving midazolam for procedural sedation were found to be significantly associated with respiratory events (OR 1.99, 95% CI 1.02-3.88).

Conclusion : Beta-blocker or calcium channel blocker use prior to ECV for AF/AFL was not associated with hypotension. However, sedation with fentanyl and home beta-blocker use was associated with hypotension. The use of midazolam for procedural sedation was significantly associated with respiratory events.

Conclusion (proposition de traduction) : L'utilisation de bêta-bloquants ou d'inhibiteurs calciques avant la cardioversion électrique pour une fibrillation auriculaire ou un flutter auriculaire n'a pas été associée à une hypotension. Cependant, la sédation par le fentanyl et l'utilisation de bêta-bloquants à domicile ont été associées à une hypotension. L'utilisation du midazolam pour la sédation procédurale a été significativement associée à des événements respiratoires.

Commentaire : Cette étude indique qu'il existe des risques associés à la sédation pour la cardioversion électrique. C'est pourquoi les médecins devraient envisager d'utiliser d'abord la cardioversion pharmacologique pour éviter les effets secondaires potentiels de la cardioversion électrique.
Si la cardioversion pharmacologique échoue ou si la décision de procéder à une cardioversion électrique est prise, le fentanyl et le midazolam doivent être évités dans la plupart des situations. Une attention particulière est requise chez les patients plus âgés et ceux qui prennent déjà des bêta-bloquants.
Enfin, il est très important, lors de l'administration de la sédation, de surveiller les patients avec un équipement approprié et des cliniciens formés, afin de détecter et de gérer toute détérioration clinique et d'éviter tout événement indésirable.
Perry JJ, Rubin Y. Caution Is Indicated When Using Fentanyl or Midazolam for Procedural Sedation in the Emergency Department. CJEM. 2024 Feb;26(2):71-72  .

Peripheral Administration of Norepinephrine: A Prospective Observational Study.
Yerke JR, Mireles-Cabodevila E, Chen AY, Bass SN, Reddy AJ, Bauer SR, Kokoczka L, Dugar S, Moghekar A. | Chest. 2024 Feb;165(2):348-355
DOI: https://doi.org/10.1016/j.chest.2023.08.019  | Télécharger l'article au format  
Keywords: catheter; hypotension; infusions; norepinephrine; parenteral; shock; vasoconstrictor agents.

Research article

Introduction : Historically, norepinephrine has been administered through a central venous catheter (CVC) because of concerns about the risk of ischemic tissue injury if extravasation from a peripheral IV catheter (PIVC) occurs. Recently, several reports have suggested that peripheral administration of norepinephrine may be safe.
Research question: Can a protocol for peripheral norepinephrine administration safely reduce the number of days a CVC is in use and frequency of CVC placement?

Méthode : This was a prospective observational cohort study conducted in the medical ICU at a quaternary care academic medical center. A protocol for peripheral norepinephrine administration was developed and implemented in the medical ICU at the study site. The protocol was recommended for use in patients who met prespecified criteria, but was used at the treating clinician's discretion. All adult patients admitted to the medical ICU receiving norepinephrine through a PIVC from February 2019 through June 2021 were included.

Résultats : The primary outcome was the number of days of CVC use that were avoided per patient, and the secondary safety outcomes included the incidence of extravasation events. Six hundred thirty-five patients received peripherally administered norepinephrine. The median number of CVC days avoided per patient was 1 (interquartile range, 0-2 days per patient). Of the 603 patients who received norepinephrine peripherally as the first norepinephrine exposure, 311 patients (51.6%) never required CVC insertion. Extravasation of norepinephrine occurred in 35 patients (75.8 events/1,000 d of PIVC infusion [95% CI, 52.8-105.4 events/1,000 d of PIVC infusion]). Most extravasations caused no or minimal tissue injury. No patient required surgical intervention.

Conclusion : This study suggests that implementing a protocol for peripheral administration of norepinephrine safely can avoid 1 CVC day in the average patient, with 51.6% of patients not requiring CVC insertion. No patient experienced significant ischemic tissue injury with the protocol used. These data support performance of a randomized, prospective, multicenter study to characterize the net benefits of peripheral norepinephrine administration compared with norepinephrine administration through a CVC.

Conclusion (proposition de traduction) : Cette étude suggère que la mise en œuvre d'un protocole d'administration périphérique de norépinéphrine en toute sécurité permet d'éviter une journée de cathéter veineux central chez un patient moyen, 51,6 % des patients ne nécessitant pas la pose d'un cathéter veineux central. Aucun patient n'a subi de lésion ischémique significative des tissus avec le protocole utilisé. Ces données soutiennent la réalisation d'une étude randomisée, prospective et multicentrique visant à caractériser les bénéfices nets de l'administration périphérique de norépinéphrine par rapport à l'administration de norépinéphrine par un cathéter veineux central.

Stopping Aspirin Within 1 Month After Stenting for Ticagrelor Monotherapy in Acute Coronary Syndrome: The T-PASS Randomized Noninferiority Trial.
Hong SJ, Lee SJ, Suh Y, Yun KH, Kang TS, Shin S, Kwon SW, Lee JW, Cho DK, Park JK, Bae JW, Kang WC, Kim S, Lee YJ, Ahn CM, Kim JS, Kim BK, Ko YG, Choi D, Jang Y, Hong MK; T-PASS (Ticagrelor Monotherapy in Patients Treated With New-Generation Drug-Eluting Stents for Acute Coronary Syndrome) Investigators. | Circulation. 2024 Feb 20;149(8):562-573
DOI: https://doi.org/10.1161/circulationaha.123.066943
Keywords: acute coronary syndrome; antiplatelet agent; aspirin; drug-eluting stents.

ORIGINAL RESEARCH ARTICLE

Introduction : Stopping aspirin within 1 month after implantation of a drug-eluting stent for ticagrelor monotherapy has not been exclusively evaluated for patients with acute coronary syndrome. The aim of this study was to investigate whether ticagrelor monotherapy after <1 month of dual antiplatelet therapy (DAPT) is noninferior to 12 months of ticagrelor-based DAPT for adverse cardiovascular and bleeding events in patients with acute coronary syndrome.

Méthode : In this randomized, open-label, noninferiority trial, 2850 patients with acute coronary syndrome who underwent drug-eluting stent implantation at 24 centers in South Korea were randomly assigned (1:1) to receive either ticagrelor monotherapy (90 mg twice daily) after <1 month of DAPT (n=1426) or 12 months of ticagrelor-based DAPT (n=1424) between April 24, 2019, and May 31, 2022. The primary end point was the net clinical benefit as a composite of all-cause death, myocardial infarction, definite or probable stent thrombosis, stroke, and major bleeding at 1 year after the index procedure in the intention-to-treat population. Key secondary end points were the individual components of the primary end point.

Résultats : Among 2850 patients who were randomized (mean age, 61 years; 40% ST-segment-elevation myocardial infarction), 2823 (99.0%) completed the trial. Aspirin was discontinued at a median of 16 days (interquartile range, 12-25 days) in the group receiving ticagrelor monotherapy after <1 month of DAPT. The primary end point occurred in 40 patients (2.8%) in the group receiving ticagrelor monotherapy after <1-month DAPT, and in 73 patients (5.2%) in the ticagrelor-based 12-month DAPT group (hazard ratio, 0.54 [95% CI, 0.37-0.80]; P<0.001 for noninferiority; P=0.002 for superiority). This finding was consistent in the per-protocol population as a sensitivity analysis. The occurrence of major bleeding was significantly lower in the ticagrelor monotherapy after <1-month DAPT group compared with the 12-month DAPT group (1.2% versus 3.4%; hazard ratio, 0.35 [95% CI, 0.20-0.61]; P<0.001).

Conclusion : This study provides evidence that stopping aspirin within 1 month for ticagrelor monotherapy is both noninferior and superior to 12-month DAPT for the 1-year composite outcome of death, myocardial infarction, stent thrombosis, stroke, and major bleeding, primarily because of a significant reduction in major bleeding, among patients with acute coronary syndrome receiving drug-eluting stent implantation. Low event rates, which may suggest enrollment of relatively non-high-risk patients, should be considered in interpreting the trial.

Conclusion (proposition de traduction) : Cette étude démontre que l'arrêt de l'aspirine dans un délai d'un mois pour une monothérapie au ticagrelor est à la fois non inférieur et supérieur à une bithérapie antiplaquettaire sur 12 mois pour le critère composite à un an (décès, infarctus du myocarde, thrombose de stent, accident vasculaire cérébral et hémorragie majeure), principalement en raison d'une réduction significative des hémorragies majeures, chez les patients atteints d'un syndrome coronarien aigu ayant bénéficié d'une implantation de stent à libération de principe actif. Les faibles taux d'événements, qui peuvent suggérer l'inclusion de patients à risque relativement faible, doivent être pris en compte dans l'interprétation de l'essai.

Safety and Efficacy of Ticagrelor Monotherapy in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: An Individual Patient Data Meta-Analysis of TWILIGHT and TICO Randomized Trials.
Baber U, Jang Y, Oliva A, Cao D, Vogel B, Dangas G, Sartori S, Spirito A, Smith KF, Branca M, Collier T, Pocock S, Valgimigli M, Kim BK, Hong MK, Mehran R. | Circulation. 2024 Feb 20;149(8):574-584
DOI: https://doi.org/10.1161/circulationaha.123.067283
Keywords: acute coronary syndrome; hemorrhage; percutaneous coronary intervention; purinergic P2Y receptor antagonists; ticagrelor.

ORIGINAL RESEARCH ARTICLE

Introduction : Dual antiplatelet therapy with a potent P2Y12 inhibitor coupled with aspirin for 1 year is the recommended treatment for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). As an alternative, monotherapy with a P2Y12 inhibitor after a short period of dual antiplatelet therapy has emerged as a bleeding reduction strategy.

Méthode : We pooled individual patient data from randomized trials that included patients with ACS undergoing PCI treated with an initial 3-month course of dual antiplatelet therapy followed by ticagrelor monotherapy versus continued ticagrelor plus aspirin. Patients sustaining a major ischemic or bleeding event in the first 3 months after PCI were excluded from analysis. The primary outcome was Bleeding Academic Research Consortium type 3 or 5 bleeding occurring between 3 and 12 months after index PCI. The key secondary end point was the composite of death, myocardial infarction, or stroke. Hazard ratios and 95% CIs were generated using Cox regression with a one-stage approach in the intention-to-treat population.

Résultats : The pooled cohort (n=7529) had a mean age of 62.8 years, 23.2% were female, and 55% presented with biomarker-positive ACS. Between 3 and 12 months, ticagrelor monotherapy significantly reduced Bleeding Academic Research Consortium 3 or 5 bleeding compared with ticagrelor plus aspirin (0.8% versus 2.1%; hazard ratio, 0.37 [95% CI, 0.24-0.56]; P<0.001). Rates of all-cause death, myocardial infarction, or stroke were not significantly different between groups (2.4% versus 2.7%; hazard ratio, 0.91 [95% CI, 0.68-1.21]; P=0.515). Findings were unchanged among patients presenting with biomarker-positive ACS.

Conclusion : Among patients with ACS undergoing PCI who have completed a 3-month course of dual antiplatelet therapy, discontinuation of aspirin followed by ticagrelor monotherapy significantly reduced major bleeding without incremental ischemic risk compared with ticagrelor plus aspirin.

Conclusion (proposition de traduction) : Chez les patients présentant un syndrome coronarien aigu et bénéficiant d'une intervention coronarienne percutanée, qui ont achevé une bithérapie antiplaquettaire de trois mois, l'arrêt de l'aspirine suivi d'une monothérapie par le ticagrelor a réduit de manière significative les saignements majeurs sans augmentation du risque ischémique, par rapport au ticagrelor associé à l'aspirine.

An Aspirin-Free Versus Dual Antiplatelet Strategy for Coronary Stenting: STOPDAPT-3 Randomized Trial.
Natsuaki M, Watanabe H, Morimoto T, Yamamoto K, Obayashi Y, Nishikawa R, Ando K, Domei T, Suwa S, Ogita M, Isawa T, Takenaka H, Yamamoto T, Ishikawa T, Hisauchi I, Wakabayashi K, Onishi Y, Hibi K, Kawai K, Yoshida R, Suzuki H, Nakazawa G, Kusuyama T, Morishima I, Ono K, Kimura T. | Circulation. 2024 Feb 20;149(8):585-600
DOI: https://doi.org/10.1161/circulationaha.123.066720
Keywords: aspirin; dual anti-platelet therapy; percutaneous coronary intervention.

ORIGINAL RESEARCH ARTICLE

Introduction : Bleeding rates on dual antiplatelet therapy (DAPT) within 1 month after percutaneous coronary intervention (PCI) remain high in clinical practice, particularly in patients with acute coronary syndrome or high bleeding risk. Aspirin-free strategy might result in lower bleeding early after PCI without increasing cardiovascular events, but its efficacy and safety have not yet been proven in randomized trials.

Méthode : We randomly assigned 6002 patients with acute coronary syndrome or high bleeding risk just before PCI either to prasugrel (3.75 mg/day) monotherapy or to DAPT with aspirin (81-100 mg/day) and prasugrel (3.75 mg/day) after loading of 20 mg of prasugrel in both groups. The coprimary end points were major bleeding (Bleeding Academic Research Consortium 3 or 5) for superiority and cardiovascular events (a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke) for noninferiority with a relative 50% margin.

Résultats : The full analysis set population consisted of 5966 patients (no-aspirin group, 2984 patients; DAPT group, 2982 patients; age, 71.6±11.7 years; men, 76.6%; acute coronary syndrome, 75.0%). Within 7 days before randomization, aspirin alone, aspirin with P2Y12 inhibitor, oral anticoagulants, and intravenous heparin infusion were given in 21.3%, 6.4%, 8.9%, and 24.5%, respectively. Adherence to the protocol-specified antiplatelet therapy was 88% in both groups at 1 month. At 1 month, the no-aspirin group was not superior to the DAPT group for the coprimary bleeding end point (4.47% and 4.71%; hazard ratio, 0.95 [95% CI, 0.75-1.20]; Psuperiority=0.66). The no-aspirin group was noninferior to the DAPT group for the coprimary cardiovascular end point (4.12% and 3.69%; hazard ratio, 1.12 [95% CI, 0.87-1.45]; Pnoninferiority=0.01). There was no difference in net adverse clinical outcomes and each component of coprimary cardiovascular end point. There was an excess of any unplanned coronary revascularization (1.05% and 0.57%; hazard ratio, 1.83 [95%CI, 1.01-3.30]) and subacute definite or probable stent thrombosis (0.58% and 0.17%; hazard ratio, 3.40 [95% CI, 1.26-9.23]) in the no-aspirin group compared with the DAPT group.

Conclusion : The aspirin-free strategy using low-dose prasugrel compared with the DAPT strategy failed to attest superiority for major bleeding within 1 month after PCI but was noninferior for cardiovascular events within 1 month after PCI. However, the aspirin-free strategy was associated with a signal suggesting an excess of coronary events.

Conclusion (proposition de traduction) : La stratégie sans aspirine utilisant une faible dose de prasugrel comparée à la stratégie de double thérapie antiplaquettaire n'a pas permis de prouver sa supériorité pour les hémorragies majeures dans le mois suivant l'intervention coronarienne percutanée mais était non inférieure pour les événements cardiovasculaires dans le mois suivant l'intervention coronarienne percutanée. Cependant, la stratégie sans aspirine a été associée à un signal suggérant un excès d'événements coronariens.

Extracorporeal cardiopulmonary resuscitation versus conventional CPR in cardiac arrest: an updated meta-analysis and trial sequential analysis.
Low CJW, Ling RR, Ramanathan K, Chen Y, Rochwerg B, Kitamura T, Iwami T, Ong MEH, Okada Y. | Crit Care. 2024 Feb 21;28(1):57
DOI: https://doi.org/10.1186/s13054-024-04830-5  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Extracorporeal membrane oxygenation; Meta-analysis.

Brief Report

Introduction : Extracorporeal cardiopulmonary resuscitation (ECPR) may reduce mortality and improve neurological outcomes in patients with cardiac arrest. We updated our existing meta-analysis and trial sequential analysis to further evaluate ECPR compared to conventional CPR (CCPR).

Méthode : We searched three international databases from 1 January 2000 through 1 November 2023, for randomised controlled trials or propensity score matched studies (PSMs) comparing ECPR to CCPR in both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). We conducted an updated random-effects meta-analysis, with the primary outcome being in-hospital mortality. Secondary outcomes included short- and long-term favourable neurological outcome and survival (30 days-1 year). We also conducted a trial sequential analysis to evaluate the required information size in the meta-analysis to detect a clinically relevant reduction in mortality.

Résultats : We included 13 studies with 14 pairwise comparisons (6336 ECPR and 7712 CCPR) in our updated meta-analysis. ECPR was associated with greater precision in reducing overall in-hospital mortality (OR 0.63, 95% CI 0.50-0.79, high certainty), to which the trial sequential analysis was concordant. The addition of recent studies revealed a newly significant decrease in mortality in OHCA (OR 0.62, 95% CI 0.45-0.84). Re-analysis of relevant secondary outcomes reaffirmed our initial findings of favourable short-term neurological outcomes and survival up to 30 days. Estimates for long-term neurological outcome and 90-day-1-year survival remained unchanged.

Conclusion : We found that ECPR reduces in-hospital mortality, improves neurological outcome, and 30-day survival. We additionally found a newly significant benefit in OHCA, suggesting that ECPR may be considered in both IHCA and OHCA.

Conclusion (proposition de traduction) : Nous avons constaté que l'ECPR réduit la mortalité hospitalière, améliore l'état neurologique et la survie à 30 jours. Nous avons également constaté un bénéfice significatif dans les arrêts cardiaques extra-hospitaliers, ce qui suggère que l'ECPR peut être envisagée dans les arrêts cardiaques intra-hospitaliers et extra-hospitaliers.

Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis.
Koroki T, Kotani Y, Yaguchi T, Shibata T, Fujii M, Fresilli S, Tonai M, Karumai T, Lee TC, Landoni G, Hayashi Y. | Crit Care. 2024 Feb 17;28(1):48
DOI: https://doi.org/10.1186/s13054-024-04831-4  | Télécharger l'article au format  
Keywords: Bayes theorem; Intensive care units; Intubation; Ketamine; Meta-analysis; Mortality; Systematic review.

Research

Introduction : Tracheal intubation is a high-risk intervention commonly performed in critically ill patients. Due to its favorable cardiovascular profile, ketamine is considered less likely to compromise clinical outcomes. This meta-analysis aimed to assess whether ketamine, compared with other agents, reduces mortality in critically ill patients undergoing intubation.

Méthode : We searched MEDLINE, Embase, and the Cochrane Library from inception until April 27, 2023, for randomized controlled trials and matched observational studies comparing ketamine with any control in critically ill patients as an induction agent. The primary outcome was mortality at the longest follow-up available, and the secondary outcomes included Sequential Organ Failure Assessment score, ventilator-free days at day 28, vasopressor-free days at day 28, post-induction mean arterial pressure, and successful intubation on the first attempt. For the primary outcome, we used a Bayesian random-effects meta-analysis on the risk ratio (RR) scale with a weakly informative neutral prior corresponding to a mean estimate of no difference with 95% probability; the estimated effect size will fall between a relative risk of 0.25 and 4. The RR and 95% credible interval (CrI) were used to estimate the probability of mortality reduction (RR < 1). The secondary outcomes were assessed with a frequentist random-effects model.

Résultats : We included seven randomized trials and one propensity-matched study totaling 2978 patients. Etomidate was the comparator in all the identified studies. The probability that ketamine reduced mortality was 83.2% (376/1475 [25%] vs. 411/1503 [27%]; RR, 0.93; 95% CrI, 0.79-1.08), which was confirmed by a subgroup analysis excluding studies with a high risk of bias. No significant difference was observed in any secondary outcomes.

Conclusion : All of the included studies evaluated ketamine versus etomidate among critically ill adults requiring tracheal intubation. This meta-analysis showed a moderate probability that induction with ketamine is associated with a reduced risk of mortality.

Conclusion (proposition de traduction) : Toutes les études incluses ont évalué la kétamine par rapport à l'étomidate chez des adultes gravement malades nécessitant une intubation trachéale. Cette méta-analyse a montré une probabilité modérée que l'induction par la kétamine soit associée à un risque réduit de mortalité.

Albumin versus saline infusion for sepsis-related peripheral tissue hypoperfusion: a proof-of-concept prospective study.
Gabarre P, Desnos C, Morin A, Missri L, Urbina T, Bonny V, Turpin M, Baudel JL, Berard L, Montil M, Guidet B, Voiriot G, Joffre J, Maury E, Ait-Oufella H. | Crit Care. 2024 Feb 7;28(1):43
DOI: https://doi.org/10.1186/s13054-024-04827-0  | Télécharger l'article au format  
Keywords: Albumin; Capillary refill time; Mottling; Sepsis; Tissue perfusion.

Research

Introduction : Albumin has potential endothelial protective effects through antioxidant and anti-inflammatory properties. However, the effect of albumin on peripheral tissue perfusion in human sepsis remains poorly known.

Méthode : Bi-centric prospective study included patients with sepsis with or without shock and prolonged CRT > 3 s despite initial resuscitation. Clinicians in charge of the patients were free to infuse either saline 500 mL or human serum albumin 20% 100 mL over 15 min. Global hemodynamic parameters as well as peripheral tissue perfusion were analyzed after 1 (H1) and 4 h (H4). The primary endpoint was CRT normalization (< 3 s) at H1.

Résultats : 62 patients were screened, and 50 patients (13 sepsis and 37 septic shock) were included, 21 in the saline group and 29 in the albumin group. SOFA score was 8 [5-11], and SAPS II was 53 [45-70]. Median age was 68 [60-76] years with a higher proportion of men (74%). The primary sources of infection were respiratory (54%) and abdominal (24%). At baseline, comorbidities, clinical and biological characteristics were similar between groups. At H1, CRT normalization (< 3 s) was more frequent in patients receiving albumin as compared to patients treated by saline (63 vs 29%, P = 0.02). The decrease in fingertip CRT was more important in the albumin group when compared to saline group (- 1.0 [- 0.3; - 1.5] vs - 0.2 [- 0.1; - 1.1] seconds, P = 0.04) as well as decrease in mottling score. At H4, beneficial effects of albumin on peripheral tissue perfusion were maintained and urinary output trended to be higher in the albumin group (1.1 [0.5-1.8] vs 0.7 [0.5-0.9] ml/kg/h, P = 0.08). Finally, arterial lactate level did not significantly change between H0 and H4 in the saline group but significantly decreased in the albumin group (P = 0.03).

Conclusion : In patients with resuscitated sepsis, albumin infusion might lead to greater improvement of tissue hypoperfusion compared to saline.

Conclusion (proposition de traduction) : Chez les patients présentant un sepsis en réanimation, la perfusion d'albumine pourrait entraîner une amélioration plus importante de l'hypoperfusion tissulaire que la perfusion de sérum physiologique.

qSOFA combined with suPAR for early risk detection and guidance of antibiotic treatment in the emergency department: a randomized controlled trial.
Adami ME, Kotsaki A, Antonakos N, Giannitsioti E, Chalvatzis S, Saridaki M, Avgoustou C, Akinosoglou K, Dakou K, Damoraki G, Katrini K, Koufargyris P, Lekakis V, Panagaki A, Safarika A, Eugen-Olsen J, Giamarellos-Bourboulis EJ. | Crit Care. 2024 Feb 6;28(1):42
DOI: https://doi.org/10.1186/s13054-024-04825-2  | Télécharger l'article au format  
Keywords: Meropenem; Risk; Sepsis; suPAR.

Research

Introduction : Sepsis guidelines suggest immediate start of resuscitation for patients with quick Sequential Organ Failure Assessment (qSOFA) 2 or 3. However, the interpretation of qSOFA 1 remains controversial. We investigated whether measurements of soluble urokinase plasminogen activator receptor (suPAR) may improve risk detection when qSOFA is 1.

Méthode : The study had two parts. At the first part, the combination of suPAR with qSOFA was analyzed in a prospective cohort for early risk detection. At the second part, the double-blind, randomized controlled trial (RCT) SUPERIOR evaluated the efficacy of the suPAR-guided medical intervention. SUPERIOR took place between November 2018 and December 2020. Multivariate stepwise Cox regression was used for the prospective cohort, while univariate and multivariate logistic regression was used for the RCT. Consecutive admissions at the emergency department (ED) with suspected infection, qSOFA 1 and suPAR ≥ 12 ng/mL were allocated to single infusion of placebo or meropenem. The primary endpoint was early deterioration, defined as at least one-point increase of admission Sequential Organ Failure Assessment (SOFA) score the first 24 h.

Résultats : Most of the mortality risk was for patients with qSOFA 2 and 3. Taking the hazard ratio (HR) for death of patients with qSOFA = 1 and suPAR < 12 ng/mL as reference, the HR of qSOFA = 1 and suPAR ≥ 12 ng/mL for 28-day mortality was 2.98 (95% CI 2.11-3.96). The prospective RCT was prematurely ended due to pandemia-related ED re-allocations, with 91 patients enrolled: 47 in the placebo and 44 in the meropenem arm. The primary endpoint was met in 40.4% (n = 19) and 15.9% (n = 7), respectively (difference 24.5% [5.9-40.8]; odds ratio 0.14 [0.04-0.50]). One post hoc analysis showed significant median changes of SOFA score after 72 and 96 h equal to 0 and - 1, respectively.

Conclusion : Combining qSOFA 1 with the biomarker suPAR improves its prognostic performance for unfavorable outcome and can help decision for earlier treatment.

Conclusion (proposition de traduction) : La combinaison du qSOFA à 1 avec le biomarqueur suPAR améliore sa performance pronostique pour une évolution défavorable et peut aider à décider d'un traitement plus précoce.

Thiamine administration in septic shock: a post hoc analysis of two randomized trials.
Vine J, Lee JH, Kravitz MS, Grossestreuer AV, Balaji L, Leland SB, Berlin N, Moskowitz A, Donnino MW. | Crit Care. 2024 Feb 6;28(1):41
DOI: https://doi.org/10.1186/s13054-024-04818-1  | Télécharger l'article au format  
Keywords: Kidney injury; Renal protective; Sepsis; Shock; Thiamine.

Brief Report

Introduction : This is a post hoc analysis of combined cohorts from two previous Phase II clinical trials to assess the effect of thiamine administration on kidney protection and mortality in patients with septic shock.

Méthode : Patient-level data from the Thiamine in Septic Shock Trial (NCT01070810) and the Thiamine for Renal Protection in Septic Shock Trial (NCT03550794) were combined in this analysis. The primary outcome for the current study was survival without the receipt of renal replacement therapy (RRT). Analyses were performed on the overall cohort and the thiamine-deficient cohort (thiamine < 8 nmol/L).

Résultats : Totally, 158 patients were included. Overall, thiamine administration was associated with higher odds of being alive and RRT-free (adjusted odds ratio [aOR]: 2.05 [95% confidence interval (CI) 1.08-3.90]) and not needing RRT (aOR: 2.59 [95% CI 1.01-6.62]). In the thiamine-deficient group, thiamine administration was associated with higher odds of being alive and RRT-free (aOR: 8.17 [95% CI 1.79-37.22]) and surviving to hospital discharge (aOR: 6.84 [95% CI 1.54-30.36]). There was a significant effect modification by baseline thiamine deficiency for alive and RRT-free (interaction, p = 0.016) and surviving to hospital discharge (p = 0.019).

Conclusion : In the combined analysis of two previous randomized trials, thiamine administration was associated with higher odds of being alive and RRT-free at hospital discharge in patients with septic shock. This signal was stronger in patients with thiamine deficiency.

Conclusion (proposition de traduction) : Dans l'analyse combinée de deux essais randomisés antérieurs, l'administration de thiamine a été associée à une plus grande probabilité d'être en vie et de ne pas avoir recours à une épuration extra-rénale à la sortie de l'hôpital chez les patients souffrant d'un choc septique. Ce signal était plus fort chez les patients présentant une carence en thiamine.

Supraglottic Airway Versus Tracheal Intubation for Airway Management in Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials.
Forestell B, Ramsden S, Sharif S, Centofanti J, Al Lawati K, Fernando SM, Welsford M, Nichol G, Nolan JP, Rochwerg B. | Crit Care Med. 2024 Feb 1;52(2):e89-e99
DOI: https://doi.org/10.1097/ccm.0000000000006112
Keywords: Aucun

Online Review Article

Introduction : Given the uncertainty regarding the optimal approach for airway management for adult patients with out-of-hospital cardiac arrest (OHCA), we conducted a systematic review and meta-analysis to compare the use of supraglottic airways (SGAs) with tracheal intubation for initial airway management in OHCA.

Méthode : We searched MEDLINE, PubMed, Embase, Cochrane Library, as well as unpublished sources, from inception to February 7, 2023.
Study selection: We included randomized controlled trials (RCTs) of adult OHCA patients randomized to SGA compared with tracheal intubation for initial prehospital airway management.
Data extraction: Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model. We used the modified Cochrane risk of bias 2 tool and assessed certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We preregistered the protocol on PROSPERO (CRD42022342935).

Résultats : We included four RCTs ( n = 13,412 patients). Compared with tracheal intubation , SGA use probably increases return of spontaneous circulation (ROSC) (relative risk [RR] 1.09; 95% CI, 1.02-1.15; moderate certainty) and leads to a faster time to airway placement (mean difference 2.5 min less; 95% CI, 1.6-3.4 min less; high certainty). SGA use may have no effect on survival at longest follow-up (RR 1.06; 95% CI, 0.84-1.34; low certainty), has an uncertain effect on survival with good functional outcome (RR 1.11; 95% CI, 0.82-1.50; very low certainty), and may have no effect on risk of aspiration (RR 1.04; 95% CI, 0.94 to 1.16; low certainty).

Conclusion : In adult patients with OHCA, compared with tracheal intubation, the use of SGA for initial airway management probably leads to more ROSC, and faster time to airway placement, but may have no effect on longer-term survival outcomes or aspiration events.

Conclusion (proposition de traduction) : Chez les patients adultes victimes d'un arrêt cardiaque extrahospitalier, l'utilisation d'un dispositif supraglottique pour la gestion initiale des voies aériennes, comparée à l'intubation trachéale, conduit probablement à un plus garnd nombre de retour à une circulation spontanée et à un délai plus rapide pour la gestion des voies aériennes, mais peut n'avoir aucun effet sur les résultats en terme de survie à plus long terme ou sur les événements d'inhalation.

Antiarrhythmic Treatment in Heart Failure.
Könemann H, Güler-Eren S, Ellermann C, Frommeyer G, Eckardt L.. | Curr Heart Fail Rep. 2024 Feb;21(1):22-32
DOI: https://doi.org/10.1007/s11897-023-00642-w  | Télécharger l'article au format  
Keywords: Atrial fibrillation; Heart failure; Sudden cardiac death; Ventricular arrhythmias.

Review

Editorial : Arrhythmias are common in patients with heart failure (HF) and are associated with a significant risk of mortality and morbidity. Optimal antiarrhythmic treatment is therefore essential. Here, we review current approaches to antiarrhythmic treatment in patients with HF.

Conclusion : In atrial fibrillation, rhythm control and ventricular rate control are accepted therapeutic strategies. In recent years, clinical trials have demonstrated a prognostic benefit of early rhythm control strategies and AF catheter ablation, especially in patients with HF with reduced ejection fraction. Prevention of sudden cardiac death with ICD therapy is essential, but optimal risk stratification is challenging. For ventricular tachycardias, recent data support early consideration of catheter ablation. Antiarrhythmic drug therapy is an adjunctive therapy in symptomatic patients but has no prognostic benefit and well-recognized (proarrhythmic) adverse effects. Antiarrhythmic therapy in HF requires a systematic, multimodal approach, starting with guideline-directed medical therapy for HF and integrating pharmacological, device, and interventional therapy.

Conclusion (proposition de traduction) : Dans la fibrillation atriale, le contrôle du rythme et le contrôle de la fréquence ventriculaire sont des stratégies thérapeutiques établies. Ces dernières années, des essais cliniques ont démontré que les stratégies précoces de contrôle du rythme et l'ablation par cathéter de la fibrillation auriculaire avaient un effet bénéfique sur le pronostic, en particulier chez les patients souffrant d'insuffisance cardiaque avec une fraction d'éjection réduite. La prévention de la mort cardiaque subite par l'implantation d'un cardioverteur-défibrillateur est essentielle, mais la stratification optimale du risque est difficile. Pour les tachycardies ventriculaires, des données récentes permettent d'envisager rapidement l'ablation par cathéter. Le traitement antiarythmique est un traitement d'appoint pour les patients symptomatiques, mais il n'apporte aucun avantage en termes de pronostic et a des effets indésirables (proarythmiques) bien connus. Le traitement antiarythmique de l'insuffisance cardiaque nécessite une approche systématique et multimodale, commençant par un traitement médical de l'insuffisance cardiaque conforme aux directives et intégrant un traitement pharmacologique, un dispositif et un traitement interventionnel.

Hemodynamic effects of positive end-expiratory pressure.
Joseph A, Petit M, Vieillard-Baron A. | Curr Opin Crit Care. 2024 Feb 1;30(1):10-19
DOI: https://doi.org/10.1097/mcc.0000000000001124
Keywords: Aucun

REVIEW

Introduction : Positive end-expiratory pressure (PEEP) is required in the Berlin definition of acute respiratory distress syndrome and is a cornerstone of its treatment. Application of PEEP increases airway pressure and modifies pleural and transpulmonary pressures according to respiratory mechanics, resulting in blood volume alteration into the pulmonary circulation. This can in turn affect right ventricular preload, afterload and function. At the opposite, PEEP may improve left ventricular function, providing no deleterious effect occurs on the right ventricle.

Résultats : This review examines the impact of PEEP on cardiac function with regards to heart-lung interactions, and describes its consequences on organs perfusion and function, including the kidney, gut, liver and the brain. PEEP in itself is not beneficious nor detrimental on end-organ hemodynamics, but its hemodynamic effects vary according to both respiratory mechanics and association with other hemodynamic variables such as central venous or mean arterial pressure. There are parallels in the means of preventing deleterious impact of PEEP on the lungs, heart, kidney, liver and central nervous system.

Conclusion : The quest for optimal PEEP settings has been a prominent goal in ARDS research for the last decades. Intensive care physician must maintain a high degree of vigilance towards hemodynamic effects of PEEP on cardiac function and end-organs circulation.

Conclusion (proposition de traduction) : La recherche du réglage optimal de la PEP a été l'un des principaux objectifs de la recherche sur le SDRA au cours des dernières décennies. Le médecin des soins intensifs doit rester très vigilant quant aux effets hémodynamiques de la PEP sur la fonction cardiaque et la circulation des organes vitaux.

Management of the Agitated Patient.
Wolfe C, McCoin N. | Emerg Med Clin North Am. 2024 Feb;42(1):13-29
DOI: https://doi.org/10.1016/j.emc.2023.06.010  | Télécharger l'article au format  
Keywords: La prise en charge d'un patient agité dans le service des urgences nécessite une approche basée sur le travail d'équipe, en gardant l'autonomie, la sécurité et le bien-être médical du patient au premier plan de toutes les considérations. L'utilisation de la désescalade non coercitive doit être une priorité, les recommandations du BETA proposant une approche structurée qui peut être suivie par l'équipe. Si nécessaire, le médecin doit choisir avec soin un médicament ou une combinaison de médicaments appropriés pour la contention chimique, avec ou sans l'ajout de contentions physiques si cela est nécessaire pour la sécurité du patient et du personnel. Une documentation minutieuse est nécessaire

Review article

Editorial : The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions and physical restraints as necessary. Face-to-face examination, monitoring, and documentation by the physician are essential. The emergency physician should be familiar with multiple pharmaceutical options, tailored to the individual patient. Use of ketamine, benzodiazepines and antipsychotics should be considered. Patient autonomy, safety, and medical well-being are paramount.

Conclusion (proposition de traduction) : Management of an agitated patient in the emergency department requires a team- based approach, keeping the patient’s autonomy, safety, and medical well-being in the forefront of all considerations. Utilization of non-coercive de-escalation should be a priority, with the BETA recommendations offering a structured approach that can be followed by the staff team. If necessary, careful selection of an appropriate pharmacologic agent or combination should be selected by the physician for chemical restraint, with or without the addition of physical restraints as necessary for patient and staff safety. Careful documentation is necessary to ensure regulatory compliance.

Commentaire : Agitation; Antipsychotics; Benzodiazepines; Physical restraints; Sedation.

The Predictive Role of Lactate in the Emergency Department in Patients with Severe Dyspnea.
Niczewski M, Gawęda S, Kluszczyk P, Rycerski M, Syguła D, Danel A, Szmigiel S, Mendrala K, Oraczewska A, Kijonka C, Nowicka M, Wita M, Cyzowski T, Brożek G, Dyrbuś M, Skoczyński S. | Emerg Med Int. 2024 Feb 29;2024:6624423
DOI: https://doi.org/10.1155/2024/6624423  | Télécharger l'article au format  
Keywords: Aucun

Research Article

Introduction : An accurate identification of patients at the need for prioritized diagnostics and care are crucial in the emergency department (ED). Blood gas (BG) analysis is a widely available laboratory test, which allows to measure vital parameters, including markers of ventilation and perfusion. The aim of our analysis was to assess whether blood gas parameters in patients with dyspnea at an increased risk of respiratory failure admitted to the ED can predict short-term outcomes.

Méthode : The study group eventually consisted of 108 patients, with available BG analysis. The clinical and laboratory parameters were retrospectively evaluated, and three groups were distinguished-arterial blood gas (ABG), venous blood gas (VBG), and mixed blood gas. The primary endpoint was short-term, all-cause mortality during the follow-up of median (quartile 1-quartile 3) 2 (1-4) months. The independent risk factors for mortality that could be obtained from blood gas sampling were evaluated.

Résultats : The short-term mortality was 35.2% (38/108). Patients who died were more frequently initially assigned to the red triage risk group, more burdened with comorbidities, and the median SpO2 on admission was significantly lower than in patients who survived the follow-up period. In the multivariable analysis, lactate was the strongest independent predictor of death, with 1 mmol/L increasing all-cause mortality by 58% in ABG (95% CI: 1.01-2.47), by 80% in VBG (95% CI: 1.13-2.88), and by 68% in the mixed blood gas analysis (95% CI: 1.22-2.31), what remained significant in VBG and mixed group after correction for base excess. In each group, pH, pO2, and pCO2 did not predict short-term mortality.

Conclusion : In patients admitted to the ED due to dyspnea, at risk of respiratory failure, lactate levels in arterial, venous, and mixed blood samples are independent predictors of short-term mortality.

Conclusion (proposition de traduction) : Chez les patients admis aux urgences pour une dyspnée et présentant un risque d'insuffisance respiratoire, le taux de lactate dans les prélèvements sanguins artériels, veineux et mixtes est un facteur prédictif indépendant de la mortalité à court terme.

Safety and efficacy of a nitrous oxide procedural sedation programme in a paediatric emergency department: a decade of outcomes.
Croughan S, Barrett M, O'Sullivan R, Beegan A, Blackburn C. | Emerg Med J. 2024 Feb 22;41(2):76-82
DOI: https://doi.org/10.1136/emermed-2022-212931
Keywords: anaesthesia; emergency department; paediatric emergency medicine; paediatric injury.

SEDATION AND PAIN MANAGEMENT

Introduction : Nitrous oxide (N₂O) has multiple benefits in paediatric procedural sedation (PPS), but use is restricted by its limited analgesic properties. Analgesic potency could be increased by combining N₂O and intranasal fentanyl (INF). We assessed safety and efficacy data from 10 years (2011-2021) of our N₂O PPS programme.

Méthode : Prospectively collected data from a sedation registry at a paediatric emergency department (PED) were reviewed. Total procedures performed with N₂O alone or with INF, success rate, sedation depth and adverse events were determined. Contributing factors for these outcomes were assessed via regression analysis and compared between different N₂O concentrations, N₂O in combination with INF, and for physician versus nurse administered sedation. A post hoc analysis on factors associated with vomiting was also performed.

Résultats : 831 N₂O procedural sedations were performed, 358 (43.1%) involved a combination INF and N2O. Nurses managed sedation in 728 (87.6%) cases. Median sedation depth on the University of Michigan Sedation Scale was 1 (IQR 1-2). Sedation was successful in 809 (97.4%) cases. Combination INF/N₂O demonstrated higher median sedation scores (2 vs 1, p<0.001) and increased vomiting (RR 1.8, 95% CI 1.3 to 2.5), with no difference in sedation success compared with N₂O alone. No serious adverse events (SAEs) were reported (desaturation, apnoea, aspiration, bradycardia or hypotension) regardless of N2O concentration or use of INF. 137 (16.5%) minor adverse events occurred. Vomiting occurred in 113 (13.6%) cases and was associated with higher concentrations of N₂O and INF use, but not associated with fasting status. There were no differences in adverse events (RR 0.98, 95% CI 0.97 to 1.04) or success rates (RR 0.93, 95% CI 0.56 to 1.7) between physician provided and nurse provided sedation.

Conclusion : N₂O can provide effective PED PPS. No SAEs were recorded. INF may be an effective PPS adjunct but remains limited by increased rates of vomiting.

Conclusion (proposition de traduction) : Le N₂O peut fournir une sédation procédurale pédiatrique efficace dans un service d'urgences pédiatriques. Aucun événement indésirable grave n'a été enregistré. Le fentanyl intranasal peut être un complément efficace à la sédation procédurale pédiatrique, mais reste limité par des taux accrus de vomissements.

Effect of intranasal sufentanil on acute post-traumatic pain in the emergency department: a randomised controlled trial.
Malinverni S, Kreps B, Lucaccioni T, Bouazza FZ, Bartiaux M, Plumacker A, Pascu A, Youatou Towo P. | Emerg Med J. 2024 Feb 22;41(2):83-88
DOI: https://doi.org/10.1136/emermed-2023-213353
Keywords: analgesia; extremities; extremity; pain management.

SEDATION AND PAIN MANAGEMENT

Introduction : Intranasal sufentanil is a potent opioid which can be used in patients with traumatic injuries presenting to the ED. Although previous studies have demonstrated the superiority of intranasal sufentanil over intravenous morphine in terms of pain relief, its clinical superiority in patients with traumatic injuries receiving adequate multimodal analgesia with acetaminophen and non-steroidal anti-inflammatory drugs is uncertain. We compared pain relief offered by intranasal sufentanil with that offered by oral and intravenous opioids in patients with acute traumatic injuries also receiving a specified regimen of non-opioid treatment.

Méthode : In this single-centre, open-label, parallel-group, randomised controlled superiority trial conducted between January 2020 and February 2022, trauma patients presenting to the ED with a pain score of ≥7 on a visual analogue scale (VAS) were randomised to receive either intranasal sufentanil or other oral/intravenous opioids alongside oral/intravenous acetaminophen and non-steroidal anti-inflammatory drugs. The primary outcome was reduction in VAS score 15-20 min after randomisation.

Résultats : An intention-to-treat analysis included 170 out of 205 patients screened for inclusion. The intranasal sufentanil group (83 patients) showed a significantly greater reduction in pain when compared with the oral/intravenous opioid group (87 patients) 15-20 min after randomisation (reduction in VAS score 3.0 (IQR 1.7-5.0) vs 1.5 (IQR 0.9-3.0); p<0.001). Similarly, a greater reduction in pain was observed in the intranasal sufentanil group 60 min after randomisation (5.0 (IQR 3.0-7.0) vs 3.0 (IQR 2.0-5.3); p<0.001). However, side effects were more frequent in the intervention group (71.1% vs 23%; p<0.001).

Conclusion : Intranasal sufentanil was associated with more effective pain relief than oral/intravenous opioids in patients with traumatic injuries treated with coanalgesia. Intranasal sufentanil could be considered for the management of pain in patients with traumatic injuries associated with severe pain.

Conclusion (proposition de traduction) : Le sufentanil intranasal a été associé à un soulagement plus efficace de la douleur que les opioïdes oraux/intraveineux chez les patients souffrant de lésions traumatiques traitées par coanalgésie. Le sufentanil intranasal pourrait être envisagé pour la prise en charge de la douleur chez les patients souffrant de lésions traumatiques associées à une douleur sévère.

Commentaire : Les vomissements, indépendants de l'état de jeûne, sont les principaux effets secondaires.

High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial.
Siddiqua N, Mathew R, Sahu AK, Jamshed N, Bhaskararayuni J, Aggarwal P, Kumar A, Khan MA. | Emerg Med J. 2024 Feb 22;41(2):96-102
DOI: https://doi.org/10.1136/emermed-2023-213285
Keywords: heart failure; resuscitation.

CRITICAL CARE

Introduction : Sympathetic crashing acute pulmonary edema (SCAPE) is a subset of heart failure with a dramatic presentation. The unique physiology of this condition requires a different management strategy from the conventional practice. The trial objective was to compare the efficacy of high-dose and low-dose GTN in patients with SCAPE.

Méthode : This was an open-label randomised control trial conducted in a tertiary care teaching hospital in India from 11 November 2021 to 30 November 2022. Consenting participants were randomised to high-dose GTN or conventional low-dose GTN. The primary outcome was symptom resolution at 6 hours and 12 hours. Secondary outcomes included intubation rates, admission rates, length of hospital stay, and any short-term adverse effects of GTN and major adverse cardiac events (MACE) at 30 days.

Résultats : Fifty-four participants were included (26 high-dose GTN, 26 low-dose GTN). At 6 hours, symptom resolution was seen in 17 patients (65.4%) in the 'high-dose' group, compared with 3 (11.5%) in the 'low-dose' group (p<0.001). At 12 hours, 88.5% of patients had a clinical resolution in the 'high-dose' arm versus 19.5% in 'low-dose' arm . The low-dose group had longer median hospital stay (12 hours vs 72 hours), more frequent MACE (3.8% vs 26.9%, p=0.02) and a higher intubation rate (3.8% vs 19.2%, p=0.08). The only short-term adverse effect seen was a headache in both the groups.

Conclusion : In SCAPE, patients receiving high-dose GTN (>100 mcg/min) had earlier symptom resolution compared with the conventional 'low dose' GTN without any significant adverse effects.

Conclusion (proposition de traduction) : Dans le SCAPE, les patients recevant une forte dose de nitroglycérine (> 100 mcg/min) ont vu leurs symptômes disparaître plus rapidement que ceux recevant une faible dose de nitroglycérine classique, sans effets indésirables significatifs.

Commentaire : Voir l'article sur le même sujet :
Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2021 Jun;44:262-266  .

Ascending with ultrasound: telementored eFAST in flight-a feasibility study.
Engelsen PC, Heyerdahl F, Maddali DD, Akhavi MS, Undseth RM, Elle OJ, Brun H. | Emerg Radiol. 2024 Feb;31(1):25-31
DOI: https://doi.org/10.1007/s10140-023-02186-x  | Télécharger l'article au format  
Keywords: Feasibility; Helicopter; Prehospital medicine; Telementoring; Ultrasound; eFAST.

Original Article

Introduction : Teleultrasound uses telecommunication technologies to transmit ultrasound images from a remote location to an expert who guides the acquisition of images and interprets them in real time. Multiple studies have demonstrated the feasibility of teleultrasound. However, its application during helicopter flight using long-term evolution (LTE) for streaming has not been studied. Therefore, we conducted a study to examine the feasibility of teleultrasound in an Airbus H145 helicopter.

Méthode : Four anesthesiologists and one military physician were recruited to perform telementored extended Focused Assessment with Sonography in Trauma (eFAST) during nine helicopter flights, each with a unique healthy volunteer. A radiologist was recruited as a remote expert, guiding the physicians in their examinations. The examining physicians reported the user experience of telementored eFAST on a questionnaire, while the remote expert rated the diagnostic quality of the images on a 1-5 Likert scale. In addition, we measured the duration of the examinations and key LTE network parameters including signal strength, quality, and continuity.

Résultats : The images were rated to an average of 4.9 by the remote expert, corresponding to good diagnostic quality. The average duration of telementored eFAST was 05:54 min. LTE coverage was negatively affected by proximity to urban areas and ceased above 2000 ft altitude. Occasional audio problems were addressed by using the Voice over LTE network for communication. The examining physicians unanimously reported on the questionnaire that they would use telementored eFAST on patients.

Conclusion : Telementored eFAST is feasible in ambulance helicopters and can produce images of good diagnostic quality. However, it relies on stable LTE coverage, which is influenced by many factors, including the helicopter's altitude and flight path. Furthermore, its benefit on patient outcomes remains to be proven.

Conclusion (proposition de traduction) : L'eFAST télétransmis est réalisable dans les hélicoptères ambulanciers et peut produire des images de bonne qualité diagnostique. Cependant, elle repose sur une couverture stable à long terme, qui est influencée par de nombreux facteurs, notamment l'altitude et la trajectoire de vol de l'hélicoptère. En outre, ses avantages sur les résultats pour les patients restent à prouver.

Pre-hospital tranexamic acid administration in patients with a severe hemorrhage: an evaluation after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol.
Gulickx M, Lokerman RD, Waalwijk JF, Dercksen B, van Wessem KJP, Tuinema RM, Leenen LPH, van Heijl M. | Eur J Trauma Emerg Surg. 2024 Feb;50(1):139-147
DOI: https://doi.org/10.1007/s00068-023-02262-4  | Télécharger l'article au format  
Keywords: Ambulance; EMS professionals; Pre-hospital; TXA; Tranexamic acid; Traumatic hemorrhage.

Original article

Introduction : To evaluate the pre-hospital administration of tranexamic acid in ambulance-treated trauma patients with a severe hemorrhage after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol.

Méthode : All patients with a severe hemorrhage who were treated and conveyed by EMS professionals between January 2015, and December 2017, to any trauma-receiving emergency department in the eight participating trauma regions in the Netherlands, were included. A severe hemorrhage was defined as extracranial injury with > 20% body volume blood loss, an extremity amputation above the wrist or ankle, or a grade ≥ 4 visceral organ injury. The main outcome was to determine the proportion of patients with a severe hemorrhage who received pre-hospital treatment with tranexamic acid. A Generalized Linear Model (GLM) was performed to investigate the relationship between pre-hospital tranexamic acid treatment and 24 h mortality.

Résultats : A total of 477 patients had a severe hemorrhage, of whom 124 patients (26.0%) received tranexamic acid before arriving at the hospital. More than half (58.4%) of the untreated patients were suspected of a severe hemorrhage by EMS professionals. Patients treated with tranexamic acid had a significantly lower risk on 24 h mortality than untreated patients (OR 0.43 [95% CI 0.19-0.97]).

Conclusion : Approximately a quarter of the patients with a severe hemorrhage received tranexamic acid before arriving at the hospital, while a severe hemorrhage was suspected in more than half of the non-treated patients. Severely hemorrhaging patients treated with tranexamic acid before arrival at the hospital had a lower risk to die within 24 h after injury.

Conclusion (proposition de traduction) : Environ un quart des patients présentant une hémorragie grave ont reçu de l'acide tranexamique avant leur arrivée à l'hôpital, alors qu'une hémorragie grave était suspectée chez plus de la moitié des patients non traités. Les patients présentant une hémorragie grave et traités avec de l'acide tranexamique avant leur arrivée à l'hôpital avaient moins de risques de mourir dans les 24 heures suivant la blessure.

Impact of antithrombotic therapy on acute and delayed intracranial haemorrhage and evaluation of the need of short-term hospitalisation based on CT findings after mild traumatic brain injury: experience from an oral and maxillofacial surgery unit.
Sakkas A, Weiß C, Wilde F, Ebeling M, Thiele OC, Mischkowski RA, Pietzka S. | Eur J Trauma Emerg Surg. 2024 Feb;50(1):157-172
DOI: https://doi.org/10.1007/s00068-023-02228-6
Keywords: Antithrombotic therapy; Delayed intracranial haemorrhage; Mild head trauma; Traumatic brain injury.

Original Article

Introduction : The primary aim was to compare the prevalence of acute and delayed intracranial haemorrhage (ICH) following mild traumatic brain injury (mTBI) in patients on antithrombotic medication referred to a clinic for oral and plastic maxillofacial surgery. The secondary aim was to evaluate the need for short-term hospitalisation based on initial radiological and clinical findings.

Méthode : This was an observational retrospective single-centre study of all patients on antithrombotic medication who were admitted to our department of oral and plastic maxillofacial surgery with mTBI over a 5 year period. Demographic and anamnesis data, injury characteristics, antithrombotic medication, radiological findings, treatment, and outcome were analysed. Patients were divided into the following four groups based on their antithrombotic medication: (1) single antiplatelet users, (2) vitamin K antagonist users, (3) direct oral anticoagulant users, and (4) double antithrombotic users. All patients underwent an emergency cranial CT (CT0) at admission. Based on clinical and radiological evaluation, different treatment protocols were applied. Patients with positive CT0 findings and patients with secondary neurological deterioration received a control CT (CT1) before discharge. Acute and delayed ICH and patient's outcome during hospitalisation were evaluated using descriptive statistical analysis.

Résultats : A total of 696 patients (mean age, 71.6 years) on antithrombotic medication who presented at our department with mTBI were included in the analysis. Most injuries were caused by a ground-level fall (76.9%). Thirty-six patients (5.1%) developed an acute traumatic ICH, and 47 intracerebral lesions were detected by radiology-most of these in patients taking acetylsalicylic acid. No association was detected between ICH and antithrombotic medication (p = 0.4353). In total, 258 (37.1%) patients were admitted for 48 h in-hospital observation. The prevalence of delayed ICH was 0.1%, and the mortality rate was 0.1%. Multivariable analysis identified a Glasgow Coma Scale (GCS) of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea as clinical characteristics significantly associated with an increased risk of acute ICH, whereas age, sex, and trauma mechanism were not associated with ICH prevalence. Of the 39 patients who underwent a control CT1, most had a decreasing or at least constant intracranial lesion; in three patients, intracranial bleeding increased but was not clinically relevant.

Conclusion : According to our experience, antithrombotic therapy does not increase the rate of ICH after mTBI. A GCS of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea are indicators of higher ICH risk. A second CT scan is more effective in patients with secondary neurological deterioration. Initial CT findings were not clinically relevant and should not indicate in-hospital observation.

Conclusion (proposition de traduction) : Dans notre expérience, le traitement anti-coagulant n'augmente pas le taux d'hémorragie intracrânienne après un traumatisme cérébral léger. Un GCS < 15, une perte de conscience, une amnésie, des céphalées, des vertiges et des nausées sont des indicateurs d'un risque plus élevé d'HTIC. Un second scanner est plus efficace chez les patients présentant une détérioration neurologique secondaire. Les résultats initiaux du scanner ne sont pas cliniquement pertinents et ne doivent pas être considérés comme une raison de rester en observation à l'hôpital.

Risk factors for thromboembolic complications in isolated severe head injury.
Jakob DA, Müller M, Lewis M, Wong MD, Exadaktylos AK, Demetriades D. | Eur J Trauma Emerg Surg. 2024 Feb;50(1):185-195
DOI: https://doi.org/10.1007/s00068-023-02292-y  | Télécharger l'article au format  
Keywords: Deep vein thrombosis; Head trauma; Mechanism of injury; Pulmonary embolism.

Original Article

Introduction : Patients with traumatic brain injury (TBI) are at high risk for venous thromboembolism (VTE). The aim of the present study is to identify factors independently associated with VTE events. Specifically, we hypothesized that the mechanism of penetrating head trauma might be an independent factor associated with increased VTE events when compared with blunt head trauma.

Méthode : The ACS-TQIP database (2013-2019) was queried for all patients with isolated severe head injuries (AIS 3-5) who received VTE prophylaxis with either unfractionated heparin or low-molecular-weight heparin. Transfers, patients who died within 72 h and those with a hospital length of stay < 48 h were excluded. Multivariable analysis was used as the primary analysis to identify independent risk factors for VTE in isolated severe TBI.

Résultats : A total of 75,570 patients were included in the study, 71,593 (94.7%) with blunt and 3977 (5.3%) with penetrating isolated TBI. Penetrating trauma mechanism (OR 1.49, CI 95% 1.26-1.77), increasing age (age 16-45: reference; age > 45-65: OR 1.65, CI 95% 1.48-1.85; age > 65-75: OR 1.71, CI 95% 1.45-2.02; age > 75: OR 1.73, CI 95% 1.44-2.07), male gender (OR 1.53, CI 95% 1.36-1.72), obesity (OR 1.35, CI 95% 1.22-1.51), tachycardia (OR 1.31, CI 95% 1.13-1.51), increasing head AIS (AIS 3: reference; AIS 4: OR 1.52, CI 95% 1.35-1.72; AIS 5: OR 1.76, CI 95% 1.54-2.01), associated moderate injuries (AIS = 2) of the abdomen (OR 1.31, CI 95% 1.04-1.66), spine (OR 1.35, CI 95% 1.19-1.53), upper extremity (OR 1.16, CI 95% 1.02-1.31), lower extremity (OR 1.46, CI 95% 1.26-1.68), craniectomy/craniotomy or ICP monitoring (OR 2.96, CI 95% 2.65-3.31) and pre-existing hypertension (OR 1.18, CI 95% 1.05-1.32) were identified as independent risk factors for VTE complications in isolated severe head injury. Increasing GCS (OR 0.93, CI 95% 0.92-0.94), early VTE prophylaxis (OR 0.48, CI 95% 0.39-0.60) and LMWH compared to heparin (OR 0.74, CI 95% 0.68-0.82) were identified as protective factors for VTE complications.

Conclusion : The identified factors independently associated with VTE events in isolated severe TBI need to be considered in VTE prevention measures. In penetrating TBI, an even more aggressive VTE prophylaxis management may be justified as compared to that in blunt.

Conclusion (proposition de traduction) : Les facteurs identifiés comme étant indépendamment associés aux événements thromboemboliques dans les traumatismes crâniens graves isolés doivent être pris en compte dans les mesures de prévention de la thrombose veineuse. Dans le cas d'un traumatisme crânien pénétrant, une prophylaxie de la maladie thromboembolique veineuse encore plus agressive peut être justifiée que dans le cas d'un traumatisme crânien contondant.

Venous thromboembolism chemoprophylaxis in geriatric trauma patients with isolated severe traumatic brain injury.
Condon F, Grigorian A, Russell D, Demetriades D. | Eur J Trauma Emerg Surg. 2024 Feb;50(1):197-203
DOI: https://doi.org/10.1007/s00068-023-02299-5  | Télécharger l'article au format  
Keywords: Geriatrics; Trauma; Traumatic brain injury; VTE prophylaxis; Venous thromboembolism.

Original Article

Introduction : Low-molecular-weight-heparin (LMWH) has been shown to be associated with a decreased risk of venous thromboembolism (VTE) and mortality compared to unfractionated heparin (UH) in severe traumatic brain injury (TBI). The aim of this study was to see if this association persists among a subset of patients, namely elderly patients with isolated TBI.

Méthode : This Trauma Quality Improvement Project (TQIP) database study included patients ≥ 65 years old with severe TBI (Abbreviated injury score [AIS] ≥ 3) that received either LMWH or UH for VTE prophylaxis. Patients with associated severe injuries (extracranial AIS ≥ 3), transferals, deaths < 72-h, hospitalization < 2 days, VTE chemoprophylaxis other than UH or LMWH, or with a history of bleeding diathesis were excluded. The association between VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE) with VTE chemoprophylaxis was analyzed with multivariable analysis, subset analyses of different grades of AIS-head injury, and a 1:1 matched LWMH:UH cohort of patients.

Résultats : Out of 14,926 patients, 11,036 (73.9%) received LMWH. Multivariate analysis showed that patients receiving LMWH had a decreased risk of mortality (OR 0.81, 95% CI 0.67-0.97, p < 0.001) but a similar risk of VTE (OR 0.83, 95% CI 0.63-1.08). Analysis according to head-AIS showed that LMWH was associated with a decreased risk of PE in patients AIS-3 but not in AIS 4 or 5. In a 1:1 matched cohort of LMWH:UH patients, the risk of PE, DVT and VTE were all similar but LMWH continued to be associated with a decreased risk of mortality (OR 0.81, CI 0.67-0.97, p = 0.023).

Conclusion : LMWH was associated with a decreased risk of overall mortality and reduced risk of PE compared to UH among geriatric patients with a severe head injury.

Conclusion (proposition de traduction) : L'HBPM a été associée à une diminution du risque de mortalité globale et du risque d'EP par rapport à l'héparine non fractionnée chez les patients gériatriques ayant subi un traumatisme crânien grave.

Diagnostic value of protein S100b as predictor of traumatic intracranial haemorrhage in elderly adults with low-energy falls: results from a retrospective observational study.
Wania R, Lampart A, Niedermeier S, Stahl R, Trumm C, Reidler P, Kammerlander C, Böcker W, Klein M, Pedersen V. | Eur J Trauma Emerg Surg. 2024 Feb;50(1):205-213
DOI: https://doi.org/10.1007/s00068-023-02324-7  | Télécharger l'article au format  
Keywords: Anticoagulation therapy; Computed tomography; Low-energy fall; Older adult; Protein S100b; Traumatic intracranial haemorrhage.

Original Article

Introduction : The objectives of this study were to analyse the clinical value of protein S100b (S100b) in association with clinical findings and anticoagulation therapy in predicting traumatic intracranial haemorrhage (tICH) and unfavourable outcomes in elderly individuals with low-energy falls (LEF).

Méthode : We conducted a retrospective study in the emergency department (ED) of the LMU University Hospital, Munich by consecutively including all patients aged ≥ 65 years presenting to the ED following a LEF between September 2014 and December 2016 and receiving an emergency cranial computed tomography (cCT) examination. Primary endpoint was the prevalence of tICH. Multivariate logistic regression models and receiver operating characteristics were used to measure the association between clinical findings, anticoagulation therapy and S100b and tICH.

Résultats : We included 2687 patients, median age was 81 years (60.4% women). Prevalence of tICH was 6.7% (180/2687) and in-hospital mortality was 6.1% (11/180). Skull fractures were highly associated with tICH (odds ratio OR 46.3; 95% confidence interval CI 19.3-123.8, p < 0.001). Neither anticoagulation therapy nor S100b values were significantly associated with tICH (OR 1.14; 95% CI 0.71-1.86; OR 1.08; 95% CI 0.90-1.25, respectively). Sensitivity of S100b (cut-off: 0.1 ng/ml) was 91.6% (CI 95% 85.1-95.9), specificity was 17.8% (CI 95% 16-19.6), and the area under the curve value was 0.59 (95% CI 0.54 - 0.64) for predicting tICH.

Conclusion : In conclusion, under real ED conditions, neither clinical findings nor protein S100b concentrations or presence of anticoagulation therapy was sufficient to decide with certainty whether a cCT scan can be bypassed in elderly patients with LEF. Further prospective validation is required.

Conclusion (proposition de traduction) : En conclusion, dans les conditions réelles de l'urgence, ni les résultats cliniques, ni les concentrations de protéine S100b, ni la présence d'un traitement anticoagulant ne sont suffisants pour décider avec certitude si un scanner peut être évité chez les patients âgés ayant fait une chute de faible énergie. Une validation prospective supplémentaire est nécessaire.

Blood pressure immediately after return of spontaneous circulation is associated with increased survival on admission following out-of-hospital cardiac arrest..
Kim SW, Kim HE, Jo YH, Kim YJ, Park SM, Kim YW, et al. . | Hong Kong J Emerg Med. 2024;31(1):28–35
DOI: https://doi.org/10.1002/hkj2.12013  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : In patients with out-of-hospital cardiac arrest (OHCA), low blood pressure after return of spontaneous circulation (ROSC) can be a sign of hemodynamic instability. We aimed to investigate whether systolic blood pressure (SBP) measured immediately after ROSC is associated with survival on admission.

Méthode : Patients with ROSC after OHCA between 2015 and 2018 were included. The primary outcome was survival on admission. Included patients were divided into three groups based on the SBP measured at the time of ROSC: group 1 (SBP ≤90 mmHg), group 2 (SBP 90–120 mmHg), and group 3 (SBP >120 mmHg). Multivariable logistic regression was used to investigate the relationship between the groups by SBP and outcomes.

Résultats : In the final analysis, 519 patients were included. In the restrictive cubic spline curve, the probability of achieving survival on admission increased gradually from low SBP to approximately 120–130 mmHg, then plateaued at a higher SBP. In the multivariable logistic regression analysis, group 1 was independently associated with decreased survival on admission compared to group 2. There was no significant difference between groups 2 and 3.

Conclusion : Low blood pressure (SBP ≤90 mmHg) at the time of ROSC was independently associated with a lower likelihood of survival on admission in patients with non-traumatic OHCA. However, high blood pressure (SBP >120 mmHg) was not associated with a higher likelihood of survival. These suggest that low blood pressure measured in the prehospital phase can serve as an indicator predicting the poor short-term prognosis of patients.

Conclusion (proposition de traduction) : Une pression artérielle basse (SBP ≤90 mmHg) au moment du retour de la circulation spontanée était indépendamment associée à une plus faible probabilité de survie à l'admission chez les patients ayant subi un arrêt cardiaque extrahospitalier non traumatique. Cependant, une pression artérielle élevée (PAS > 120 mmHg) n'était pas associée à une probabilité de survie plus élevée. Ces résultats suggèrent qu'une pression artérielle basse mesurée pendant la phase préhospitalière peut servir d'indicateur pour prédire le mauvais pronostic à court terme des patients.

Parental supporter during pediatric resuscitation: Qualitative exploration of caregivers' and healthcare professionals' experiences and perceptions.
Ghavi A, Hassankhani H, Powers K, Sawyer A, Karimi B, Kharidar M. | Int Emerg Nurs. Int Emerg Nurs. 2024 Feb;72:101381
DOI: https://doi.org/10.1016/j.ienj.2023.101381
Keywords: Caregiver; Family nursing; Healthcare professional; Parents; Pediatrics; Qualitative research; Resuscitation.

Research article

Introduction : Child resuscitation is a critical and stressful time for family caregivers and healthcare professionals. The aim of this study was to explore caregivers' and healthcare professionals' experiences and perceptions of a parental supporter during pediatric cardiopulmonary resuscitation to provide guidance to healthcare professionals on supporting parents and other family caregivers during resuscitation.

Méthode : This study used an exploratory descriptive qualitative approach. The setting was two large referral pediatric governmental hospitals. Participants were 17 caregivers who had experienced their child's resuscitation, and 13 healthcare professionals who served on resuscitation teams in emergency rooms or intensive care wards. Semi-structured, in-depth interviews were conducted and data were analyzed using thematic analysis. COREQ guidelines were followed.

Résultats : Participants shared their experiences and perceptions of a parental supporter during pediatric resuscitation in three themes: 1) Requirement for the presence of a parental supporter, 2) Expectations of the parental supporter, and 3) Characteristics of the parental supporter.

Conclusion : Study findings highlight the need for a parental supporter during pediatric resuscitation; however, there is no defined parental supporter role in current guiding policies due to limited research on this role. More research on the parental supporter role is needed so effective policies and protocols can be developed to enhance family-centered care practices in pediatric emergency and acute care settings.

Conclusion (proposition de traduction) : Les résultats de l'étude soulignent la nécessité d'un accompagnement parental pendant la réanimation pédiatrique ; cependant, il n'y a pas de définition du rôle de l'accompagnement parental dans les politiques directrices actuelles en raison du peu de recherches sur ce rôle. Des recherches plus approfondies sur le rôle de parent accompagnateur sont nécessaires pour que des politiques et des protocoles efficaces puissent être élaborés afin d'améliorer les pratiques de soins centrées sur la famille dans les situations d'urgence pédiatrique et les établissements de soins aigus.

The future of prehospital emergency care: Embracing AI applications in ambulance services.
Al Badawi AK, Nashwan AJ. | Int Emerg Nurs. 2024 Feb;72:101385
DOI: https://doi.org/10.1016/j.ienj.2023.101385
Keywords: Artificial intelligence; Prehospital emergency care; Ambulance services; Telemedicine; EMS optimization

Contemporary issues

Editorial : The integration of Artificial Intelligence (AI) is poised to be a game- changer, as it holds the potential to transform and elevate the quality, efficiency, and precision of critical interventions in emergency medical services (EMS), which has historically been at the forefront of innova- tion. Through this discourse, we aim to explore the current applications and implications of integrating AI in EMS, analyzing key aspects of its incorporation that could profoundly impact prehospital care.

Conclusion : To sum up, the use of AI in prehospital emergency care has the po- tential to greatly improve ambulance services. By incorporating these technologies, we can make the EMS system more efficient, precise, and responsive, resulting in more saved lives and better patient outcomes. We urge healthcare providers, policymakers, and technology developers to collaborate in promoting the integration of AI in our emergency medical services.

Conclusion (proposition de traduction) : En résumé, l'utilisation de l'IA dans les soins d'urgence préhospitaliers a le potentiel d'améliorer considérablement les interventions ambulancières. En intégrant ces technologies, nous pouvons rendre le système EMS plus efficace, plus précis et plus réactif, ce qui permettra de sauver davantage de vies et d'améliorer les résultats pour les patients. Nous encourageons vivement les professionnels de la santé, les décideurs politiques et les développeurs de technologies à collaborer pour promouvoir l'intégration de l'IA dans nos services médicaux d'urgence.

Administering tetanus boosters vaccination to adults in the emergency department: Have you completed all the necessary checks?.
Lau R | Int Emerg Nurs. 2024 Feb;72:101382
DOI: https://doi.org/10.1016/j.ienj.2023.101382
Keywords: Tetanus immunisation; Prophylaxis; BoosterEmergency department; Digital medical record; Immunisation record; Combination vaccines; Knowledge deficits in tetanus immunisation; booster in ED; Pertussis vaccination; Patient education about immunisation

Contemporary issues

Editorial : The administration of tetanus vaccination, commonly known as “tetanus shot”, is a common practice in emergency departments (EDs) due to its crucial role in preventing tetanus infections within the healthcare setting. Tetanus is caused by the Clostridium tetani bacterium, which enters the body through wounds or punctures in the skin. Although it is a rare disease, it can have serious consequences. The bacteria release toxins, which can cause muscle stiffness, painful spasms, fits, and death. The immunity provided by the tetanus vaccine does decrease over time, and the booster doses are recommended generally every 5–10 years, although the exact timing may vary based on indi- vidual risk factors.

Conclusion : By prioritising these strategies and improving clinician's knowledge through training programs, EDs can ensure that tetanus boosters are administered judiciously based on risk assessment. This approach min- imises the risk of unnecessary vaccinations and associated adverse ef- fects, while optimising patient care and safety in the emergency setting.

Conclusion (proposition de traduction) : En donnant la priorité à ces stratégies et en améliorant les connaissances des cliniciens grâce à des programmes de formation, les services d'urgence peuvent s'assurer que les rappels antitétaniques sont administrés judicieusement sur la base d'une évaluation du risque. Cette approche minimise le risque de vaccinations inutiles et les effets indésirables associés, tout en optimisant les soins et la sécurité des patients dans le contexte des urgences.

Chest tube placement in trauma patients: please use sonography.
Saroukh F, Bouchama A, Belhadj A, Aissaoui Y. | Int J Emerg Med. 2024 Feb 13;17(1):20
DOI: https://doi.org/10.1186/s12245-024-00596-3  | Télécharger l'article au format  
Keywords: Aucun

Image

Introduction : A 27-year-old patient with no known medical history was admitted for polytrauma resulting from a traffic accident. The initial thoraco-abdominal computed tomography (CT) scan revealed a minimal left pneumothorax, liver lacerations with intracapsular hematoma, and moderate hemoperitoneum. After 48 h, the patient’s respiratory status worsened. A subsequent chest CT scan identified a medium-sized right hemothorax leading to the insertion of a 28-Fr chest tube (Fig. 1, panel A). Approximately 400 mL of blood flowed freely through the chest tube before ceasing spontaneously. However, the chest tube was found to be dangerously low in its placement.

Conclusion : This case highlights the importance of using US guidance to prevent chest tube misplacement, emphasizingthat reliance solely on anatomical landmarks can leadto errors. Ultrasound guidance enables the selection of the best puncture site and provides real-time visualization of chest structures.Incorporating ultrasound guidance for chest drainage into routine medical practice is recommended.However, further comparative studies are necessary to determine whether these approaches should be established as standard care.

Conclusion (proposition de traduction) : Ce cas met en évidence l'importance de l'utilisation de l'échographie pour éviter un mauvais positionnement du drain thoracique, en soulignant que le fait de se fier uniquement aux repères anatomiques peut conduire à des erreurs. L'échographie permet de sélectionner le meilleur site de ponction et de visualiser en temps réel les structures thoraciques. L'intégration de l'échographie pour le drainage thoracique dans la pratique médicale courante est recommandée. Cependant, d'autres études comparatives sont nécessaires pour déterminer si ces approches devraient être établies comme soins standard.

Commentaire :  Illustrations du site d'insertion (panneau A), de la radiographie thoracique (panneau B) et du scanner abdominal (panneaux C et D) montrant un tube aberrant intrahépatique mis en évidence par une flèche noire sur la radiographie thoracique.
Illustration montrant la position recommandée de la sonde pendant l'échographie thoracique pour le drainage de l'épanchement pleural. Il est possible d'utiliser soit la sonde cardiaque, soit une sonde digestive ; dans cette illustration, une sonde cardiaque est utilisée pour le drainage de l'épanchement pleural.

Diagnostic challenges between takotsubo cardiomyopathy and acute myocardial infarction-where is the emergency?: a literature review.
Scafa-Udriste A, Horodinschi RN, Babos M, Dinu B. | Int J Emerg Med. 2024 Feb 15;17(1):22
DOI: https://doi.org/10.1186/s12245-024-00595-4  | Télécharger l'article au format  
Keywords: Acute myocardial infarction; Echocardiography; Prognosis; Takotsubo cardiomyopathy; Therapeutic strategy.

Review

Introduction : Takotsubo cardiomyopathy (TC) is an emergency cardiovascular disease, with clinical and paraclinical manifestations similar to acute myocardial infarction (AMI), but it is characterized by reversible systolic dysfunction of the left ventricle (LV) in the absence (most of the time) of obstructive coronary artery disease (CAD).

Discussion : TC seems to be more frequent in post-menopausal women and it is triggered by emotional or physical stress. The diagnosis of TC is based on the Mayo Clinic criteria. Initially, patients with TC should be treated as those with AMI and carefully monitored in intensive care unit. Urgent clinical and paraclinical distinction between TC and AMI is mandatory in all patients, because of the different therapeutical management between the two diseases. Chest pain and dyspnea are the most common symptoms in TC. Paraclinical diagnosis is based on cardiac biomarkers, electrocardiogram (ST-segment elevation/T wave inversion in precordial leads without reciprocal ST-segment depression in inferior leads and absence of Q waves), echocardiography (LV systolic dysfunction, regional wall motion abnormalities extended in more than one coronary territory), cardiac magnetic resonance and in most of the cases the positive diagnosis is established by performing CA to exclude obstructive CAD. The prognosis of patients with TC is considered benign in most cases, with a complete LV function recovery, but severe complications may occur, such as cardiogenic shock, LV free wall rupture, life-threatening arrhythmia, and cardiac arrest. Postoperative TC may develop after any type of surgical intervention due to acute stress and it should be differentiated from postoperative AMI. The management of patients with TC is medical and it is based on supportive care and the treatment of heart failure, while patients

Conclusion : TC leads to transient LV dysfunction that mimics AMI from which it should be differentiated for a good therapeutic approach. Patients with TC should be carefully monitored during hospitalization because they have a high recovery potential if optimally treated.

Conclusion (proposition de traduction) : Le syndrome de Tako-tsubo entraîne une dysfonction ventriculaire gauche transitoire qui imite l'infarctus aigu du myocarde, dont elle doit être différenciée pour une bonne approche thérapeutique. Les patients atteints de syndrome de Tako-tsubo doivent être surveillés de près pendant l'hospitalisation car ils ont un fort potentiel de récupération s'ils sont traités de manière optimale.

Impact of teaching on use of mechanical chest compression devices: a simulation-based trial.
Steffen R, Burri S, Roten FM, Huber M, Knapp J. | Int J Emerg Med. 2024 Feb 26;17(1):26
DOI: https://doi.org/10.1186/s12245-024-00611-7  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Mechanical chest compression devices; Medical education; Simulation.

Educational Advances in Emergency Medicine

Introduction : The use of mechanical chest compression devices on patients in cardiac arrest has not shown benefits in previous trials. This is surprising, given that these devices can deliver consistently high-quality chest compressions without interruption. It is possible that this discrepancy is due to the no-flow time (NFT) during the application of the device. In this study, we aimed to demonstrate a reduction in no-flow time during cardiopulmonary resuscitation (CPR) with mechanical chest compression devices following 10 min of structured training in novices.

Méthode : 270 medical students were recruited for the study. The participants were divided as a convenience sample into two groups. Both groups were instructed in how to use the device according to the manufacturer's specifications. The control group trained in teams of three, according to their own needs, to familiarise themselves with the device. The intervention group received 10 min of structured team training, also in teams of three. The participants then had to go through a CPR scenario in an ad-hoc team of three, in order to evaluate the training effect.

Résultats : The median NFT was 26.0 s (IQR: 20.0-30.0) in the intervention group and 37.0 s (IQR: 29.0-42.0) in the control group (p < 0.001). In a follow-up examination of the intervention group four months after the training, the NFT was 34.5 s (IQR: 24.0-45.8). This represented a significant deterioration (p = 0.015) and was at the same level as the control group immediately after training (p = 0.650). The position of the compression stamp did not differ significantly between the groups. Groups that lifted the manikin to position the backboard achieved an NFT of 35.0 s (IQR: 27.5-42.0), compared to 41.0 s (IQR: 36.5-50.5) for the groups that turned the manikin to the side (p = 0.074).

Conclusion : This simulation-based study demonstrated that structured training can significantly reduce the no-flow time when using mechanical resuscitation devices, even in ad-hoc teams. However, this benefit seems to be short-lived: after four months no effect could be detected.

Conclusion (proposition de traduction) : Cette étude basée sur la simulation a démontré qu'une formation structurée peut réduire de manière significative le temps de no-flow lors de l'utilisation d'appareils de réanimation mécanique, même au sein d'équipes ad hoc. Toutefois, ce bénéfice semble être de courte durée : après quatre mois, aucun effet n'a pu être détecté.

Lower versus higher oxygen targets after resuscitation from out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials.
Xu Y, Peng F, Wang S, Yu H. | J Crit Care. 2024 Feb;79:154448
DOI: https://doi.org/10.1016/j.jcrc.2023.154448  | Télécharger l'article au format  
Keywords: Meta-analysis; Out-of-hospital cardiac arrest; Post-resuscitation care; Supplemental oxygen; Survival.

Systematic Reviews/Meta-Analysis

Introduction : To update the existing evidence and gain further insight into effects of lower versus higher oxygen targets on the outcomes in patients resuscitated from out-of-hospital cardiac arrest (OHCA).

Méthode : We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing lower versus higher oxygen targets on the outcomes among adults resuscitated from OHCA. The primary outcome was short-term survival (in hospital or within 30 days). Subgroup analyses were performed according to timing of study interventions.

Résultats : Seven RCTs with 1454 patients were finally included. The short-term survival did not differ between the two groups with a relative risk (RR) of 0.98 (95% CI, 0.86 to 1.11). There were no significant differences in survival at longest follow-up (RR, 1.01; 95% CI, 0.91 to 1.14), favorable neurological outcome (RR, 1.00; 95% CI, 0.91 to 1.11), length of intensive care unit stay (mean difference, -4.94 h; 95% CI, -14.83 to 4.96 h), or risk of re-arrest (RR, 0.68; 95% CI, 0.21 to 2.19). The quality of evidence ranged from moderate to very low.

Conclusion : urrent evidence suggests that targeting a lower or higher oxygen therapy in patients after resuscitation from OHCA results in similar short-term survival and other clinical outcomes.

Conclusion (proposition de traduction) : Les données actuelles suggèrent que le fait de cibler une oxygénothérapie plus faible ou plus élevée chez les patients après une réanimation suite à un arrêt cardiaque extrahospitalier entraîne des résultats similaires en termes de survie à court terme et d'autres résultats cliniques.

Passive leg raising test induced changes in plethysmographic variability index to assess fluid responsiveness in critically ill mechanically ventilated patients with acute circulatory failure.
Mallat J, Lemyze M, Fischer MO. | J Crit Care. 2024 Feb;79:154449
DOI: https://doi.org/10.1016/j.jcrc.2023.154449  | Télécharger l'article au format  
Keywords: Acute circulatory failure; Cardiac output; Fluid challenge; Fluid responsiveness; Gray zone; Mechanical ventilation; Passive leg raising test; Perfusion index; Plethysmographic variability index; Pulse oximetry; Pulse pressure variation; Sepsis.

Circulation

Introduction : Passive leg raising (PLR) reliably predicts fluid responsiveness but requires a real-time cardiac index (CI) measurement or the presence of an invasive arterial line to achieve this effect. The plethysmographic variability index (PVI), an automatic measurement of the respiratory variation of the perfusion index, is non-invasive and continuously displayed on the pulse oximeter device. We tested whether PLR-induced changes in PVI (ΔPVI_PLR) could accurately predict fluid responsiveness in mechanically ventilated patients with acute circulatory failure.

Méthode : This was a secondary analysis of an observational prospective study. We included 29 mechanically ventilated patients with acute circulatory failure in this study. We measured PVI (Radical-7 device; Masimo Corp., Irvine, CA) and CI (Echocardiography) before and during a PLR test and before and after volume expansion of 500 mL of crystalloid solution. A volume expansion-induced increase in CI of >15% defined fluid responsiveness. To investigate whether ΔPVI_PLR can predict fluid responsiveness, we determined areas under the receiver operating characteristic curves (AUROCs) and gray zones for ΔPVI_PLR.

Résultats : Of the 29 patients, 27 (93.1%) received norepinephrine. The median tidal volume was 7.0 [IQR: 6.6-7.6] mL/kg ideal body weight. Nineteen patients (65.5%) were classified as fluid responders (increase in CI > 15% after volume expansion). Relative ΔPVI_PLR accurately predicted fluid responsiveness with an AUROC of 0.89 (95%CI: 0.72-0.98, p < 0.001). A decrease in PVI ≤ -24.1% induced by PLR detected fluid responsiveness with a sensitivity of 95% (95%CI: 74-100%) and a specificity of 80% (95%CI: 44-97%). Gray zone was acceptable, including 13.8% of patients. The correlations between the relative ΔPVI_PLR and changes in CI induced by PLR and by volume expansion were significant (r = -0.58, p < 0.001, and r = -0.65, p < 0.001; respectively).

Conclusion : In sedated and mechanically ventilated ICU patients with acute circulatory failure, PLR-induced changes in PVI accurately predict fluid responsiveness with an acceptable gray zone.

Conclusion (proposition de traduction) : Chez les patients sédatés et ventilés mécaniquement en USI souffrant d'insuffisance circulatoire aiguë, les changements de l'indice de variabilité pléthysmographique induits par le lever de jambes passif permettent de prédire avec précision la réponse au remplissage avec une zone grise acceptable.

Association of Shock Index with Echocardiographic Parameters in Cardiac Intensive Care Unit.
Tabi M, Padkins M, Burstein B, Younis A, Asher E, Bennett C, Jentzer JC. | J Crit Care. 2024 Feb;79:154445
DOI: https://doi.org/10.1016/j.jcrc.2023.154445  | Télécharger l'article au format  
Keywords: Cardiac intensive care unit; Cardiac pathology; Echocardiography; Hemodynamics; Shock index.

Circulation

Introduction : A high shock index (SI), the ratio of heart rate (HR) to systolic blood pressure (SBP), has been associated with unfavorable outcomes. We sought to determine the hemodynamic underpinnings of an elevated SI using 2-D and doppler Transthoracic Echocardiography (TTE) in unselected cardiac intensive care unit (CICU) patients.

Méthode : We included Mayo Clinic CICU admissions from 2007 to 2018 who were in sinus rhythm at the time of TTE. The SI was calculated using HR and SBP at the time of TTE. Patients were grouped according to SI: <0.7, 4012 (64%); 0.7-0.99, 1764 (28%); and ≥ 1.0, 513 (8%). Pearson's correlation coefficient was used to assess associations between continuous variables.

Résultats : We included 6289 unique CICU patients, 58% of whom had acute coronary syndrome. The median age was 67.9 years old and 37.8% were females. The mean SI was 0.67 BPM/mmHg. As the SI increased, markers of left ventricular (LV) systolic function and forward flow decreased, including left ventricular ejection fraction (LVEF), fractional shortening, left ventricular outflow tract (LVOT) velocity time integral (VTI), stroke volume, LV stroke work index, and cardiac power output. Biventricular filling pressures increased, and markers of right ventricular function worsened with rising SI. Most TTE measurements reflecting LV function and forward flow were inversely correlated with SI, including LV stroke work index (r = -0.59) and LVOT VTI (r = -0.41), as were both systemic vascular resistance index (r = -0.43) and LVEF (r = -0.23).

Conclusion : CICU patients with elevated SI have worse biventricular function and systemic hemodynamics, particularly decreased stroke volume and related calculated TTE parameters. The SI is an easily available marker that can be used to identify CICU patients with unfavorable hemodynamics who may require further assessment.

Conclusion (proposition de traduction) : Les patients des unités de soins intensifs cardiaques dont l'IS est élevé présentent une fonction biventriculaire et une hémodynamique systémique moins bonnes, en particulier une diminution du volume systolique et des paramètres calculés de l'ETT qui s'y rapportent. L'IS est un marqueur facilement disponible qui peut être utilisé pour identifier les patients de l'unité de soins intensifs cardiaques présentant une hémodynamique défavorable et pouvant nécessiter une évaluation plus approfondie.

Unit-to-unit transfer due to shortage of intensive care beds in Sweden 2015-2019 was associated with a lower risk of death but a longer intensive care stay compared to no transfer: a registry study.
Rylander C, Sternley J, Petzold M, Oras J. | J Intensive Care. 2024 Feb 27;12(1):10
DOI: https://doi.org/10.1186/s40560-024-00722-6  | Télécharger l'article au format  
Keywords: Critical care; ICU transfer; Intensive care; Intensive care unit; Inter-hospital transfer; Logistics; Mortality; Patient transfer; Transport; Transportation of patients.

Research

Introduction : Intensive care unit-to-unit transfer due to temporary shortage of beds is increasing in Sweden. Transportation induces practical hazards, and the change of health care provider may prolong the length of stay in intensive care. We previously showed that the risk of death at 90 days did not differ between patients transferred due to a shortage of beds and non-transferred patients with a similar burden of illness in a tertiary intensive care unit. The aim of this study was to widen the analysis to a nation-wide cohort of critically ill patients transferred to another intensive care unit in Sweden due to shortage of intensive care beds.

Méthode : Retrospective comparison between capacity transferred and non-transferred patients, based on data from the Swedish Intensive Care Registry during a 5-year period before the COVID-19 pandemic. Patients with insufficient data entries or a recurring capacity transfer within 90 days were excluded. To assess the association between capacity transfer and death as well as intensive care stay within 90 days after ICU admission, logistic regression models with step-wise adjustment for SAPS3 score, primary ICD-10 ICU diagnosis and the number of days in the intensive care unit before transfer were applied.

Résultats : From 161,140 eligible intensive care admissions, 2912 capacity transfers were compared to 135,641 discharges or deaths in the intensive care unit. Ninety days after ICU admission, 28% of transferred and 21% of non-transferred patients were deceased. In the fully adjusted model, capacity transfer was associated with a lower risk of death within 90 days than no transfer; OR (95% CI) 0.71 (0.65-0.69) and the number of days spent in intensive care was longer: 12.4 [95% CI 12.2-12.5] vs 3.3 [3.3-3.3].

Conclusion : Intensive care unit-to-unit transfer due to shortage of bed capacity as compared to no transfer during a 5-year period preceding the COVID-19 pandemic in Sweden was associated with lower risk of death within 90 days but with longer stay in intensive care.

Conclusion (proposition de traduction) : Le transfert d'une unité de soins intensifs à une autre en raison d'une pénurie de lits par rapport à l'absence de transfert au cours d'une période de 5 ans précédant la pandémie de COVID-19 en Suède était associé à un risque plus faible de décès dans les 90 jours, mais à un séjour plus long en soins intensifs.

Etiologies, Mechanisms, Management, and Outcomes of Electrical Storm.
Trohman RG | J Intensive Care Med. 2024 Feb;39(2):99-117
DOI: https://doi.org/10.1177/08850666231192050
Keywords: anesthesia; antiarrhythmic drugs; cardiac arrest; cardiac surgery; catheter ablation; hemodynamics; hospital mortality; ventricular fibrillation.

Original Research

Editorial : Electrical storm (ES) is characterized by three or more discrete sustained ventricular tachyarrhythmia episodes occurring within a limited time frame (generally ≤ 24 h) or an incessant ventricular tachyarrhythmia lasting > 12 h. In patients with an implantable cardioverterdefibrillator (ICD), ES is defined as three or more appropriate device therapies, separated from each other by at least 5 min, which occur within a 24-h period. ES may constitute a medical emergency, depending on the number arrhythmic episodes, their duration, the type, and the cycle length of the ventricular arrhythmias, as well as the underlying ventricular function. This narrative review was facilitated by a search of MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1999 and 2023. ES was searched using the terms mechanisms, genetics, channelopathies, management, pharmacological therapy, sedation, neuraxial modulation, cardiac sympathetic denervation, ICDs, and structural heart disease. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. This manuscript examines the current strategies available to treat ES and compares pharmacological and invasive treatment strategies to diminish ES recurrence, morbidity, and mortality.

Conclusion : Electrical Storm is often a medical emergency and occurs most frequently in patients with structural heart disease. Optimal management involves expertise in arrhythmia management. This is pivotal and may require prompt referral and transfer to a high-volume tertiary care facility for management. If possible, triggers should be identified. Reducing sympathetic drive with β-blockers and amiodarone is the best pharmacological option. Additional measures such as sedation ± intubation and mechanical ventilation as well neuraxial modulation via percutaneous or surgical cardiac sympathetic denervation may be required. Catheter ablation may be curative, but Electrical Storm recurrence remains an issue. orthotopic heart transplantation may be required. While our options for treatment of Electrical Storm have expanded, they fall way short of perfection. Hopefully, ongoing investigation will provide us with additional tools to treat and improve the outcomes of this challenging entity.

Conclusion (proposition de traduction) : L'orage électrique est souvent une urgence médicale et se produit le plus souvent chez des patients souffrant d'une maladie cardiaque structurelle. La prise en charge optimale implique une expertise dans la gestion des arythmies. Il s'agit d'un élément essentiel qui peut nécessiter une orientation et un transfert rapides vers un établissement de soins tertiaires à haut volume pour la prise en charge. Dans la mesure du possible, les facteurs déclenchants doivent être identifiés. La meilleure option pharmacologique consiste à réduire la commande sympathique à l'aide de β-bloquants et d'amiodarone. Des mesures supplémentaires telles que la sédation ± l'intubation et la ventilation mécanique ainsi que la modulation neuraxiale par dénervation cardiaque sympathique percutanée ou chirurgicale peuvent être nécessaires. L'ablation par cathéter peut être curative, mais la récurrence de l'orage électrique reste un problème. Une transplantation cardiaque artificielle peut s'avérer nécessaire. Bien que les possibilités de traitement de l'orage électrique se soient élargies, elles sont loin d'être parfaites. Il est à espérer que les recherches en cours nous fourniront des outils supplémentaires pour traiter et améliorer les résultats de cette entité difficile.

Commentaire : Médicaments antiarythmiques et traitement pour la prise en charge aiguë de l'orage électrique.
Médicaments les plus fréquemment utilisés dans l'orage électrique.

Pediatric antiarrhythmics and toxicity: A clinical review.
Geanacopoulos AT, Zielonka B, Fox MT, Kerr S, Chambers KD, Przybylski R, Burns MM. | J Am Coll Emerg Physicians Open. 2024 Feb 15;5(1):e13090
DOI: https://doi.org/10.1002/emp2.13090  | Télécharger l'article au format  
Keywords: antiarrhythmic ingestion; antiarrhythmics; pediatric electrophysiology; pediatrics; pharmacology; toxicology

REVIEW ART I C L E

Introduction : Antiarrhythmic medications are fundamental in the acute and chronic management of pediatric arrhythmias. Particularly in the pediatric patient population, associated antiarrhythmic toxicities represent important potential adverse effects. Emergency medicine clinicians must be skilled in the detection, workup, and management of antiarrhythmic toxicity. This is a clinical review of the indications, pharmacology, adverse effects, and toxicologic treatment of antiarrhythmics commonly used in the pediatric patient population.

Conclusion : Cardiac antiarrhythmics are commonly used in the treatment of pediatric arrhythmias. Antiarrhythmics have distinct pharmacokinetics, potential interactions, and dosing and formulation considerations in the pediatric population that represent important sources of medication error and toxicity. An understanding of the mechanisms of action and potential associated toxicities of these medications is essential to ensure the appropriate management and monitoring of patients with rhythm disturbances as well as those presenting with accidental or intentional antiarrhythmic ingestion. Prompt recognition of antiarrhythmic toxicity is required to prevent significant morbidity and mortality.
There are several important gaps in the literature regarding antiarrhythmics and toxicity in the pediatric population. Epidemiologic data regarding the incidence of ingestions are limited to the cardiovascular drug classification and information surrounding the rate of accidental and/or intentional ingestion of individual antiarrhythmics is lacking. There is limited evidence regarding antiarrhythmic toxicity management in the children, and management strategy continues to be guided by case series and expert consensus. The toxicologic profile andmanagement strategy inpediatrics for newer medications, such as ivabradine, a voltage-regulated inward funny current (If)anatagonist used in the management of heart failure and automatic atrial arrhythmias, merits further study.

Conclusion (proposition de traduction) : Les antiarythmiques cardiaques sont couramment utilisés dans le traitement des arythmies pédiatriques. Les antiarythmiques ont une pharmacocinétique distincte, des interactions potentielles et des considérations de dosage et de formulation dans la population pédiatrique qui représentent des sources importantes d'erreurs médicamenteuses et de toxicité. Il est essentiel de comprendre les mécanismes d'action et les toxicités potentielles associées à ces médicaments pour assurer une prise en charge et une surveillance appropriées des patients présentant des troubles du rythme ainsi que de ceux qui présentent une ingestion accidentelle ou intentionnelle d'antiarythmiques. La reconnaissance rapide de la toxicité des antiarythmiques est nécessaire pour éviter une morbidité et une mortalité importantes.
La littérature concernant les antiarythmiques et leur toxicité dans la population pédiatrique présente plusieurs lacunes importantes. Les données épidémiologiques concernant l'incidence des ingestions sont limitées à la classification des médicaments cardiovasculaires et les informations concernant le taux d'ingestion accidentelle et/ou intentionnelle des antiarythmiques individuels font défaut. Les données concernant la prise en charge de la toxicité des antiarythmiques chez les enfants sont limitées et la stratégie de prise en charge continue d'être guidée par des séries de cas et un consensus d'experts. Le profil toxicologique et la stratégie de prise en charge en pédiatrie des nouveaux médicaments, tels que l'ivabradine (PROCORALAN), inhibiteur du courant I_f (dit funny current) généré par le nœud sinusal, utilisé dans la prise en charge de l'insuffisance cardiaque et des arythmies auriculaires automatiques, méritent d'être étudiés plus avant.

Commentaire : L’ivabradine (PROCORALAN) – premier de la classe thérapeutique des inhibiteurs du courant pacemaker I_f – est un inhibiteur sélectif et spécifique du courant I_f. II permet une réduction exclusive de la fréquence cardiaque (bradycardisant), tout en préservant la contractilité du myocarde, la conduction atrioventriculaire, la repolarisation ventriculaire et la pression artérielle.
Chez les patients présentant une maladie coronarienne, une fréquence cardiaque élevée (≥ 70 bpm), notamment, est associée à un risque élevé d’événements cardiovasculaires. L’ivabradine apporte un bénéfice clinique chez ces patients, symptomatiques ou non sans tenir compte du traitement initial.

International Consensus Criteria for Pediatric Sepsis and Septic Shock.
Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Biban P, Carrol ED, Chiotos K, Chisti MJ, DeWitt PE, Evans I, Flauzino de Oliveira C, Horvat CM, Inwald D, Ishimine P, Jaramillo-Bustamante JC, Levin M, Lodha R, Martin B, Nadel S, Nakagawa S, Peters MJ, Randolph AG, Ranjit S, Rebull MN, Russell S, Scott HF, de Souza DC, Tissieres P, Weiss SL, Wiens MO, Wynn JL, Kissoon N, Zimmerman JJ, Sanchez. | JAMA. 2024 Feb 27;331(8):665-674
DOI: https://doi.org/10.1001/jama.2024.0179
Keywords: Aucun

Original Investigation

Introduction : Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children.

Méthode : To update and evaluate criteria for sepsis and septic shock in children.
Evidence review: The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria.

Résultats : Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively.

Conclusion : The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.

Conclusion (proposition de traduction) : Les critères de Phoenix pour le sepsis et le choc septique chez l'enfant ont été dérivés et validés par le groupe de travail international du SCCM sur la définition du sepsis pédiatrique, à l'aide d'une vaste base de données internationale et d'une enquête, d'une revue systématique et d'une méta-analyse, ainsi que d'une approche de consensus Delphi modifiée. Un score Phoenix Sepsis d'au moins 2 identifie un dysfonctionnement organique potentiellement mortel chez les enfants de moins de 18 ans atteints d'une infection, et son utilisation peut améliorer les soins cliniques, l'évaluation épidémiologique et la recherche sur le sepsis pédiatrique et le choc septique dans le monde entier.

Commentaire : The Phoenix Sepsis Score Abréviations : UFE, unités équivalentes de fibrinogène ; VMI, ventilation mécanique invasive ; INR, rapport international normalisé du temps de prothrombine ; PAM, pression artérielle moyenne ; PaO2:FIO2, rapport entre la pression partielle artérielle d'oxygène et la fraction d'oxygène inspirée ; SpO2, saturation en oxygène mesurée par oxymétrie de pouls (SpO2 de 97% seulement).
Facteur de conversion SI : Pour convertir le lactate de mmol/L en mg/dL, diviser par 0,111.
^a Le score peut être calculé en l'absence de certaines variables (par exemple, même si le taux de lactate n'est pas mesuré et que les médicaments vasoactifs ne sont pas utilisés, un score cardiovasculaire peut toujours être déterminé à l'aide de la pression artérielle). Il est prévu que les tests de laboratoire et les autres mesures soient obtenus à la discrétion de l'équipe médicale sur la base d'un jugement clinique. Les variables non mesurées n'apportent aucun point au score. Les âges ne sont pas ajustés en fonction de la prématurité, et les critères ne s'appliquent pas aux hospitalisations à la naissance, aux nouveau-nés dont l'âge post-conceptionnel est inférieur à 37 semaines, ou à ceux âgés de 18 ans ou plus.
^b Le rapport SpO2:FIO2 n'est calculé que si la SpO2 est inférieure ou égale à 97 %.
^c La dysfonction respiratoire de 1 point peut être évaluée chez tout patient recevant de l'oxygène, un débit élevé, une pression positive non invasive ou une ventilation mécanique invasive, et comprend un rapport PaO2:FIO2 inférieur à 200 et un rapport SpO2:FIO2 inférieur à 220 chez les enfants ne recevant pas de VMI. Pour les enfants bénéficiant d'une ventilation mécanique invasive avec un rapport PaO2:FIO2 inférieur à 200 et un rapport SpO2:FIO2 inférieur à 220, voir les critères des points 2 et 3.
^d Les médicaments vasoactifs comprennent toute dose d'épinéphrine, de norépinéphrine, de dopamine, de dobutamine, de milrinone et/ou de vasopressine (en cas de choc).
^e La plage de référence du lactate est comprise entre 0,5 et 2,2 mmol/L. Le lactate peut être artériel ou veineux.f L'âge n'est pas ajusté en fonction de la prématurité, et les critères ne s'appliquent pas aux hospitalisations à la naissance, aux enfants dont l'âge post-conceptionnel est inférieur à 37 semaines, ou à ceux âgés de 18 ans ou plus.
^g Utiliser de préférence la PAM mesurée (artérielle invasive si disponible ou oscillométrique non invasive), et si la PAM mesurée n'est pas disponible, une PAM calculée (1/3 × systolique + 2/3 × diastolique)…

Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock.
Sanchez-Pinto LN, Bennett TD, DeWitt PE, Russell S, Rebull MN, Martin B, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Chisti MJ, Evans I, Horvat CM, Jaramillo-Bustamante JC, Kissoon N, Menon K, Scott HF, Weiss SL, Wiens MO, Zimmerman JJ, Argent AC, Sorce LR, Schlapbach LJ, Watson RS; Society of Critical Care Medicine Pediatric Sepsis Definition Task Force; Biban P, Carrol E, Chiotos K, Flauzino De Oliveira C, Hall MW, Inwald D, Ishimine P, Levin M, Lodha . | JAMA. 2024 Feb 27;331(8):675-686
DOI: https://doi.org/10.1001/jama.2024.0196
Keywords: Aucun

Original Investigation

Introduction : The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force sought to develop and validate new clinical criteria for pediatric sepsis and septic shock using measures of organ dysfunction through a data-driven approach.

Méthode : To derive and validate novel criteria for pediatric sepsis and septic shock across differently resourced settings.
Design, setting, and participants: Multicenter, international, retrospective cohort study in 10 health systems in the US, Colombia, Bangladesh, China, and Kenya, 3 of which were used as external validation sites. Data were collected from emergency and inpatient encounters for children (aged <18 years) from 2010 to 2019: 3 049 699 in the development (including derivation and internal validation) set and 581 317 in the external validation set.
Exposure: Stacked regression models to predict mortality in children with suspected infection were derived and validated using the best-performing organ dysfunction subscores from 8 existing scores. The final model was then translated into an integer-based score used to establish binary criteria for sepsis and septic shock.
Main outcomes and measures: The primary outcome for all analyses was in-hospital mortality. Model- and integer-based score performance measures included the area under the precision recall curve (AUPRC; primary) and area under the receiver operating characteristic curve (AUROC; secondary). For binary criteria, primary performance measures were positive predictive value and sensitivity.

Résultats : Among the 172 984 children with suspected infection in the first 24 hours (development set; 1.2% mortality), a 4-organ-system model performed best. The integer version of that model, the Phoenix Sepsis Score, had AUPRCs of 0.23 to 0.38 (95% CI range, 0.20-0.39) and AUROCs of 0.71 to 0.92 (95% CI range, 0.70-0.92) to predict mortality in the validation sets. Using a Phoenix Sepsis Score of 2 points or higher in children with suspected infection as criteria for sepsis and sepsis plus 1 or more cardiovascular point as criteria for septic shock resulted in a higher positive predictive value and higher or similar sensitivity compared with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria across differently resourced settings.

Conclusion : The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.

Conclusion (proposition de traduction) : Les nouveaux critères Phoenix pour le sepsis, qui ont été dérivés et validés à l'aide de données provenant de milieux à ressources élevées et faibles, ont amélioré les performances pour le diagnostic du sepsis pédiatrique et du choc septique par rapport aux critères existants de l'IPSCC.

Diagnosis and Management of Paroxysmal Supraventricular Tachycardia.
Peng G, Zei PC. | JAMA. 2024 Feb 20;331(7):601-610
DOI: https://doi.org/10.1001/jama.2024.0076
Keywords: Aucun

Review

Introduction : Paroxysmal supraventricular tachycardia (PSVT), defined as tachyarrhythmias that originate from or conduct through the atria or atrioventricular node with abrupt onset, affects 168 to 332 per 100 000 individuals. Untreated PSVT is associated with adverse outcomes including high symptom burden and tachycardia-mediated cardiomyopathy.

Résultats : Approximately 50% of patients with PSVT are aged 45 to 64 years and 67.5% are female. Most common symptoms include palpitations (86%), chest discomfort (47%), and dyspnea (38%). Patients may rarely develop tachycardia-mediated cardiomyopathy (1%) due to PSVT. Diagnosis is made on electrocardiogram during an arrhythmic event or using ambulatory monitoring. First-line acute therapy for hemodynamically stable patients includes vagal maneuvers such as the modified Valsalva maneuver (43% effective) and intravenous adenosine (91% effective). Emergent cardioversion is recommended for patients who are hemodynamically unstable. Catheter ablation is safe, highly effective, and recommended as first-line therapy to prevent recurrence of PSVT. Meta-analysis of observational studies shows single catheter ablation procedure success rates of 94.3% to 98.5%. Evidence is limited for the effectiveness of long-term pharmacotherapy to prevent PSVT. Nonetheless, guidelines recommend therapies including calcium channel blockers, β-blockers, and antiarrhythmic agents as management options.

Conclusion : Paroxysmal SVT affects both adult and pediatric populations and is generally a benign condition. Catheter ablation is the most effective therapy to prevent recurrent PSVT. Pharmacotherapy is an important component of acute and long-term management of PSVT.

Conclusion (proposition de traduction) : La tachycardie supraventriculaire paroxystique touche les populations adultes et pédiatriques et est généralement une affection bénigne. L'ablation par cathéter est le traitement le plus efficace pour prévenir les tachycardies supraventriculaires paroxystiques récurrentes. La pharmacothérapie est un élément important de la prise en charge aiguë et à long terme de la tachycardie paroxystique supraventriculaire.

Commentaire :  A, Prise en charge aiguë de la tachycardie paroxystique supraventriculaire (PSVT). La tachycardie paroxystique supraventriculaire se manifeste généralement par une tachyarythmie régulière à complexe QRS fin. Les patients dont l'hémodynamique est instable en raison de leur arythmie doivent bénéficier d'une cardioversion synchronisée. Sinon, le traitement de première intention consiste à utiliser des manœuvres vagales telles que la manœuvre de Valsalva modifiée ou le massage du sinus carotidien. En cas d'inefficacité, il est recommandé d'administrer de l'adénosine par voie intraveineuse. D'autres agents peuvent aider à mettre fin à la tachycardie paroxystique supraventriculaire, notamment les inhibiteurs calciques intraveineux et les β-bloquants.
B, Diagnostic du sous-type de tachycardie paroxystique supraventriculaire basé sur la réponse au blocage du nœud auriculo-ventriculaire. Les réponses potentielles à la manœuvre vagale ou à l'adénosine intraveineuse comprennent le ralentissement de l'arythmie, l'arrêt, la poursuite du bloc auriculo-ventriculaire et l'absence d'effet. Un ralentissement de la fréquence auriculaire ou jonctionnelle peut se produire pour les arythmies dues à une automaticité accrue en raison du réflexe barorécepteur ou de l'effet médicamenteux de l'adénosine. La fin de l'arythmie peut se produire pour les arythmies réentrantes dont les circuits impliquent le nœud auriculo-ventriculaire. Certaines tachycardies auriculaires focales dues à une activité déclenchée peuvent également être interrompues par l'adénosine. Le flutter auriculaire et certaines tachycardies auriculaires persistent malgré les effets de l'adénosine. Le blocage du nœud auriculo-ventriculaire permet de révéler l'activité auriculaire sous-jacente dans ces arythmies et facilite le diagnostic. L'adénosine peut n'avoir aucun effet apparent dans les cas où le dosage est inadéquat ou si une tachycardie ventriculaire fasciculaire est présente et se manifeste comme une tachycardie à complexe étroit telle que la TVP.
^a Doses pour les adultes ; voir Page et al. (Circulation. 2016 Apr 5;133(14):e471-505  )
^b En pratique clinique, les doses moyennes de bolus intraveineux pour les inhibiteurs calciques sont de 5 mg pour le vérapamil et de 20 mg pour le diltiazem.

Basse V, Manaouil C. | Med Droit. 2024 Feb;2024(184):11–21
DOI: https://doi.org/10.1016/j.meddro.2023.09.001
Keywords: Aucun

Research article

Editorial : À l’heure où le législateur s’apprête à modifier la loi Claeys Léonetti, il paraît utile de rappeler la législation en vigueur pour les mineurs et les enjeux éthiques du débat. Si la décision de limitation ou d’arrêt d’une thérapeutique active (LATA) concerne un mineur, l’avis des titulaires de l’autorité parentale est demandé, sauf si l’urgence rend impossible cette consultation. Il n’y a en revanche pas d’obligation législative ou réglementaire d’obtenir le consentement des parents. Le Conseil d’État et le Conseil constitutionnel ont ouvert la brèche à un contentieux complexe à comprendre pour les soignants qui doivent, à la demande de la justice, poursuivre des soins, qu’ils estiment relever de l’obstination déraisonnable. Nous étudierons quatre cas concernant des mineurs jugés par le Conseil d’État.

Conclusion (proposition de traduction) : Le Conseil d’État et le Conseil constitutionnel ont ouvert la brèche à un contentieux sans fin qui ne pourra être que source de souffrances d’abord pour l’enfant maintenu en vie, pour ses parents car il est atroce de voir son enfant mourir mais aussi pour les soignants qui doivent à la demande de la justice poursuivre des soins, qu’ils estiment relever de l’obstination déraisonnable.
Espérons que la future loi sur l’aide active à mourir soit claire et précise pour ne pas susciter des contentieuse source de nouvelles difficultés entre l’entourage des patients et l’équipe médicale.
La difficulté est que chacun voudrait que la loi sur la fin de vie résolve des situations particulières. Chaque fin de vie est différente, en fonction du pronostic difficile à évaluer même pour les médecins, de l’entourage du patient, de l’opinion que l’on a de la qualité d’une vie ou du caractère déraisonnable d’un traitement. La volonté du patient et de sa famille est aussi souvent incertaine. Il n’est pas si facile d’évoquer sa fin de vie. Ami lecteur, avez-vous rédigé vos directives anticipées, désigné une personne de confiance et partagé avec elle vos souhaits pour le jour où vous ne pourriez plus vous exprimer ?

Chest Pain Risk Stratification in the Emergency Department: Current Perspectives.
Yukselen Z, Majmundar V, Dasari M, Arun Kumar P, Singh Y. | Open Access Emerg Med. 2024 Feb 4;16:29-43
DOI: https://doi.org/10.2147/oaem.s419657  | Télécharger l'article au format  
Keywords: ED; acute coronary syndrome; adverse events; angina; cardiac mortality.

REVIEW

Editorial : Chest pain is the second leading cause of all emergency department (ED) visits in adults in the United States, with nearly 11 million encounters yearly. While identifying low-risk patients is crucial for early discharge, identifying high-risk patients in ED is vital in timely and appropriate acute coronary syndrome (ACS) management. Traditional methods such as physical examination, cardiac markers, or imaging tests cannot reliably confirm or rule out ACS; they cannot be singularly incorporated to risk stratify patients. Various clinical risk scores have been proposed to address this challenge for risk stratification in patients being evaluated for suspected ACS. The ideal risk score should demonstrate high sensitivity and specificity to accurately differentiate between patients with varying levels of risk, particularly in identifying those at high risk for major adverse cardiovascular events. Simultaneously, an ideal scoring system should also be able to compute information for other non-coronary etiologies of chest pain that require time-sensitive interventions and workups (eg, aortic dissection and pulmonary embolism). In this review, we have assembled major risk scores used for risk stratification in patients with acute chest pain in ED. We have abbreviated their salient features to assist readers in their clinical decision-making.

Conclusion : Cardiac biomarkers, particularly cTn-I and cTn-T, are crucial in assessing chest pain for AMI diagnosis, risk stratifica- tion, and distinguishing cardiac from non-cardiac causes. High-sensitivity cardiac troponin assays, offering greater sensitivity and negative predictive value, have revolutionized early detection and management of patients with suspected acute coronary syndrome (ACS). The introduction of ESC hs-cTnT strategies for rapid rule-out, particularly the 0/1-hr and 0/3-hr algorithms, has shown promising results in identifying low-risk patients, allowing for early discharge. These strategies significantly reduce the length of stay in the emergency department, enhancing overall efficiency.
Early risk stratification in the emergency department relies on various clinical risk scores. While TIMI scores of 0 or 1 cannot safely rule out AMI in patients with chest pain, higher scores are used to determine the likelihood of ischemic events, therefore TIMI scores are more useful for ED physicians to identify patients who need to be hospitalized for further interventions. The HEART Score stratifies the risk of patients into low, moderate, and high-risk categories. This helps early discharge of low-risk patients and earlier interventions for moderate and high-risk patients. The original VCPR, new VCPR, ASPECT, and ADAPT scores are useful for low-risk patients considered early discharge as no additional investigations are required, and patients can be discharged home if none of the criteria are met. Newer scores such as HE-MACS and SVEAT contribute to efficient risk stratification and patient disposition. The safe and effective evaluation of chest pain can be facilitated by optimizing and validating these risk scores, avoiding needless admissions, and testing for those at low risk. Additional studies should compare and improve the diagnostic reliability and accuracy of the various available scores across a range of patient populations.

Conclusion (proposition de traduction) : Les biomarqueurs cardiaques, en particulier la cTn-I et la cTn-T, sont essentiels dans l'évaluation de la douleur thoracique pour le diagnostic de l'infarctus aigu du myocarde, la stratification du risque et la distinction entre les causes cardiaques et non cardiaques. Les dosages de troponine cardiaque à haute sensibilité, qui offrent une meilleure sensibilité et une valeur prédictive négative plus élevée, ont révolutionné la détection précoce et la prise en charge des patients suspectés de syndrome coronarien aigu (SCA). L'introduction des stratégies ESC hs-cTnT pour une exclusion rapide, en particulier les algorithmes 0/1 heure et 0/3 heures, a montré des résultats prometteurs dans l'identification des patients à faible risque, permettant une sortie précoce. Ces stratégies réduisent considérablement la durée du séjour aux urgences, améliorant ainsi l'efficacité globale.
La stratification précoce du risque dans le service des urgences repose sur différents scores de risque clinique. Alors que les scores TIMI de 0 ou 1 ne permettent pas d'exclure en toute sécurité un infarctus aigu du myocarde chez les patients souffrant de douleurs thoraciques, des scores plus élevés sont utilisés pour déterminer la probabilité d'événements ischémiques, de sorte que les scores TIMI sont plus utiles aux médecins des urgences pour identifier les patients qui doivent être hospitalisés pour d'autres interventions. Le score HEART stratifie le risque des patients en catégories de risque faible, modéré et élevé. Cela permet une sortie précoce des patients à faible risque et des interventions plus précoces pour les patients à risque modéré et élevé. Les scores VCPR original, nouveau VCPR, ASPECT et ADAPT sont utiles pour les patients à faible risque pour lesquels une sortie précoce est envisagée, car aucun examen supplémentaire n'est nécessaire et les patients peuvent rentrer chez eux si aucun des critères n'est rempli. Les scores plus récents tels que HE-MACS et SVEAT contribuent à une stratification efficace du risque et à la prise en charge du patient. L'évaluation sûre et efficace de la douleur thoracique peut être facilitée par l'optimisation et la validation de ces scores de risque, en évitant les admissions inutiles et en testant les personnes à faible risque. D'autres études devraient comparer et améliorer la fiabilité et la précision diagnostiques des différents scores disponibles sur un éventail de populations de patients.

The desire for side-effect information in pain treatment: an experimental analysis of contextual and individual difference factors.
Clemens KS, Vang M, Colloca L, Sieg M, Vase L, Ruble A, Geers AL. | Pain. 2024 Feb 1;165(2):383-391
DOI: https://doi.org/10.1097/j.pain.0000000000003025
Keywords: Pain; Side effects; Nocebo; Desire; Shared decision making; Authorized concealment

Research Paper

Editorial : Informing patients about potential side effects of pain treatment is a requirement that protects patients and aids decision making, but it increases the likelihood of unwanted nocebo side effects. If patients do not desire all side-effect information, it may be possible to ethically reduce nocebo effects through authorized concealment of side effects, whereby patients and clinicians engage in shared decision-making to regulate the disclosure of side-effect information. Currently, there is no experimental data clarifying the factors that causally influence desire for side-effect information in pain treatment. In 2 cross-sectional, between-subjects scenario experiments (experiment 1 N = 498, experiment 2 N = 501), 18 to 79-year-old community adults learned about a lower back pain treatment, and potential side-effect severity, frequency, and duration were manipulated. Individual differences in information avoidance were also recorded. In both experiments, participants reported high desire for side-effect information, but the desire was reduced when side effects were described as less severe, less frequent, and participants scored high in information avoidance. Results were not moderated by participants' level of contact with the health care system, chronic health condition, or clinical pain history. Additional analyses indicated that low side-effect severity and frequency lessen desire for side-effect information because these variables reduce belief that side-effect information will be needed in the future and lower feelings of anticipated regret. The experiments identify situational and individual-difference factors that decrease the desire for side-effect information and provide evidence on when and for whom it may be useful for physicians to engage in shared medical decision-making with the goal of reducing nocebo side effects.

Conclusion : Nocebo side effects increase patient distress, reduce treatmentadherence, and can result from simply informing patients abouttreatment side effects. Patients may not always desire receivingthe information that causes nocebo side effects. Not providing allside-effect information, with patient preauthorized consent, couldprovide an ethical strategy, in some cases, for reducing patientsuffering. Two experiments, using randomized between-subjectsdesigns, provide evidence that desire to obtain side-effect information is high but varies based on the characteristics ofthe anticipated side effects and the individual’s tendency to avoidinformation. The result establish a direction for future research onhow to ethically decrease nocebo side effects while valuingpatients’ desires and preferences.

Conclusion (proposition de traduction) : Les effets secondaires nocebo augmentent la détresse des patients, réduisent l'adhésion au traitement et peuvent résulter de la simple information des patients sur les effets secondaires du traitement. Les patients ne souhaitent pas toujours recevoir les informations qui provoquent les effets secondaires nocebo. Le fait de ne pas fournir d'informations sur tous les effets secondaires, avec le consentement préalable du patient, pourrait constituer une stratégie éthique, dans certains cas, pour réduire la souffrance du patient. Deux expériences, utilisant des modèles randomisés entre sujets, démontrent que le désir d'obtenir des informations sur les effets secondaires est élevé mais varie en fonction des caractéristiques des effets secondaires anticipés et de la tendance de l'individu à éviter l'information. Ces résultats ouvrent la voie à de futures recherches sur la manière de réduire éthiquement les effets secondaires nocebo tout en valorisant les désirs et les préférences des patients.

Tracheal Intubation by Advanced Practice Registered Nurses in Pediatric Critical Care: Retrospective Study From the National Emergency Airway for Children Registry (2015-2019).
Tarquinio KM, Giuliano JS Jr, Ruppe MD, Kierys KL, Breuer RK, Parsons SJ, Mallory PP, Shenoi AN, Swain KA, Polikoff LA, Lee A, Adu-Darko MA, Napolitano N, Shults J, Nishisaki A, Berkenbosch JW; National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). | Pediatr Crit Care Med. 2024 Feb 1;25(2):139-146
DOI: https://doi.org/10.1097/pcc.0000000000003386
Keywords: Aucun

Feature Article

Introduction : To describe tracheal intubation (TI) practice by Advanced Practice Registered Nurses (APRNs) in North American PICUs, including rates of TI-associated events (TIAEs) from 2015 to 2019.

Méthode : Retrospective study using the National Emergency Airway Registry for Children with all TIs performed in PICU and pediatric cardiac ICU between January 2015 and December 2019. The primary outcome was first attempt TI success rate. Secondary outcomes were TIAEs, severe TIAEs, and hypoxemia.
Subjects: Critically ill children requiring TI in a PICU or pediatric cardiac ICU.
Interventions: None.

Résultats : Among 11,012 TIs, APRNs performed 1,626 (14.7%). Overall, TI by APRNs, compared with other clinicians, occurred less frequently in patients with known difficult airway (11.1% vs. 14.3%; p < 0.001), but more frequently in infants younger than 1 year old (55.9% vs. 44.4%; p < 0.0001), and in patients with cardiac disease (26.3% vs. 15.9%; p < 0.0001).There was lower odds of success in first attempt TI for APRNs vs. other clinicians (adjusted odds ratio, 0.70; 95% CI, 0.62-0.79). We failed to identify a difference in rates of TIAE, severe TIAE, and oxygen desaturation events for TIs by APRNs compared with other clinicians. The TI first attempt success rate improved with APRN experience (< 1 yr: 54.2%, 1-5 yr: 59.4%, 6-10 yr: 67.6%, > 10 yr: 63.1%; p = 0.021).

Conclusion : TI performed by APRNs was associated with lower odds of first attempt success when compared with other ICU clinicians although there was no appreciable difference in procedural adverse events. There appears to be a positive relationship between experience and success rates. These data suggest there is an ongoing need for opportunities to build on TI competency with APRNs.

Conclusion (proposition de traduction) : L'intubation trachéale réalisée par des infirmières de pratique avancée était associée à des chances plus faibles de réussite de la première tentative par rapport à d'autres cliniciens des soins intensifs, bien qu'il n'y ait pas eu de différence appréciable dans les événements indésirables liés à la procédure. Il semble y avoir une relation positive entre l'expérience et les taux de réussite. Ces données suggèrent qu'il existe un besoin permanent pour renforcer les compétences en matière d'intubation trachéale des infirmières de pratique avancée.

Regional Anesthesia as an Alternative to Procedural Sedation for Forearm Fracture Reductions in the Pediatric Emergency Department.
Sulton CD, Fletcher N, Murphy J, Gillespie S, Burger RK. | Pediatr Emerg Care. 2024 Feb 1;40(2):83-87
DOI: https://doi.org/10.1097/pec.0000000000002993
Keywords: Aucun

Original Article

Introduction : Pediatric forearm fractures are common injuries in the pediatric emergency department (PED). Pediatric procedural sedation (PPS) is often required for forearm fracture reductions and pain control for casting. Bier blocks and hematoma blocks are types of regional anesthesia (RA) procedures that can be performed as a potential alternative to PPS.

Méthode : The objective of this study is to compare the safety of RA with that of PPS. We hypothesized that RA has a safety profile that is equal or superior to PPS as well as a shorter duration of treatment in the PED.
Methods: Pediatric emergency department encounters in patients presenting with a diagnosis of radius fracture, ulna fracture, distal "both-bone" fracture, Monteggia fracture, and/or Galeazzi fracture were included. Outcomes of interest included patient adverse events (AEs), sedation medications used, PED duration of treatment (arrival time to disposition time), sedation failures, and reduction failures.

Résultats : Propensity matching was performed resulting in 632 well-matched RA-PPS pairs. The PPS cohort had 13% of encounters with at least 1 AE compared with 0.2% in the RA cohort, P < 0.001. The most common AE in the PPS group was hypoxia (9.8%), and the only AE in the RA group was an intravenous infiltrate (0.16%). Within the matched cohorts, PPS required more medications than RA (100% vs 60%, P < 0.001). Ketamine alone was more commonly used in the PPS group than the RA group (86% vs 0.2%, P < 0.001). Propofol was used only in the PPS group. The average duration of treatment was 205 (SD, 81) minutes in the PPS group and 178 (SD, 75) minutes in the RA group ( P < 0.001). There were no reduction failures in either group.

Conclusion : Bier blocks and hematoma blocks are an acceptable alternative to PPS for children requiring forearm reductions. The AE rate is low and the reduction success rate is high. Duration of treatment in the PED is shorter for patients receiving RA compared with PPS.

Conclusion (proposition de traduction) : Les blocs de Bier et les blocs d'hématome sont une alternative acceptable à l'anesthésie régionale pour les enfants nécessitant une réduction de l'avant-bras. Le taux d'EI est faible et le taux de réussite de la réduction est élevé. La durée du traitement dans le service des urgences pédiatriques est plus courte pour les patients recevant une anesthésie régionale que pour ceux recevant une sédation procédurale pédiatrique.

Commentaire : L'anesthésie locorégionale intraveineuse (ALRIV) ou blocs de Bier est une technique simple et efficace pour l’avant-bras, le poignet et la main (par exemple pour réduire une fracture de l’extrémité distale du radius). L’ALRIV entraîne une diffusion directe de l’anesthésique des veines vers les nerfs adjacents. Référence  

Protocole de l'étude :
Dans notre établissement, les blocs de Bier suivent un protocole standard.
La décision de choisir l'anesthésie régionale plutôt que la sédation procédurale pédiatrique est basée sur plusieurs facteurs : l'âge du patient, le niveau de développement du patient, les ressources du service des urgences pédiatriques et la préférence du prestataire.
Les patients sont exclus s'ils présentent l'un des éléments suivants : allergie à la lidocaïne, traumatisme multisystémique, drépanocytose, fracture ouverte, cellulite dans l'extrémité affectée, incapacité à obtenir un accès intraveineux périphérique, absence de langage, retard de développement, antécédents de thrombose, cardiopathie congénitale, trouble convulsif, insuffisance hépatique, ou âge inférieur à 6 ans. Les consentements à la procédure et au bloc de Bier sont tous deux requis.
Une intraveineuse périphérique est placée dans le bras affecté. Aucun autre accès intraveineux périphérique n'est nécessaire. Une surveillance cardiaque complète est nécessaire. Un brassard pneumatique est placé sur l'extrémité concernée. De la lidocaïne à 1 % sans épinéphrine, diluée dans du sérum physiologique, est injectée à raison de 1 ml/kg, la dose maximale étant de 50 ml.
La réduction est commencée 15 à 20 minutes après l'injection pour permettre une analgésie maximale. Le dégonflage progressif du brassard est alors initié et la réduction et le moulage sont effectués. La durée minimale de gonflage du brassard est de 15 minutes. La durée maximale de gonflage du brassard est de 90 minutes. Les signes vitaux sont enregistrés toutes les 10 minutes pendant l'intervention et le patient doit rester en observation pendant 30 minutes au total après la fin de la réduction. La perfusion des extrémités, la couleur et les pouls sont documentés avec les signes vitaux. Aucun score de douleur n'a été enregistré.

A Novel Algorithm for Improving the Diagnostic Accuracy of Prehospital ST-Elevation Myocardial Infarction.
Goebel M, Vaida F, Kahn C, Donofrio JJ. | Prehosp Disaster Med. 2019 Oct;34(5):489-496
DOI: https://doi.org/10.1017/s1049023x19004849  | Télécharger l'article au format  
Keywords: ECG; STEMI; paramedic.

Original Research

Introduction : ST-segment elevation myocardial infarction (STEMI) is a time-sensitive entity that has been shown to benefit from prehospital diagnosis by electrocardiogram (ECG). Current computer algorithms with binary decision making are not accurate enough to be relied on for cardiac catheterization lab (CCL) activation.

Méthode : An algorithmic approach is proposed to stratify binary STEMI computerized ECG interpretations into low, intermediate, and high STEMI probability tiers.
Methods: Based on previous literature, a four-criteria algorithm was developed to rule out/in common causes of prehospital STEMI false-positive computer interpretations: heart rate, QRS width, ST elevation criteria, and artifact. Prehospital STEMI cases were prospectively collected at a single academic center in Salt Lake City, Utah (USA) from May 2012 through October 2013. The prehospital ECGs were applied to the algorithm and compared against activation of the CCL by an emergency department (ED) physician as the outcome of interest. In addition to calculating test characteristics, linear regression was used to look for an association between number of criteria used and accuracy, and logistic regression was used to test if any single criterion performed better than another.

Résultats : There were 63 ECGs available for review, 39 high probability and 24 intermediate probability. The high probability STEMI tier had excellent test characteristics for ruling in STEMI when all four criteria were used, specificity 1.00 (95% CI, 0.59-1.00), positive predictive value 1.00 (0.91-1.00). Linear regression showed a strong correlation demonstrating that false-positives increased as fewer criteria were used (adjusted r-square 0.51; P <.01). Logistic regression showed no significant predictive value for any one criterion over another (P = .80). Limiting physician overread to the intermediate tier only would reduce the number of ECGs requiring physician overread by a factor of 0.62 (95% CI, 0.48-0.75; P <.01).

Conclusion : Prehospital ST-segment elevation myocardial infarction ECGs can be accurately stratified to high, intermediate, and low probabilities for ST-segment elevation myocardial infarction using the four criteria. While additional study is required, using this tiered algorithmic approach in prehospital ECGs could lead to changes in cardiac catheterization lab activation and decreased requirements for physician overread. This may have significant clinical and quality implications.

Conclusion (proposition de traduction) : Les ECG préhospitaliers d'infarctus du myocarde avec sus-décalage du segment ST peuvent être stratifiés avec précision en fonction des probabilités élevées, intermédiaires et faibles d'infarctus du myocarde avec sus-décalage du segment ST en utilisant les quatre critères (fréquence cardiaque <130, QRS <100, vérification du sus-décalage du segment ST et absence d'artefact). Bien que des études supplémentaires soient nécessaires, l'utilisation de cette approche algorithmique à plusieurs niveaux dans les ECG préhospitaliers pourrait conduire à des changements dans l'activation du laboratoire de cathétérisme cardiaque et à une diminution des besoins de relecture par le médecin. Cela pourrait avoir des conséquences importantes sur le plan clinique et de la qualité.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.
Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, Weiner GM, Cheng A, Djärv T, Abelairas-Gómez C, Acworth J, Andersen LW, Atkins DL, Berry DC, Bhanji F, Bierens J, Bittencourt Couto T, Borra V, Böttiger BW, Bradley RN, Breckwoldt J, Cassan P, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Dassanayake V, Davis PG, Dawson JA, Fernanda de Almeida M, De Caen AR, Deakin . | Resuscitation. 2024 Feb;195:109992
DOI: https://doi.org/10.1016/j.resuscitation.2023.109992  | Télécharger l'article au format  
Keywords: AHA Scientific Statements; Advanced life support; Cardiac arrest; First aid; Infant; Newborn; Pediatrics.

ILCOR Summary Statement

Editorial : The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Conclusion : This summary statement contains the final wording of the treat- ment recommendations and good practice statements as approved by the ILCOR task forces, but it differs in several respects from the online CoSTRs: The language used to describe the evidence is not restricted to standard Grading of Recommendations Assessment, Development, and Evaluation (GRADE) terminology, making it more accessible to a wider audience; in some cases, only the high-priority outcomes are reported; the Justification and Evidence-to-Decision Framework Highlights sections are shortened in some cases but aim to provide a transparent rationale for treatment recommenda- tions; and last, the task forces have prioritized knowledge gaps requiring future research studies.

Conclusion (proposition de traduction) : Ce résumé contient la formulation finale des recommandations de traitement et des déclarations de bonnes pratiques telles qu'approuvées par les groupes de travail de l'ILCOR, mais il diffère à plusieurs égards du Consensus on Science with Treatment Recommendations (Consensus scientifique avec recommandations de traitement) en ligne : Le langage utilisé pour décrire les preuves n'est pas limité à la terminologie standard GRADE (Grading of Recommendations Assessment, Development, and Evaluation), ce qui le rend plus accessible à un public plus large ; dans certains cas, seuls les résultats hautement prioritaires sont rapportés ; les sections Justification et Evidence-to-Decision Framework Highlights (Points forts du concept des éléments probants pour la prise de décision) sont raccourcies dans certains cas mais visent à fournir une justification transparente des recommandations de traitement ; enfin, les groupes de travail ont classé par ordre de priorité les lacunes dans les connaissances qui nécessitent des études de recherche futures.

Top cardiac arrest randomised trials of 2023.
Scquizzato T, Sandroni C, Soar J, Nolan JP. | Resuscitation. 2024 Febr;110133
DOI: https://www.resuscitationjournal.com/article/S0300-9572(24)00026-1/fulltext?dgcid=raven_jbs_aip_email
Keywords: cardiac arrest, out-of-hospital cardiac arrestcardiopulmonary resuscitationrandomised trial

Editorial

Editorial : Cardiac arrest and resuscitation science is advancing rapidly, with the last decade witnessing a surge in the publication of randomised clinical trials (RCT) that can inform guidelines and clinical practice. Several RCTs focusing on temperature control,[1], [2], [3] post-resuscitation physiological targets,[4], [5], [6] and treatment of refractory cardiac arrest[7], [8] were published in 2021 and in 2022, and mostly of out-of-hospital cardiac arrest (OHCA). This trend of high-quality RCTs continued in 2023.

Conclusion : In this article, we summarise the key findings from four important multicentre RCTs published in 2023: Early Initiation of Extracorporeal Life Support in Refractory OHCA (INCEPTION) trial, Targeted Therapeutic Mild Hypercapnia after Resuscitated Cardiac Arrest (TAME), A Randomized tRial of Expedited transfer to a cardiac arrest center for non-ST elevation OHCA (ARREST), and STERoid for Out-of-Hospital Cardiac Arrest (STEROHCA) trial (Figure 1). Articles were selected based on their large sample size, multicentre design, assessment of significant clinical outcomes, and publication on high-impact medical Journals.

Conclusion (proposition de traduction) : Dans cet article, nous résumons les principales conclusions des quatre plus importants essais contrôlés randomisés multicentriques publiés en 2023 :
• Essai sur l'initiation précoce de l'assistance respiratoire extracorporelle en cas d'arrêt cardiaque extrahospitalier réfractaire (INCEPTION).
• Hypercapnie thérapeutique ciblée légère après un arrêt cardiaque en réanimation (TAME).
• Essai randomisé de transfert accéléré vers un centre d'arrêt cardiaque en cas d'arrêt cardiaque extrahospitalier sans sus-décalage du segment ST (ARREST).
• Essai STERoid dans le cadre de l'arrêt cardiaque extrahospitalier (STEROHCA) (Figure 1).
Les articles ont été sélectionnés en fonction de la taille de leur échantillon, de leur conception multicentrique, de l'évaluation de résultats cliniques significatifs et de leur publication dans des revues médicales à fort impact.

Commentaire :  Figure 1. Infographie de quatre essais cliniques randomisés importants publiés en 2023 dans les domaines de l'arrêt cardiaque et de la réanimation cardiopulmonaire.
Abréviations : OHCA, arrêt cardiaque extrahospitalier ; CPR, réanimation cardio-pulmonaire ; RCT, essai clinique randomisé ; PaCO₂, pression partielle de dioxyde de carbone, STEMI, infarctus du myocarde avec sus-décalage du segment ST ; IL-6, interleukine-6 ; NSE, Énolase neurospécifique.

• Essai sur l'initiation précoce de l'assistance respiratoire extracorporelle en cas d'arrêt cardiaque extrahospitalier réfractaire (INCEPTION) : Le Comité international de liaison sur la réanimation (ILCOR) suggère que l'ECPR peut être considérée comme une technique de sauvetage pour des patients sélectionnés lorsque la RCP conventionnelle ne parvient pas à rétablir la circulation spontanée dans des contextes où elle peut être mise en œuvre.
• Hypercapnie thérapeutique ciblée légère après un arrêt cardiaque en réanimation (TAME) : Les effets indésirables potentiels de l'hypercapnie légère comprennent l'aggravation de l'œdème cérébral et l'élévation de la pression intracrânienne ; cependant, les données de cette étude suggèrent que des élévations cliniquement pertinentes de la pression intracrânienne sont peu probables.
• Essai randomisé de transfert accéléré vers un centre d'arrêt cardiaque en cas d'arrêt cardiaque extrahospitalier sans sus-décalage du segment ST (ARREST) : L'essai avait la puissance nécessaire pour détecter une réduction de 10 % du risque absolu de mortalité grâce au transport vers un centre d'arrêt cardiaque (disposant, en particulier, de l'accès à la coronarographie immédiate), ce qui aurait pu être beaucoup plus important que l'effet réel potentiel.
• Essai STERoid dans le cadre de l'arrêt cardiaque extrahospitalier (STEROHCA) : Il est important de noter que l'injection de méthylprednisolone à forte dose a été jugée sûre, comme le montre l'incidence similaire d'événements indésirables entre les groupes. Deux essais cliniques randomisés antérieurs portant sur des patients ayant subi un arrêt cardiaque et ayant reçu des glucocorticoïdes en même temps que de la vasopressine ont fait état d'un taux de survie et d'un résultat neurologique plus élevés, et l'un d'entre eux d'une incidence accrue de réanimation.

Influence of antibiotic therapy with hemodynamic optimization on 30-day mortality among septic shock patients cared for in the prehospital setting.
Jouffroy R, Holub M, Gilbert B, Travers S, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Vivien B, Gueye-Ngalgou P. | Am J Emerg Med. 2024 Feb;76:48-54
DOI: https://doi.org/10.1016/j.ajem.2023.11.014
Keywords: Antibiotic therapy; Mean arterial pressure; Mortality; Pre-hospital; Septic shock.

Research article

Introduction : In order to reduce septic shock mortality, international guidelines recommend early treatment implementation, antibiotic therapy (ABT) and hemodynamic optimisation, within 1-h. This retrospective multicentric study aims to investigate the relationship between prehospital ABT delivered within 1st hour and mean blood pressure (MAP) ≥ 65 mmHg at the end of the prehospital stage, and 30-day mortality among patients with septic shock.

Méthode : From May 2016 to December 2021, patients with septic shock requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To assess the relationship between 30-day mortality and prehospital ABT delivered within 1st hour and/or MAP ≥ 65 mmHg at the end of the prehospital stage, Inverse Probability Treatment Weighting (IPTW) propensity score method was performed.

Résultats : Among the 530 patients included, 341 were male gender (64%) with a mean age of 69 ± 15 years. One-hundred and thirty-two patients (25%) patients received prehospital ABT, among which 98 patients (74%) were treated with 3rd generation cephalosporin. Suspected pulmonary, urinary and digestive infections were the cause of sepsis in respectively 43%, 25% and 17%. The 30-day overall mortality was 31%. A significant association was observed between 30-day mortality rate and (i) ABT administration within the first hour: RRa = 0.14 [0.04-0.55], (ii) ABT administration within the first hour associated with a MAP ≥ 65 mmHg: RRa = 0.08 [0.02-0.37] and (iii) ABT administration within the first hour in the prehospital setting associated with a MAP < 65 mmHg at the end of the prehospital stage: RRa = 0.75 [0.45-0.85]. Patients who received prehospital ABT after the first hour have also a 30-day mortality rate decrease: RRa = 0.87 [0.57-0.99], whereas patients who did not received ABT had an increased 30-day mortality rate: RRa = 2.36 [1.89-2.95].

Conclusion : In this study, we showed that pre-hospital ABT within the first hour and MAP≥65 mmHg at the end of prehospital stage are both associated with 30-day mortality decrease among patients suffering from septic shock cared for by a MICU. Further prospective studies are needed to confirm these preliminary results.

Conclusion (proposition de traduction) : Dans cette étude, nous avons montré qu'une antibiothérapie préhospitalière dans la première heure et une pression artérielle moyenne ≥ 65 mmHg à la fin de l'étape préhospitalière sont toutes deux associées à une diminution de la mortalité à 30 jours chez les patients souffrant d'un choc septique pris en charge par une unité de soins intensifs multidisciplinaires. D'autres études prospectives sont nécessaires pour confirmer ces résultats préliminaires.

Minor head injury in anticoagulated patients: Outcomes and analysis of clinical predictors. A prospective study.
Menditto VG, Moretti M, Babini L, Sampaolesi M, Buzzo M, Montillo L, Raponi A, Riccomi F, Marcosignori M, Rocchi M, Pomponio G. | Am J Emerg Med. 2024 Feb;76:105-110
DOI: https://doi.org/10.1016/j.ajem.2023.11.023
Keywords: Anticoagulated patients; Delayed intracranial hemorrhage; Injury; Minor head injury; Mortality.

Research article

Introduction : The optimal management of patients taking oral anticoagulants who experience minor head injury (MHI) is unclear. The availability of validated protocols and reliable predictors of prognosis would be of great benefit. We investigated clinical factors as predictors of clinical outcomes and intracranial injury (ICI).

Méthode : We conducted a single-cohort, prospective, observational study in an ED. Our structured clinical pathway included a first head CT scan, 24 h observation and a second CT scan. The primary outcome was the occurrence of MHI-related death or re-admission to ED at day +30. The secondary outcome was the rate of delayed ICI (dICI), defined as second positive CT scan after a first negative CT scan. We assessed some clinical predictors derived from guidelines and clinical prediction rules as potential risk factors for the outcomes.

Résultats : 450 patients with a negative first CT scan who underwent a second CT scan composed our 'study population'. The rate of the primary outcome was 4%. The rate of the secondary outcome was 4.7%. Upon univariate and multivariate analysis no statistically significant predictors for the outcomes were found.

Conclusion : Previous retrospective studies showed a lot of negative predictive factors for anticoagulated patients suffering a minor head injury. In our prospective study no clinical factors emerged as predictors of poor clinical outcomes and dICI. So, even if we confirmed a low rate of adverse outcomes, the best management of these patients in ED remains not so clear and future trials are needed.

Conclusion (proposition de traduction) : Des études rétrospectives antérieures ont montré un grand nombre de facteurs prédictifs négatifs chez les patients anticoagulés présentant un traumatisme crânien léger. Dans notre étude prospective, aucun facteur clinique n'est apparu comme prédictif de mauvais résultats cliniques et de lésions intracrâniennes retardées. Ainsi, même si nous avons confirmé un faible taux de résultats négatifs, la meilleure prise en charge de ces patients aux urgences n'est pas si claire et de futurs essais sont nécessaires.

Low-dose ketamine versus morphine in the treatment of acute pain in the emergency department: A meta-analysis of 15 randomized controlled trials.
Guo J, Zhao F, Bian J, Hu Y, Tan J. | Am J Emerg Med. 2024 Feb;76:140-149
DOI: https://doi.org/10.1016/j.ajem.2023.11.056
Keywords: Acute pain; Ketamine; Meta-analysis; Morphine.

Research article

Introduction : To compare the effectiveness and safety of ketamine and morphine in adult patients with acute pain in emergency department (ED) by using a meta-analysis method.

Méthode : This study was based on the Cochrane methodology for conducting a meta-analysis. Only randomized controlled trials (RCTs) were eligible for this study, with an experimental group that received low-dose ketamine and a control group that received morphine. The participants were adults who had acute pain in the ED. The primary outcome measures were the numeric rating scale (NRS) and visual analog scale (VAS). The secondary outcome measures were the complete resolution of pain, NRS reduction ≥3 points, NRS reduction ≥50% or 60%, change of NRS score, change of VAS score, rescue analgesia, satisfaction and adverse events. Subgroup analysis was performed for studies with intravenous and intranasal administration of ketamine. The Review Manager Database was used to analyze the included studies.

Résultats : 15 RCTs involving 1768 patients were included. The ketamine group had lower NRS scores than morphine group at 30 min (MD, -0.77 [95% CI, -0.93 to -0.61]; p < 0.00001), while the morphine had better analgesic effects at 120 min after treatment (MD, 0.33 [95% CI, 0.15 to 051]; p = 0.0003). The subjects of complete resolution of pain in the ketamine group performed better than those in the morphine group at 15 min (RR 3.18, 95% CI 1.75 to 5.78; p = 0.0001). Compared with the morphine group, the ketamine group had a lower incidence of adverse events requiring intervention (RR, 0.34 [95% CI, 0.18 to 0.66]; p = 0.001). Subgroup analysis of intravenous ketamine showed that ketamine had lower VAS score than the morphine group at 30 min. However, also on the 30-min VAS score, intranasal ketamine analgesia was less effective than morphine.

Conclusion : Ketamine had better analgesic effects in the early stages after treatment, while morphine maintained more durable effects. Compared with morphine, ketamine had a lower incidence of adverse events requiring intervention. The results of subgroup analysis showed that intravenous administration of ketamine was more effective than intranasal administration.

Conclusion (proposition de traduction) : La kétamine avait de meilleurs effets analgésiques dans les premiers stades après le traitement, tandis que la morphine conservait des effets plus durables. Comparée à la morphine, la kétamine présentait une incidence plus faible d'effets indésirables nécessitant une intervention. Les résultats de l'analyse des sous-groupes ont montré que l'administration intraveineuse de kétamine était plus efficace que l'administration intranasale.

Risk factors for delayed hemothorax in patients with rib fracture in the emergency department.
Ahn S, Lee S, Kim S, Moon S, Cho H, Shin HJ, Park JH. | Am J Emerg Med. 2024 Feb;76:173-179
DOI: https://doi.org/10.1016/j.ajem.2023.11.047
Keywords: Delayed chest tube insertion; Delayed hemothorax; Emergency department; Rib fracture.

Research article

Introduction : Although rib fractures are a risk factor, not all rib fracture patients will develop delayed hemothorax. This study aimed to evaluate risk factors which can identify rib fracture patients in the emergency department who may develop delayed hemothorax.

Méthode : Adult patients seen in the emergency room between January 2016 and February 2021 with rib fractures caused by blunt chest trauma were included in this retrospective observational study. Patients who underwent chest tube insertion within 2 days and those without follow-up chest radiographs within 2-30 days were excluded. We used a stepwise backward-elimination multivariable logistic regression model for analysis.

Résultats : A total of 202 patients were included in this study. The number of total (P < 0.001), lateral (P = 0.019), and displaced (P < 0.001) rib fractures were significantly associated with delayed hemothorax. Lung contusions (P = 0.002), and initial minimal hemothorax (P < 0.001) and pneumothorax (P < 0.001) were more frequently associated with delayed hemothorax. Age (adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.00-1.06, P = 0.022), mechanical ventilator use (aOR 9.67, 95% CI 1.01-92.75, P = 0.049), initial hemothorax (aOR 2.21, 95% CI 1.05-4.65, P = 0.037) and pneumothorax (aOR 2.99, 95% CI 1.36-6.54, P = 0.006), and displaced rib fractures (aOR 3.51, 95% CI 1.64-7.53, P = 0.001) were independently associated with delayed hemothorax.

Conclusion : Age, mechanical ventilation, initial hemo- or pneumothorax, and displaced rib fractures were risk factors for delayed hemothorax. Patients with these risk factors, and especially those with ≥2 displaced rib fractures, require close chest radiography follow-up of 2-30 days after the initial trauma.

Conclusion (proposition de traduction) : L'âge, la ventilation mécanique, l'hémothorax ou le pneumothorax initial et les fractures de côtes déplacées sont des facteurs de risque d'hémothorax tardif. Les patients présentant ces facteurs de risque, et en particulier ceux présentant ≥ 2 fractures de côtes déplacées, nécessitent un suivi radiographique thoracique rapproché de 2 à 30 jours après le traumatisme initial.

The accuracy of total body weight estimation in adults - A systematic review and meta-analysis.
Wells M, Goldstein LN, Alter SM, Solano JJ, Engstrom G, Shih RD. | Am J Emerg Med. 2024 Feb;76:123-135
DOI: https://doi.org/10.1016/j.ajem.2023.11.037
Keywords: 3-D camera weight estimation; Drug dosing; Lorenz formula; Weight estimation.

Review article

Introduction : Weight estimation is required in adult patients when weight-based medication must be administered during emergency care, as measuring weight is often impossible. Inaccurate estimations may lead to inaccurate drug doses, which may cause patient harm. Little is known about the relative accuracy of different methods of weight estimation that could be used during resuscitative care. The aim of this study was to evaluate the performance and suitability of existing weight estimation methods for use in adult emergency care.

Méthode : A systematic literature search was performed for suitable articles that studied the accuracy of weight estimation systems in adults. The study characteristics, the quality of the studies, the weight estimation methods evaluated, the accuracy data, and any information on the ease-of-use of the method were extracted and evaluated.

Résultats : A total of 95 studies were included, in which 27 different methods of total body weight estimation were described, with 42 studies included in the meta-analysis. The most accurate methods, determined from the pooled estimates of accuracy (the percentage of estimates within 10% of true weight, with 95% confidence intervals) were 3-D camera estimates (88.8% (85.8 to 91.8%)), patient self-estimates (88.7% (87.7 to 89.7%)), the Lorenz method (77.5% (76.4 to 78.6%)) and family estimates (75.0% (71.5 to 78.6%)). However, no method was without significant potential limitations to use during emergency care.

Conclusion : Patient self-estimations of weight were generally very accurate and should be the method of choice during emergency care, when possible. However, since alternative estimation methods must be available when confused, or otherwise incapacitated, patients are unable to provide an estimate, alternative strategies of weight estimation should also be available.

Conclusion (proposition de traduction) : Les auto-estimations du poids par les patients étaient généralement très précises et devraient être la méthode de choix lors des soins d'urgence, dans la mesure du possible. Cependant, étant donné que d'autres méthodes d'estimation doivent être disponibles lorsque des patients confus ou incapables de fournir une estimation, d'autres stratégies d'estimation du poids doivent également être disponibles.

Prevalence of intra-abdominal injury among patients with seatbelt signs, a systematic review and meta-analysis.
Pourmand A, Terrebonne E, Shapovalov V, Kartiko S, AlRemeithi R, Tran QK. | Am J Emerg Med. 2024 Feb;76:199-206
DOI: https://doi.org/10.1016/j.ajem.2023.11.058
Keywords: Abdominal imaging; Abdominal seat belt sign; Intra-abdominal injury; Seat belt sign; Surgical intervention.

Review article

Introduction : The advancement of seat belts have been essential to reducing morbidity and mortality related to motor vehicle collisions (MVCs). The "seat belt sign" (SBS) is an important physical exam finding that has guided management for decades. This study, comprising a systematic review and random-effects meta-analysis, asses the current literature for the likelihood of the SBS relating to intra-abdominal injury and surgical intervention.

Méthode : PubMed and Scopus databases were searched from their beginnings through August 4, 2023 for eligible studies. Outcomes included the prevalence of intra-abdominal injury and need for surgical intervention. Cochrane's Risk of Bias (RoB) tool and the Newcastle-Ottawa Scale (NOS) were applied to assess risk of bias and study quality; Q-statistics and I2 values were used to assess for heterogeneity.

Résultats : The search yielded nine observational studies involving 3050 patients, 1937 (63.5%) of which had a positive SBS. The pooled prevalence of any intra-abdominal injury was 0.42, (95% CI 0.28-0.58, I² = 96%) The presence of a SBS was significantly associated with increased odds of intra-abdominal injury (OR 3.62, 95% CI 1.12-11.6, P = 0.03; I² = 89%), and an increased likelihood of surgical intervention (OR 7.34, 95% CI 2.03-26.54, P < 0.001; I² = 29%). The measurement for any intra-abdominal injury was associated with high heterogeneity, I² = 89%.

Conclusion : This meta-analysis suggests that the presence of a SBS was associated with a statistically significant higher likelihood of intra-abdominal injury and need for surgical intervention. The study had high heterogeneity, likely due to the technological advancements over the course of this study, including seat belt design and diagnostic imaging sensitivity. Further studies with more recent data are needed to confirm these results.

Conclusion (proposition de traduction) : Cette méta-analyse suggère que la présence d'un signe de ceinture de sécurité est associée à une probabilité statistiquement plus élevée de lésions intra-abdominales et à la nécessité d'une intervention chirurgicale. L'étude présentait une grande hétérogénéité, probablement en raison des progrès technologiques réalisés au cours de cette étude, notamment en ce qui concerne la conception des ceintures de sécurité et la sensibilité de l'imagerie diagnostique. D'autres études avec des données plus récentes sont nécessaires pour confirmer ces résultats.

Sodium bicarbonate Ringer's solution for hemorrhagic shock: A meta-analysis comparing crystalloid solutions.
Shafique MA, Shaikh NA, Haseeb A, Mussarat A, Mustafa MS. | Am J Emerg Med. 2024 Feb;76:41-47
DOI: https://doi.org/10.1016/j.ajem.2023.11.003
Keywords: Hemorrhagic shock; Mortality; Normal saline; Ringers solution; Shock.

Research article

Introduction : The choice of fluid resuscitation in Traumatic Hemorrhagic shock (THS) remains a critical aspect of patient management. Bicarbonated Ringers solution (BRS) has shown promise due to its composition resembling human Extracellular Fluid and its potential benefits on hemodynamics.
Objective: To evaluate the efficacy, mortality rates, hemodynamic effects, and adverse outcomes of Sodium Bicarbonate Ringer's Solution in the treatment of hemorrhagic shock, as compared to other relevant interventions.

Méthode : A comprehensive examination of the available literature was performed by conducting systematic searches in prominent databases such as Cochrane, EMBASE, MEDLINE, and PubMed. The process employed predefined criteria to extract relevant data and evaluate the quality of the studies. The outcome measures considered encompassed survival rates, mortality, mean arterial pressure (MAP), heart rate (HR), and adverse events.

Résultats : The meta-analysis of three studies showed that compared to the other crystalloids, the use of BRS had an odds ratio for survival of 1.86 (95% CI: 0.94, 3.71; p = 0.08; I² = 0%), an odds ratio for total adverse events of 0.14 (95% CI: 0.06, 0.35; p < 0.0001; I² = 22%), a mean difference in heart rate of -4.49 (95% CI: -7.55, -1.44; p = 0.004; I² = 13%), and a mean difference in mean arterial pressure of 2.31 (95% CI: -0.85, 5.47; p = 0.15; I² = 66%).

Conclusion : BRS demonstrated a significant reduction in complications, including adult respiratory distress syndrome (ARDS), Multiple Organ Dysfunction (MODS), and Total Adverse Effects, when compared to other solutions in the treatment of THS. Additionally, THS patients resuscitated with BRS experienced a notable decrease in heart rate. The findings suggest BRS may contribute to organ stability and potential survival improvement due to its similarity to human Extracellular Fluid and minimal impact on the liver.

Conclusion (proposition de traduction) : La solution de Ringer bicarbonatée a démontré une réduction significative des complications, y compris le syndrome de détresse respiratoire de l'adulte (SDRA), les dysfonctionnements multiples des organes (MODS) et les effets indésirables totaux, par rapport à d'autres solutions dans le traitement du choc hémorragique traumatique. En outre, les patients en choc hémorragique traumatique réanimés avec la solution de Ringer bicarbonaté ont connu une diminution notable de la fréquence cardiaque. Les résultats suggèrent que la solution de Ringer bicarbonatée peut contribuer à la stabilité des organes et à l'amélioration potentielle de la survie en raison de sa similarité avec le liquide extracellulaire humain et de son impact minimal sur le foie.

Duration of cardiopulmonary resuscitation and outcomes for adults with in-hospital cardiac arrest: retrospective cohort study.
Okubo M, Komukai S, Andersen LW, Berg RA, Kurz MC, Morrison LJ, Callaway CW; American Heart Association’s Get With The Guidelines—Resuscitation Investigators. | BMJ. 2024 Feb 7;384:e076019.
DOI: https://doi.org/10.1136/bmj-2023-076019  | Télécharger l'article au format  
Keywords: Aucun

RESEARCH

Introduction : To quantify time dependent probabilities of outcomes in patients after in-hospital cardiac arrest as a function of duration of cardiopulmonary resuscitation, defined as the interval between start of chest compression and the first return of spontaneous circulation or termination of resuscitation.

Méthode : Retrospective cohort study.
Setting: Multicenter prospective in-hospital cardiac arrest registry in the United States.
Participants: 348 996 adult patients (≥18 years) with an index in-hospital cardiac arrest who received cardiopulmonary resuscitation from 2000 through 2021.
Main outcome measures: Survival to hospital discharge and favorable functional outcome at hospital discharge, defined as a cerebral performance category score of 1 (good cerebral performance) or 2 (moderate cerebral disability). Time dependent probabilities of subsequently surviving to hospital discharge or having favorable functional outcome if patients pending the first return of spontaneous circulation at each minute received further cardiopulmonary resuscitation beyond the time point were estimated, assuming that all decisions on termination of resuscitation were accurate (that is, all patients with termination of resuscitation would have invariably failed to survive if cardiopulmonary resuscitation had continued for a longer period of time).

Résultats : Parmi les 348 996 patients inclus, 233 551 (66,9 %) ont obtenu un retour de la circulation spontanée avec un intervalle médian de 7 (intervalle interquartile 3-13) minutes entre le début des compressions thoraciques et le premier retour de la circulation spontanée, tandis que 115 445 (33,1 %) patients n'ont pas obtenu de retour de la circulation spontanée avec un intervalle médian de 20 (14-30) minutes entre le début des compressions thoraciques et l'arrêt de la réanimation. 78 799 (22,6 %) patients ont survécu jusqu'à leur sortie de l'hôpital. Les probabilités de survie et d'évolution fonctionnelle favorable en fonction du temps chez les patients en attente d'un retour d'une activité cardio-circulatoire spontanée (RACS) après une minute de réanimation cardiopulmonaire étaient respectivement de 22,0 % (75 645/343 866) et de 15,1 % (49 769/328 771). Les probabilités diminuent avec le temps et sont < 1 % pour la survie à 39 minutes et < 1 % pour une issue fonctionnelle favorable à 32 minutes de durée de la réanimation cardio-pulmonaire.

Conclusion : This analysis of a large multicenter registry of in-hospital cardiac arrest quantified the time dependent probabilities of patients' outcomes in each minute of duration of cardiopulmonary resuscitation. The findings provide resuscitation teams, patients, and their surrogates with insights into the likelihood of favorable outcomes if patients pending the first return of spontaneous circulation continue to receive further cardiopulmonary resuscitation.

Conclusion (proposition de traduction) : Cette analyse d'un vaste registre multicentrique d'arrêts cardiaques survenus à l'hôpital a permis de quantifier les probabilités d'évolution des patients en fonction du temps pour chaque minute de durée de la réanimation cardio-pulmonaire. Les résultats fournissent aux équipes de réanimation, aux patients et à leurs substituts des indications sur la probabilité d'une évolution favorable si les patients en attente d'un premier retour de la circulation spontanée continuent à recevoir une réanimation cardio-pulmonaire.

Spiced RCT: Success and Pain Associated with Intravenous Cannulation in the Emergency Department Randomized Controlled Trial.
Mitra TP, Coulter-Nile S, Jegathees T, Luong J, Shetty A, Lai K. | J Emerg Med. 2024 Feb;66(2):57-63
DOI: https://doi.org/10.1016/j.jemermed.2023.10.008  | Télécharger l'article au format  
Keywords: cannula size; cannulation; pain; procedural skills difficulty; randomized controlled trial.

Original Contribution

Introduction : Peripheral venous cannulation is one of the most common procedures in medicine. A larger cannula allows higher rates of fluid to be provided if needed in a deteriorating patient; however, it is also perceived that larger-gauge cannula placement is associated with increased pain and procedural difficulty.
Objective: This study aimed to compare the pain and procedural difficulty experienced during insertion between 18-gauge (18G) and 20-gauge (20G) cannulas.

Méthode : We conducted a single-blinded, randomized controlled trial on adult patients who required peripheral IV cannulation within a tertiary hospital emergency department between April and October 2018. Patients were randomized to either the 18G or 20G cannula group. The primary outcomes of the study-pain experienced by patients and procedural difficulties experienced by clinical staff-were recorded on two separate 10-cm visual analog scales. Other outcomes include first-attempt success rate, operator designation, complications, and the intent and actual use of the IV cannula were documented on preformatted questionnaires.

Résultats : Data from 178 patients were included in the analysis. Eighty-nine patients were allocated to each cannula group. There were no statistically or clinically significant differences between mean pain score (0.23; 95% CI 0.56-1.02; p = 0.5662) and mean procedural difficulty score (0.12; 95% CI 0.66-0.93; p = 0.7396). between the two groups. There was no difference in first-attempt success rate (73 of 89 vs. 75 of 89; p = 0.1288), complications (2 of 89 vs. 1 of 89) between the 20G group and 18G group, respectively.

Conclusion : There was no significant difference between the 18G or 20G cannula for either pain experienced by patients or procedural difficulty experienced by clinicians.

Conclusion (proposition de traduction) : Il n'y avait pas de différence significative entre les cathéters 18G et 20G en ce qui concerne la douleur ressentie par les patients ou les difficultés de procédure ressenties par les cliniciens.

Three Simple Parameters on Admission to the Emergency Department are Predictors for Endoscopic Intervention in Patients with Suspected Nonvariceal Upper Gastrointestinal Bleeding.
Acehan F, Karsavuranoğlu B, Kalkan C, Aslan M, Altiparmak E, Ates I. | J Emerg Med. 2024 Feb;66(2):64-73
DOI: https://doi.org/10.1016/j.jemermed.2023.08.016  | Télécharger l'article au format  
Keywords: blood urea nitrogen; endoscopic intervention; mean arterial pressure; syncope; upper gastrointestinal bleeding.

Research article

Introduction : A considerable number of patients with nonvariceal upper gastrointestinal bleeding (UGIB) need endoscopic intervention. Objective: The aim of this study was to determine factors that predict the need for endoscopic intervention at the time of admission to the emergency department.

Méthode : Consecutive patients with International Classification of Diseases, Tenth Revision diagnosis code K92.2 (gastrointestinal hemorrhage) who underwent upper endoscopy between February 2019 and February 2022, including patients diagnosed with nonvariceal UGIB in the emergency department in the study were reviewed retrospectively. The patients were divided into two groups: those treated endoscopically and those not treated endoscopically. These two groups were compared according to clinical and laboratory findings at admission and independent predictors for endoscopic intervention were determined using multivariate regression analysis.

Résultats : Although 123 patients (30.3%) were treated endoscopically, endoscopic treatment was not required in 283 (69.7%) patients. Syncope, mean arterial pressure (MAP), and blood urea nitrogen (BUN) at admission were independent predictors for endoscopic intervention in the multivariate analysis, after adjusting for endoscopy time. The area under the curve of the syncope+MAP+BUN combination for endoscopic intervention was 0.648 (95% CI 0.588-0.708). Although the syncope+MAP+BUN combination predicted the need for intervention significantly better than pre-endoscopy Rockall and AIMS65 scores (p = 0.010 and p < 0.001, respectively), there was no significant difference in its comparison with the Glasgow-Blatchford score (p = 0.103).

Conclusion : Syncope, MAP, and BUN at admission were independent predictors for endoscopic therapy in patients with nonvariceal UGIB. Rather than using complicated scores, it would be more practical and easier to predict the need for endoscopic intervention with these three simple parameters, which are included in the Glasgow-Blatchford score.

Conclusion (proposition de traduction) : Une syncope, la PAM et l'urée sanguine à l'admission sont des facteurs prédictifs indépendants d'un traitement endoscopique chez les patients présentant une hémorragie gastro-intestinale supérieure non variqueuse. Plutôt que d'utiliser des scores compliqués, il serait plus pratique et plus facile de prédire la nécessité d'une intervention endoscopique à l'aide de ces trois paramètres simples, qui sont inclus dans le score de Glasgow-Blatchford.

Intradermal Sterile Water Injection: Safe and Effective Alternative for Relief of Acute Renal Colic in the Emergency Department.
Az A, Sogut O, Akdemir T, Dogan Y. | J Emerg Med. 2024 Feb;66(2):83-90
DOI: https://doi.org/10.1016/j.jemermed.2023.10.014  | Télécharger l'article au format  
Keywords: diclofenac; intradermal sterile water injection; paracetamol; renal colic; tramadol.

Research article

Introduction : The optimal pain relief method for acute renal colic in the emergency department remains controversial. Objective: We compared the safety and efficacy of intradermal sterile water injection (ISWI) to treatment with intramuscular (IM) diclofenac, intravenous (IV) opioids, and IV paracetamol in patients with acute renal colic.

Méthode : This randomized, single-blind study included 320 patients with renal colic to one of four treatment groups. The first group received ISWI at four different points around the most painful flank area. Patients in the DI, PARA, and TRAM groups received 75 mg IM diclofenac, 1 g IV paracetamol, and 100 mg IV tramadol, respectively. Pain intensity was measured using a visual analog scale (VAS) before treatment and 15, 30, and 60 min after treatment.

Résultats : VAS scores 15 and 30 min after treatment were significantly lower in group ISWI than in groups DI, PARA, and TRAM. However, there were no significant differences in the decrease in the pain score at baseline and at 60 min after treatment. In addition, fewer patients required rescue analgesia in group ISWI than in group TRAM. However, no significant differences were observed between group ISWI and group DI or PARA in terms of the need for rescue analgesia. Finally, there were significantly fewer adverse events in group ISWI than in groups DI and TRAM.

Conclusion : ISWI had similar efficacy, faster pain relief, and lower need for rescue analgesia compared with diclofenac, paracetamol, and tramadol for the management of acute renal colic. In addition, ISWI was well-tolerated and had no adverse effects.

Conclusion (proposition de traduction) : L'injection intradermique d'eau stérile a eu une efficacité similaire, un soulagement plus rapide de la douleur et un besoin moindre d'analgésie de secours par rapport au diclofénac, au paracétamol et au tramadol pour la prise en charge de la colique néphrétique aiguë. En outre, l'injection intradermique d'eau stérile a été bien tolérée et n'a pas eu d'effets indésirables.

Commentaire : L'injection intradermique d'eau stérile se fait en quatre points (0,5 mL par point) autour de la zone la plus douloureuse du flanc à l'aide d'une aiguille à insuline de 1 mL, après avoir nettoyé le site d'injection avec de l'alcool.

Analgesic Techniques for Managing Orthopedic Injuries: A Review for the Emergency Clinician.
Long B, Bridwell RE, Gottlieb M. | J Emerg Med. 2024 Feb;66(2):211-220
DOI: https://doi.org/10.1016/j.jemermed.2023.10.010  | Télécharger l'article au format  
Keywords: Bier blocks; analgesia; hematoma blocks; intra-articular injection; orthopedics; periosteal block; periosteal injection; reduction.

Techniques and Procedures - Research article

Introduction : Orthopedic injuries are commonly managed in the emergency department (ED) setting. Fractures and dislocations may require reduction for proper management. There are a variety of analgesic and sedative strategies to provide patient comfort during reduction.

Méthode : This narrative review evaluates hematoma block, intra-articular injection, intravenous regional analgesia (IVRA) (also known as the Bier block), and periosteal block for orthopedic analgesia in the ED setting.

Résultats : Analgesia is an essential component of management of orthopedic injuries, particularly when reduction is necessary. Options in the ED setting include hematoma blocks, intra-articular injections, IVRA, and periosteal blocks, which provide adequate analgesia without procedural sedation or opioid administration. When used in isolation, these analgesic techniques decrease complications from sedation and the need for other medications, such as opioids, while decreasing ED length of stay. Emergency clinicians can also use these techniques as analgesic adjuncts. However, training in these techniques is recommended prior to routine use, particularly with IVRA.

Conclusion : Knowledge of analgesic techniques for orthopedic procedures can assist clinicians in optimizing patient care.

Conclusion (proposition de traduction) : La connaissance des techniques d'analgésie pour les procédures orthopédiques peut aider les cliniciens à optimiser les soins aux patients.

Arterial hypertension in the chronic evolution of migraine: bystander or risk factor? An overview.
Mazzacane F, Vaghi G, Cotta Ramusino M, Perini G, Costa A. | J Headache Pain. 2024 Feb 5;25(1):13.. J Headache Pain. 2024 Feb 5;25(1):13.
DOI: https://doi.org/10.1186/s10194-024-01720-7  | Télécharger l'article au format  
Keywords: Arterial hypertension; Chronic migraine; Chronicization; Endothelial dysfunction; Migraine.

REVIEW

Introduction : Several risk factors are associated with the chronic evolution of migraine. Clinical and preclinical studies have provided data about the role of hypertension (HT) as one of the potential modifiable risk factors of chronic migraine (CM). This review is focused on the biological and clinical evidence supporting common mechanisms underlying HT and migraine and the potential role of HT in the transition from episodic to chronic migraine.

Méthode : We conducted a narrative review from a literature search covering the available evidence from studies investigating: i) the role of HT in the transition to CM in clinical practice; ii) the biological mechanisms potentially underpinning the association between HT and evolution to CM; iii) the role of antihypertensive medications in migraine prophylaxis.

Résultats : HT proved to be at the base of multiple mechanisms underlying migraine and migraine chronicization. Endothelial dysfunction, blood-brain barrier alterations, calcitonin gene-related peptide signaling, and renin-angiotensin-aldosterone system dysregulation are involved in the worsening effect of HT on migraine frequency, and the role of HT in the transition to CM is supported by clinical observations.

Conclusion : The observed evidence supports HT contribution to CM evolution due to shared pathophysiologic mechanisms. While a bidirectional influence appears to be ascertained, data are still lacking about the one-way role of HT as direct risk factor for CM transition. Further research is needed to confirm a causal role of HT in this process.

Conclusion (proposition de traduction) : Les données observées confirment la responsabilité de l'hypertension dans l'évolution de la migraine chronique en raison de mécanismes physiopathologiques communs. Bien qu'une influence réciproque semble être établie, on manque encore de données sur le rôle unidirectionnel de l'hypertension en tant que facteur de risque direct pour la transition vers la migraine chronique. Des recherches supplémentaires sont nécessaires pour confirmer le rôle causal de l'hypertension dans ce processus.

Trauma-induced coagulopathy: What you need to know.
Buzzard L, Schreiber M. | J Trauma Acute Care Surg. 2024 Feb 1;96(2):179-185
DOI: https://doi.org/10.1097/ta.0000000000004170
Keywords: Aucun

WHAT YOU NEED TO KNOW SERIES – REVIEWS

Editorial : Trauma-induced coagulopathy (TIC) is a global inflammatory state accompanied by coagulation derangements, acidemia, and hypothermia, which occurs after traumatic injury. It occurs in approximately 25% of severely injured patients, and its incidence is directly related to injury severity. The mechanism of TIC is multifaceted; proposed contributing factors include dysregulation of activated protein C, increased tPA, systemic endothelial activation, decreased fibrinogen, clotting factor consumption, and platelet dysfunction. Effects of TIC include systemic inflammation, coagulation derangements, acidemia, and hypothermia. Trauma-induced coagulopathy may be diagnosed by conventional coagulation tests including platelet count, Clauss assay, international normalized ratio, thrombin time, prothrombin time, and activated partial thromboplastin time; viscoelastic hemostatic assays such as thrombelastography and rotational thrombelastography; or a clinical scoring system known as the Trauma Induced Coagulopathy Clinical Score. Preventing TIC begins in the prehospital phase with early hemorrhage control, blood product resuscitation, and tranexamic acid therapy. Early administration of prothrombin complex concentrate is also being studied in the prehospital environment.

Conclusion : The mainstays of trauma-induced coagulopathy treatment include hemorrhage control, blood and component transfusions, and correction of abnormalities such as hypocalcemia, acidosis, and hypothermia.

Conclusion (proposition de traduction) : Les piliers du traitement de la coagulopathie induite par un traumatisme comprennent le contrôle de l'hémorragie, les transfusions de sang et de composants, et la correction des anomalies telles que l'hypocalcémie, l'acidose et l'hypothermie.

Commentaire :  Obstacles à la coagulopathie induite par le traumatisme.
Les étapes essentielles de la prévention de la coagulopathie induite par un traumatisme comprennent le contrôle précoce de l'hémorragie, la réanimation à l'aide de produits sanguins et le traitement par l'acide tranexamique. L'administration précoce d'un concentré de complexe prothrombique est également à l'étude. PCC, concentré de complexe prothrombinique.

Éteindre l'incendie de la coagulopathie induite par le traumatisme.
Les étapes essentielles du traitement de la coagulopathie induite par un traumatisme comprennent le contrôle de l'hémorragie, les transfusions de produits et de composants sanguins et la correction des anomalies telles que l'acidose, l'hypocalcémie et l'hypothermie.

When is it safe to start venous thromboembolism prophylaxis after blunt solid organ injury? A prospective American Association for the Surgery of Trauma multi-institutional trial.
Schellenberg M, Owattanapanich N, Emigh B, Van Gent JM, Egodage T, Murphy PB, Ball CG, Spencer AL, Vogt KN, Keeley JA, Doris S, Beiling M, Donnelly M, Ghneim M, Schroeppel T, Bradford J, Breinholt CS, Coimbra R, Berndtson AE, Anding C, Charles MS, Rieger W, Inaba K; AAST VTE Prophylaxis Study Group. | J Trauma Acute Care Surg. 2024 Feb 1;96(2):209-215
DOI: https://doi.org/10.1097/ta.0000000000004163
Keywords: Aucun

AAST PODIUM 2023

Introduction : The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice.

Méthode : Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a 1-year study period beginning between August 1 and October 1, 2021. Inclusions were age older than 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management. Exclusions were transfers, emergency department death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 hours of admission) versus Late (>48 hours). Bivariate and multivariable analyses compared outcomes.

Résultats : In total, 1,173 patients satisfied the study criteria with 571 liver (49%), 557 spleen (47%), and 277 kidney injuries (24%). The median patient age was 34 years (interquartile range, 25-49 years), and 67% (n = 780) were male. The median Injury Severity Score was 22 (interquartile range, 14-29) with Abbreviated Injury Scale Abdomen score of 3 (interquartile range, 2-3), and the median American Association for the Surgery of Trauma grade of solid organ injury was 2 (interquartile range, 2-3). Early VTEp patients (n = 838 [74%]) had significantly lower rates of VTE (n = 28 [3%] vs. n = 21 [7%], p = 0.008), comparable rates of nonoperative management failure (n = 21 [3%] vs. n = 12 [4%], p = 0.228), and lower rates of post-VTEp blood transfusion (n = 145 [17%] vs. n = 71 [23%], p = 0.024) when compared with Late VTEp patients (n = 301 [26%]). Late VTEp was independently associated with VTE (odd ratio, 2.251; p = 0.046).

Conclusion : Early initiation of VTEp was associated with significantly reduced rates of VTE with no increase in bleeding complications. Venous thromboembolism chemoprophylaxis initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury.

Conclusion (proposition de traduction) : L'instauration précoce de la prophylaxie de la thrombo-embolie veineuse a été associée à une réduction significative des taux de thrombo-embolie veineuse sans augmentation des complications hémorragiques. L'instauration d'une chimioprophylaxie de la thromboembolie veineuse ≤48 heures est donc sûre et efficace et devrait constituer la norme de soins pour les patients ayant subi une blessure contondante à des organes solides.

A comparative analysis of tranexamic acid dosing strategies in traumatic major hemorrhage.
Gunn F, Stevenson R, Almuwallad A, Rossetto A, Vulliamy P, Brohi K, Davenport R. | J Trauma Acute Care Surg. 2024 Feb 1;96(2):216-224
DOI: https://doi.org/10.1097/ta.0000000000004177
Keywords: Aucun

AAST PODIUM 2023

Introduction : Tranexamic acid (TXA) is a life-saving treatment for traumatic hemorrhage, but the optimal dosing regimen remains unknown. Different doses and treatment strategies have been proposed, including single bolus, repeated bolus, or bolus plus infusion. The aim of this study was to determine the effect of different TXA dosing strategies on clinical outcomes in bleeding trauma patients.

Méthode : Secondary analysis of a perpetual cohort study from a UK Level I trauma center. Adult patients who activated the local major hemorrhage protocol and received TXA were included. The primary outcome was 28-day mortality. Secondary outcomes were 24-hour mortality, multiple organ dysfunction syndrome, venous thromboembolism, and rotational thromboelastometry fibrinolysis.

Résultats : Over an 11-year period, 525 patients were included. Three dosing groups were identified: 1 g bolus only (n = 317), 1 g bolus +1 g infusion over 8 hours (n = 80), and 2 g bolus (n = 128). Demographics and admission physiology were similar, but there were differences in injury severity (median Injury Severity Score, 25, 29, and 25); and admission systolic blood pressure (median Systolic Blood Pressure, 99, 108, 99 mm Hg) across the 1-g, 1 g + 1 g, and 2-g groups. 28-day mortality was 21% in each treatment group. The incidence of multiple organ dysfunction syndrome was significantly higher in the bolus plus infusion group (84%) vs. 1 g bolus (64%) and 2 g bolus (62%) group, p = 0.002, but on multivariable analysis was nonsignificant. Venous thromboembolism rates were similar in the 1-g bolus (4%), 2 g bolus (8%) and bolus plus infusion groups (7%). There was no difference in rotational thromboelastometry maximum lysis at 24 hours: 5% in both the 1-g and 2-g bolus groups vs. 4% in bolus plus infusion group.

Conclusion : Clinical outcomes and 24-hour fibrinolysis state were equivalent across three different dosing strategies of TXA. Single bolus administration is likely preferable to a bolus plus infusion regimen.

Conclusion (proposition de traduction) : Les résultats cliniques et l'état de la fibrinolyse sur 24 heures étaient équivalents dans les trois différentes stratégies de dosage de l'acide tranexamique. L'administration d'un bolus unique est probablement préférable à un schéma bolus et perfusion continue.

Critical systolic blood pressure threshold for endovascular aortic occlusion-A multinational analysis to determine when to place a REBOA.
Ordoñez CA, Parra MW, Caicedo Y, Rodríguez-Holguín F, García AF, Serna JJ, Serna C, Franco MJ, Salcedo A, Padilla-Londoño N, Herrera-Escobar JP, Zogg C, Orlas CP, Palacios H, Saldarriaga L, Granados M, Scalea T, McGreevy DT, Kessel B, Hörer TM, Dubose J, Brenner M; AAST-AORTA Investigators*, ABO Trauma Registry Group*. | J Trauma Acute Care Surg. 2024 Feb 1;96(2):247-255
DOI: https://doi.org/10.1097/ta.0000000000004160
Keywords: Aucun

AAST POSTER 2021

Introduction : Systolic blood pressure (SBP) is a potential indicator that could guide when to use a resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma patients with life-threatening injuries. This study aims to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in severely injured hemodynamically unstable trauma patients.

Méthode : We performed a pooled analysis of the aortic balloon occlusion (ABO) trauma and AORTA registries. These databases record the details related to the use of REBOA and include data from 14 countries worldwide. We included patients who had suffered penetrating and/or blunt trauma. Patients who arrived at the hospital with a SBP pre-REBOA of 0 mm Hg and remained at 0 mm Hg after balloon inflation were excluded. We evaluated the impact that SBP pre-REBOA had on the probability of death in the first 24 hours.

Résultats : A total of 1,107 patients underwent endovascular aortic occlusion, of these, 848 met inclusion criteria. The median age was 44 years (interquartile range [IQR], 27-59 years) and 643 (76%) were male. The median injury severity score was 34 (IQR, 25-45). The median SBP pre-REBOA was 65 mm Hg (IQR, 49-88 mm Hg). Mortality at 24 hours was reported in 279 (32%) patients. Math modeling shows that predicted probabilities of the primary outcome increased steadily in SBP pre-REBOA below 100 mm Hg. Multivariable mixed-effects analysis shows that when SBP pre-REBOA was lower than 60 mm Hg, the risk of death was more than 50% (relative risk, 1.5; 95% confidence interval, 1.17-1.92; p = 0.001).

Conclusion : In patients who do not respond to initial resuscitation, the use of REBOA in SBPs between 60 mm Hg and 80 mm Hg may be a useful tool in resuscitation efforts before further decompensation or complete cardiovascular collapse. The findings from our study are clinically important as a first step in identifying candidates for REBOA.

Conclusion (proposition de traduction) : Chez les patients qui ne répondent pas à la réanimation initiale, l'utilisation du REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) lorsque la pression artérielle systolique se situe entre 60 mm Hg et 80 mm Hg peut être un outil utile dans les efforts de réanimation avant une nouvelle décompensation ou un collapsus cardiovasculaire complet. Les résultats de notre étude sont cliniquement importants car ils constituent une première étape dans l'identification des candidats au REBOA.

The usefulness of point-of-care ultrasound in dehydrated patients in a pediatric emergency department.
Bellini T, Chianucci B, D'Alessandro M, Ricci M, Calevo MG, Misley S, Piccotti E, Moscatelli A. | Ultrasound J. 2024 Feb 21;16(1):13
DOI: https://doi.org/10.1186/s13089-023-00354-1  | Télécharger l'article au format  
Keywords: Acute gastroenteritis; Dehydration; Pediatric emergency department; Point-of-care ultrasound.

Original article

Introduction : Dehydration is among the most common causes of Pediatric Emergency Department admission; however, no clinical signs, symptoms, or biomarkers have demonstrated sufficient sensitivity, specificity, or reliability to predict dehydration.

Méthode : We conducted a prospective, monocentric, observational study at Giannina Gaslini Hospital, a tertiary care pediatric hospital. Our study aimed to compare inferior vena cava ultrasound measurement with volume depletion biomarkers to understand if point-of-care ultrasound could help grade, evaluate, and better manage dehydration in children presenting to the pediatric emergency department. We enrolled patients under the age of 14 who required blood tests in the suspect of dehydration; for each patient, we collected values of venous pH, natremia, bicarbonatemia, uric acid, chloremia, and blood urea nitrogen. For each patient, we performed two ultrasound scans to calculate the Inferior Vena Cava/Aorta area ratio and to assess the IVC collapsibility index; moreover, we described the presence of the "kiss sign" (100% IVC walls collapsing during the inspiratory phase).

Résultats : Patients with the "kiss sign" (25/65 patients, 38.5% of the total) showed worse blood tests, in particular, uric acid levels (p = 0.0003), bicarbonatemia (p = 0.001) and natriemia (p = 0.0003). Moreover, patients with the "kiss sign" showed a high frequency of ≥ 2 pathological blood tests (p = 0.0002). We found no statistical significant difference when comparing the IVC/Ao ratio and IVC-CI with the considered blood tests.

Conclusion : The "kiss sign" seems to be related to worse hydration state, whereas IVC/Ao and IVC-CI are not. In an emergency setting, where physicians must take diagnostic-therapeutic decisions quickly, the presence of the "kiss sign" in patients suspected to be dehydrated can be a helpful tool in their management.

Conclusion (proposition de traduction) : Le "signe du baiser" semble être lié à un état plus grave de déshydratation, alors que le rapport entre la surface de la veine cave inférieure et celle de l'aorte et l'indice de collapsibilité de la veine cave inférieure ne le sont pas. Dans un contexte d'urgence, où les médecins doivent prendre rapidement des décisions diagnostiques et thérapeutiques, la présence du "signe du baiser" chez les patients suspectés d'être déshydratés peut être un outil utile dans leur prise en charge.

Commentaire : 

Thoracic ultrasound use in hospitalized and ambulatory adult patients: a quantitative picture.
Xirouchaki N, Bolaki M, Psarologakis C, Pediaditis E, Proklou A, Papadakis E, Kondili E, Georgopoulos D. | Ultrasound J. 2024 Feb 21;16(1):11
DOI: https://doi.org/10.1186/s13089-024-00359-4  | Télécharger l'article au format  
Keywords: Ambulatory; Diaphragmatic dysfunction; Malignancy; Pregnancy; Thoracic ultrasound.

Original article

Introduction : Thoracic ultrasound (TUS) has been established as a powerful diagnostic and monitoring tool in the Intensive Care Unit (ICU). However, studies outside the critical care setting are scarce. The aim of this study was to investigate the value of TUS for hospitalized or ambulatory community patients.

Méthode : This was a retrospective study conducted from 2016 to 2020 in the TUS clinic at Heraklion University Hospital. TUS examination was performed using a standard ultrasound machine (EUB HITACHI 8500), and a high-frequency microconvex probe (5-8 MHz). Patients had been referred by their primary physician to address a range of different questions. The various respiratory system entities were characterised according to internationally established criteria.

Résultats : 762 TUS studies were performed on 526 patients due to underlying malignancy (n = 376), unexplained symptoms/signs (n = 53), pregnancy related issues (n = 42), evaluation of abnormal findings in X-ray (n = 165), recent surgery/trauma (n = 23), recent onset respiratory failure (n = 12), acute respiratory infection (n = 66) and underlying non-malignant disease (n = 25). Pleural effusion was the commonest pathologic entity (n = 610), followed by consolidation (n = 269), diaphragmatic dysfunction/paradox (n = 174) and interstitial syndrome (n = 53). Discrepancies between chest X-ray and ultrasonographic findings were demonstrated in 96 cases. The TUS findings guided invasive therapeutic management in 448 cases and non-invasive management in 43 cases, while follow-up monitoring was decided in 271 cases.

Conclusion : This study showed that TUS can identify the most common respiratory pathologic entities encountered in hospitalized and community ambulatory patients, and is especially useful in guiding the decision making process in a diverse group of patients.

Conclusion (proposition de traduction) : Cette étude a montré que l'échographie thoracique permettait d'identifier les entités pathologiques respiratoires les plus courantes rencontrées chez les patients hospitalisés et les patients ambulatoires de la communauté, et qu'elle était particulièrement utile pour guider le processus de prise de décision dans un groupe diversifié de patients.

Comparing contamination rates of sterile-covered and uncovered transducers for ultrasound-guided peripheral intravenous lines.
Estrella Y, Panzlau N, Vinokur K, Ayala S, Lin M, Gaeta T, Melniker L, Chiricolo G, Gulec N. | Ultrasound J. 2024 Feb 7;16(1):6
DOI: https://doi.org/10.1186/s13089-023-00347-0  | Télécharger l'article au format  
Keywords: Hospital acquired infections; Intravenous catheters; Randomized control study; Ultrasound-guided procedures; Venous access.

Original article

Introduction : Physicians frequently use point-of-care ultrasound for intravenous access and bloodwork in the ED. Recently, AIUM and ACEP released recommendations on ultrasound-guided peripheral intravenous lines (USPIVs), but there are no agreed upon standardized policies. We sought to determine whether the use of sterile-covered transducers (SCT) decreases the rate of contamination when compared to uncovered transducers (UCT) after standard low-level disinfection (LLD).

Méthode : This is a randomized control trial comparing contamination rates of US transducers between SCT and UCT after their use for USPIV by the vascular access team, also known as the "PICC" team, over a 3-month period. A sample of admitted patient with an USPIV order were included and randomized to SCT (experimental) or UCT (control) arms. Transducers were swabbed and inserted into the SystemSURE Plus Adenosine Triphosphate (ATP) Luminometer to calculate Relative Light Units (RLU). We performed a cost analysis of requiring sterile covers for USPIVs.

Résultats : The UCT and SCT arms contained 35 and 38 patients, respectively. The SCT group had a mean of 0.34 compared to the UCT group mean of 2.29. Each sterile cover costs $8.49, and over 3000 USPIVs are placed annually by the "PICC" team.

Conclusion : Contamination rates were similar among the UCT and SCT groups after LLD. 254 inpatient USPIVs are performed monthly, not including failed attempts or covers used in the ED where USPIV placement is an essential part of ED workflow. This study suggests that the use of SCT does not significantly affect transducer contamination rates. These findings question burdensome regulatory hospital policies that are not evidence-based.

Conclusion (proposition de traduction) : Les taux de contamination étaient similaires dans les groupes des transducteurs couverts et non couverts de façon stérile après une désinfection de bas niveau. 254 cathéters intraveineux périphériques échoguidés en milieu hospitalier sont posés chaque mois, sans compter les échecs de tentatives ou de couvertures réalisées aux urgences, où la pose de cathéters intraveineux périphériques échoguidés est un élément essentiel du flux de travail des urgences. Cette étude suggère que l'utilisation de transducteurs à couverture stérile n'affecte pas de manière significative les taux de contamination des transducteurs. Ces résultats remettent en question les politiques hospitalières réglementaires lourdes qui ne sont pas fondées sur des données probantes.

Diagnostic Accuracy of a Handheld Ultrasound vs a Cart-based Model: A Randomized Clinical Trial.
Gibbons RC, Jaeger DJ, Berger M, Magee M, Shaffer C, Costantino TG.. | West J Emerg Med. 2024;25(2)268–274
DOI: https://doi.org/10.5811/westjem.17822  | Télécharger l'article au format  
Keywords: Aucun

Original research

Introduction : Numerous studies have demonstrated the accuracy of point-of-care ultrasound (POCUS). Portable, handheld devices have expanded the clinical scope of POCUS at a fraction of the cost of traditional, cart-based models. There is a paucity of data assessing the diagnostic accuracy of portable devices. Our objective in this study was to compare the diagnostic accuracy of a portable device with a cart-based model.

Méthode : This was an institutional review board-approved, observational, prospective, randomized clinical trial (NCT05196776) of a convenience sample of adult patients who presented to a university-based health system. Patients who required a cardiac, lung, renal, aorta, or biliary POCUS were randomized to a portable device or to a cart-based model. We hypothesized that the cart-based model would have a 90% diagnostic accuracy vs 70% for the handheld device. To detect a 20% difference, the sample size was calculated to be 98, with 49 patients randomized to each arm. We used standard 2x2 tables to calculate test characteristics with 95% confidence intervals (CI).

Résultats : A total of 110 patients were enrolled, with 56 patients randomized to the cart-based model and 54 to the handheld device. The sensitivity, specificity, and diagnostic accuracy of the cart-based vs handheld were 77.8% (40–97.2) vs 92.9% (66.1–99.8), 91.5% (79.6–97.6) vs 92.3% (79.1–98.4%), and 89.3% (78.1–96) vs 92.5% (81.8–97.9), respectively.

Conclusion : The diagnostic accuracy of a portable, handheld device is similar to that of a cart-based model.

Conclusion (proposition de traduction) : La précision diagnostique d'un appareil ultraportable est similaire à celle d'un modèle sur chariot.

Ultrasound Performed by Emergency Physicians for Deep Vein Thrombosis: A Systematic Review.
Hercz D, Mechanic OJ, Varella M, Fajardo F, Levine RL. | West J Emerg Med. 2024;25(2)282–290
DOI: https://doi.org/10.5811/westjem.18125  | Télécharger l'article au format  
Keywords: Aucun

SYSTEMATIC REVIEW

Introduction : Point-of-care ultrasound (POCUS) performed by emergency physicians (EP) has emerged as an effective alternative to radiology department ultrasounds for the diagnosis of lower extremity deep vein thrombosis (DVT). Systematic reviews suggested good sensitivity and specificity overall for EP-performed POCUS for DVT diagnosis, yet high levels of heterogeneity were reported.

Méthode : In this systematic review and meta-analysis, we aimed to provide the most up-to-date estimates of the accuracy of EP-performed POCUS for diagnosis of DVT and to explore potential correlations with test performance. We performed systematic searches in MEDLINE and Embase for original, primary data articles from January 2012–June 2021 comparing the efficacy of POCUS performed by EPs to the local standard. Quality Assessment of Diagnostic Accuracy Studies-2 for individual articles are reported. We obtained summary measures of sensitivity, specificity, and their corresponding 95% confidence intervals (CI) using bivariate mixed-effects regression models. We performed meta-regression, subgroup, and sensitivity analyses as planned in the protocol CRD42021268799 submitted to PROSPERO.

Résultats : Fifteen publications fit the inclusion criteria, totaling 2,511 examinations. Pooled sensitivity and specificity were 90% (95% CI 82%–95%) and 95% (CI 91%–97%), respectively. Subgroup analyses by EP experience found significantly better accuracy for exams performed by EP specialists (93%, CI 88%–97%) vs trainees (77%, CI 60%–94%). Specificity for EP specialists (97%, CI 94%–99%) was higher than for trainees (87%, CI 76%–99%, P = 0.01). Three-point compression ultrasound (CUS) was more sensitive than two-point CUS but was only statistically significant when limited to EP specialists (92% vs 88%, P = 0.07, and 95% vs 88%, P = 0.02, respectively).

Conclusion : Point-of-care ultrasound performed by emergency physicians is sensitive and specific for the diagnosis of suspected DVT when performed by trained attending EPs. Three-point compression ultrasound examination may be more sensitive than two-point CUS.

Conclusion (proposition de traduction) : L'échographie au point d'intervention réalisée par les médecins urgentistes est sensible et spécifique pour le diagnostic d'une suspicion de thrombose veineuse profonde lorsqu'elle est réalisée par des médecins urgentistes titulaires formés. L'échographie par compression en trois points peut être plus sensible que l'échographie en deux points.

Effect of a cervical collar on optic nerve sheath diameter in trauma patients.
Yazici MM, Yavaşi Ö. | World J Emerg Med. 2024;15(2):126-130
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2024.023  | Télécharger l'article au format  
Keywords: Computed tomography; Emergency medicine; Optic nerve sheath diameter; Trauma.

Original Article

Introduction : As advocated in advanced trauma life support and prehospital trauma life support protocols, cervical immobilization is applied until cervical spine injury is excluded. This study aimed to show the difference in optic nerve sheath diameter (ONSD) between patients with and without a cervical collar using computed tomography (CT).

Méthode : This was a single-center, retrospective study examining trauma patients who presented to the emergency department between January 1, 2021, and December 31, 2021. The ONSD on brain CT of the trauma patients was measured and analyzed to determine whether there was a difference between the ONSD with and without the cervical collar.

Résultats : The study population consisted of 169 patients. On CT imaging of patients with (n=66) and without (n=103) cervical collars, the mean ONSD in the axial plane were 5.43 ± 0.50 mm and 5.04 ± 0.46 mm respectively for the right eye and 5.50 ± 0.52 mm and 5.11 ± 0.46 mm respectively for the left eye. The results revealed an association between the presence of a cervical collar and the mean ONSD, which was statistically significant (P<0.001) for both the right and left eyes.

Conclusion : A cervical collar may be associated with increased ONSD. The effect of this increase in the ONSD on clinical outcomes needs to be investigated, and the actual need for cervical collar in the emergency department should be evaluated on a case-by-case basis.

Conclusion (proposition de traduction) : Le port du collier cervical peut être associé à une augmentation du diamètre de la gaine du nerf optique. L'effet de cette augmentation du diamètre de la gaine du nerf optique sur les résultats cliniques doit être étudié, et la nécessité réelle du port d'un collier cervical dans le service des urgences doit être évaluée au cas par cas.