Bibliographie de Médecine d'Urgence

Mois de janvier 2018

Academic Emergency Medicine

Hot off the Press: Embedded Clinical Decision Support in Electronic Health Record Decreases Use of High-cost Imaging in the Emergency Department: EmbED Study.
Heitz C, Morgenstern J, Milne WK. | Acad Emerg Med. 2018 Jan;25(1):41-43
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Original contributions

Editorial : This longitudinal before/after study of embedded clinical decision rules assessed the effects of clinical decision support on use of common imaging studies. Among high users, rates of computed tomograhy (CT) scan of the brain and CT of the cervical spine were reduced after implementation of embedded clinical decision instruments, while in low users, rates increased. This article summarizes the manuscript and the Skeptics Guide to Emergency Medicine podcast, as well as the ensuing social media/online discussion.

Conclusion : This was a longitudinal before/after study of embedded CDRs within 5 EDs in a system sharing an EHR. Three CDS tools were created based on the North American X- Radiography Utilization Study (NEXUS) C Spine rule, Pulmonary Embolism Rule Out Criteria (PERC), the Wells score for PE, and the Canadian Head Injury rule. An alert was created whenever an order for the appropriate imaging study was placed. If the study was not indicated, the provider was given an explanation and alternatives were offered. The provider could choose to override the alert and still place the order. The primary outcome was the proportion of CTs ordered by each provider for each of the studies. 235,858 patient visits were analyzed, with an absolute reduction of 6106 CTs ordered across all three imaging studies. After deployment of the CDS tool, usage of both CT brain and c-spine decreased, but CT-PE usage was statistically unchanged. CT usage among physicians who were the highest utilizers at baseline decreased by 14% for all 3 imaging studies, while average users did not change their practices, and low users increased usage for CT c-spine.

Conclusion (proposition de traduction) : Il s'agissait d'une étude longitudinale avant/après des règles de décision clinique intégrées dans cinq services d'urgence dans un système partageant un dossier de santé électronique. Trois outils de règles de décision clinique ont été créés sur la base de la règle nord-américaine C NEXUS (étude sur l’usage de la radiographie), des critères d’exclusion de la règle dans l’embolie pulmonaire (PERC), du score de Wells pour les embolies pulmonaires et de la règle canadienne des lésions traumatiques. Une alerte était créée chaque fois qu'une demande pour l'étude d'imagerie appropriée était passée. Si l'étude n'était pas indiquée, le demandeur recevait une explication et des alternatives étaient proposées. Le demandeur d'examen pouvait choisir d'ignorer l'alerte tout en confirmant la demande. Le résultat principal était la proportion de scanner calculés demandés par chaque demandeur pour chacune des études. 235 858 consultations ont été analysées, avec une réduction absolue de 6106 scanners prescrits au cours des trois études d'imagerie.
Après le déploiement de l'outil de règles de décision clinique, l'utilisation à la fois de la tomodensitométrie cérébrale et de la colonne vertébrale a diminué, mais la tomodensitométrie pour suspicion d'embolies pulmonaires était statistiquement inchangée. L'utilisation de la tomodensitométrie pour les médecins qui utilisaient le plus grand nombre d'utilisateurs au départ a diminué de 14 % pour les trois études d'imagerie, tandis que les utilisateurs moyens n'ont pas changé leurs pratiques et que les utilisateurs peu nombreux ont augmenté l'utilisation de la tomodensitométrie pour la colonne vertébrale.

Commentaire : Fait suite à l'article : "National trends in use of computed tomography in the emergency department" de juillet 2017" Acad Emerg Med. 2017 Jul;24(7):839-845.
Retrouvez la ligne directrice "National Trends in Use of Computed Tomography in the Emergency Department" Ann Emerg Med. 2011 Nov;58(5):452-62.e3.

Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study.
Hawkins T, Greenslade JH, Suna J, Williams J, Rickard CM, Jensen M, Donohue M, Cho E, Hise CV, Egerton-Warburton D, Cullen L. | Acad Emerg Med. 2018 Jan;25(1):26-32
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Original Contribution

Introduction : The objective was to examine cannulation practice and effectiveness of a multimodal intervention to reduce peripheral intravenous cannula (PIVC) insertion in emergency department (ED) patients.

Méthode : A prospective before and after study and cost analysis was conducted at a single tertiary ED in Australia. Data were collected 24 hours a day for 2 weeks pre- and post implementation of a multimodal intervention. PIVC placement and utilization within 24 hours were evaluated in all eligible patients.

Résultats : A total of 4,173 participants were included in the analysis. PIVCs were placed in 42.1% of patients' pre intervention and 32.4% post intervention, a reduction of 9.8% (95% confidence interval [CI] = 6.8 to -12.72%). PIVC usage within 24 hours of admission was 70.5% pre intervention and 83.4% post intervention, an increase of 12.9% (95% CI = 8.8% to 17.0%). Sixty-six patients were observed in the ED for cost analysis. The mean time per PIVC insertion was 15.3 (95% CI = 12.6 to 17.9) minutes. PIVC insertion cost, including staff time and consumables per participant, was A$22.79 (95% CI = A$19.35 to A$26.23).

Conclusion : The intervention reduced PIVC placement in the ED and increased the percentage of PIVCs placed that were used. This program benefits patients and health services alike, with potential for large cost savings.

Conclusion (proposition de traduction) : L'intervention a réduit la mise en place des cathéter veineux périphériques au service des urgences et a augmenté le pourcentage de cathéter veineux périphériques mis en place qui ont été utilisées.
Ce programme profite autant aux patients qu’aux services de santé, ce qui peut entraîner des économies importantes.

Commentaire : Article qui confirme la nécessaire réflexion sur l'indication de la pose d'une VVP aux urgences (majoration du risque infectieux et des coûts). En l'absence de ligne directrice, l'indication de la pose par un médecin semble indispensable. La règle proposée de 80 % de certitude d'une utilisation semble pertinence dans le contexte de l'urgence.

Improved Survival for Rural Trauma Patients Transported by Helicopter to a Verified Trauma Center: A Propensity Score Analysi.
Zhu TH, Hollister L, Opoku D, Galvagno SM Jr. | Acad Emerg Med. 2018 Jan;25(1):44-53
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Original Contribution

Introduction : Recent studies using advanced statistical methods to control for confounders have demonstrated an association between helicopter transport (HT) versus ground ambulance transport (GT) in terms of improved survival for adult trauma patients. The aim of this study was to apply a methodologically vigorous approach to determine if HT is associated with a survival benefit for when trauma patients are transported to a verified trauma center in a rural setting.

Méthode : The ascertainment of trauma patients age ≥ 15 years (n = 469 cases) by HT and (n = 580 cases) by GT between 1999 and 2012 was restricted to the scene of injury in a rural area of 10 to 35 miles from the trauma center. The propensity score (PS) was determined using data including demographics, prehospital physiology, intubation, total prehospital time, and injury severity. The PS matching was performed with different calipers to select a higher percentage of matches of HT compared to GT patients. The outcome of interest was survival to discharge from hospital. Identical logistic regression analysis was done taking into account for each matched design to select an appropriate effect estimate and confidence interval (CI) controlling for initial vital signs in the emergency department, the need for urgent surgery, intensive care unit admission, and mechanical ventilation.

Résultats : Unadjusted mortalities for HT compared to GT were 7.7 and 5.3%, respectively (p > 0.05). The adjusted rates were 4.0% for HT and 7.6% for GT (p < 0.05). In a PS well-matched data set, HT was associated with a 2.69-fold increase in odds of survival compared to GT patients (adjusted odds ratio = 2.69; 95% CI = 1.21-5.97).

Conclusion : In a rural setting, we demonstrated improved survival associated with HT compared to GT for scene transportation of adult trauma patients to a verified Level II trauma center using an advanced methodologic approach, which included adjustment for transport distance. The implication of survival benefit to rural population is discussed. We recommend larger studies with multiple trauma systems need to be repeated using similar study methodology to substantiate our findings.

Conclusion (proposition de traduction) : En milieu rural, nous avons démontré une amélioration de la survie associée au transport par hélicoptère par rapport au transport ambulancier terrestre pour transporter des patients adultes traumatisés vers un centre de traumatologie de niveau II autorisé en utilisant une approche méthodologique avancée, incluant un ajustement pour la distance de transport. L'implication des bénéfices de survie pour la population rurale est discutée. Nous recommandons de répéter des études plus poussées comportant des traumatismes multiples en utilisant une méthodologie d'étude similaire pour étayer nos résultats.

Academic Emergency Medicine Education and Training

Hands-off Ultrasound Technique: UtilizingSimultaneous Modeling to EnhanceUltrasound Training.
Gottlieb M | AEM Education and Training. 2018 January;2(1):55–56.
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New Ideas in B‐E‐D‐side Teaching

Editorial : Image acquisition can be a challenging component of obtaining ultrasound proficiency. To assist with obtaining the correct image, instructors may take the transducer away or guide the learner's hand. However, this passive form of learning has been suggested to be much less valuable, as it removes learner autonomy and somatosensory cueing. This paper describes the hands‐off ultrasound technique, a simultaneous modeling teaching strategy using multimodal feedback to improve ultrasound image acquisition.

Conclusion : Specific comments from learners highlighted a greater sense of autonomy, with one person stating that he felt that he was “actually performing the exam instead of watching it”.

Conclusion (proposition de traduction) : Les commentaires spécifiques des apprenants ont mis en évidence un plus grand sens de l'autonomie, avec une personne déclarant qu'il sentait qu'il « effectuait réellement l'examen au lieu de le regarder ».

American Journal of Respiratory and Critical Care Medicine

Effect of Telemedicine Education and Telemonitoring on Continuous Positive Airway Pressure Adherence. The Tele-OSA Randomized Trial.
Hwang D, Chang JW, Benjafield AV, Crocker ME, Kelly C, Becker KA, Kim JB, Woodrum RR, Liang J, Derose SF. | Am J Respir Crit Care Med. 2018 Jan 1;197(1):117-126
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Original Articles

Introduction : Automated telemedicine interventions could potentially improve adherence to continuous positive airway pressure (CPAP) therapy. OBJECTIVES: Examining the effects of telemedicine-delivered obstructive sleep apnea (OSA) education and CPAP telemonitoring with automated patient feedback messaging on CPAP adherence.

Méthode : This four-arm, randomized, factorial design clinical trial enrolled 1,455 patients (51.0% women; age, 49.1 ± 12.5 yr [mean ± SD]) referred for suspected OSA. Nine hundred and fifty-six underwent home sleep apnea testing, and 556 were prescribed CPAP. Two telemedicine interventions were implemented: 1) web-based OSA education (Tel-Ed) and 2) CPAP telemonitoring with automated patient feedback (Tel-TM). Patients were randomized to 1) usual care, 2) Tel-Ed added, 3) Tel-TM added, or 4) Tel-Ed and Tel-TM added (Tel-both).

Résultats : The primary endpoint was 90-day CPAP usage. Secondary endpoints included attendance to OSA evaluation, and change in Epworth Sleepiness Scale score. CPAP average daily use at 90 days was 3.8 ± 2.5, 4.0 ± 2.4, 4.4 ± 2.2, and 4.8 ± 2.3 hours in usual care, Tel-Ed, Tel-TM, and Tel-both groups. Usage was significantly higher in the Tel-TM and Tel-both groups versus usual care (P = 0.0002 for both) but not for Tel-Ed (P = 0.10). Medicare adherence rates were 53.5, 61.0, 65.6, and 73.2% in usual care, Tel-Ed, Tel-TM, and Tel-both groups (Tel-both vs. usual care, P = 0.001; Tel-TM vs. usual care, P = 0.003; Tel-Ed vs. usual care, P = 0.07), respectively. Telemedicine education improved clinic attendance compared with no telemedicine education (show rate, 68.5 vs. 62.7%; P = 0.02).

Conclusion : The use of CPAP telemonitoring with automated feedback messaging improved 90-day adherence in patients with OSA. Telemedicine-based education did not significantly improve CPAP adherence but did increase clinic attendance for OSA evaluation.

Conclusion (proposition de traduction) : L'utilisation de la télésurveillance de la CPAP par des messages automatisés de retour d’information a amélioré l'observance à 90 jours chez les patients souffrant d'apnée obstructive du sommeil. L'éducation basée sur la télémédecine n'a pas amélioré de manière significative l'adhésion à la CPAP mais a augmenté la participation au suivi clinique de l'apnée obstructive du sommeil.

Mechanical Ventilation-induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes.
Goligher EC, Dres M, Fan E Rubenfeld GD, Scales DC, Herridge MS, Vorona S, Sklar MC, Rittayamai N, Lanys A, Murray A, Brace D, Urrea C, Reid WD, Tomlinson G, Slutsky AS, Kavanagh BP, Brochard LJ, Ferguson ND. | Am J Respir Crit Care Med. 2018 Jan 15;197(2):204-213
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Original Articles

Introduction : Diaphragm dysfunction worsens outcomes in mechanically ventilated patients, but the clinical impact of potentially preventable changes in diaphragm structure and function caused by mechanical ventilation is unknown. OBJECTIVES: To determine whether diaphragm atrophy developing during mechanical ventilation leads to prolonged ventilation.

Méthode : Diaphragm thickness was measured daily by ultrasound in adults requiring invasive mechanical ventilation; inspiratory effort was assessed by thickening fraction. The primary outcome was time to liberation from ventilation. Secondary outcomes included complications (reintubation, tracheostomy, prolonged ventilation, or death). Associations were adjusted for age, severity of illness, sepsis, sedation, neuromuscular blockade, and comorbidity.

Résultats : Of 211 patients enrolled, 191 had two or more diaphragm thickness measurements. Thickness decreased more than 10% in 78 patients (41%) by median Day 4 (interquartile range, 3-5). Development of decreased thickness was associated with a lower daily probability of liberation from ventilation (adjusted hazard ratio, 0.69; 95% confidence interval [CI], 0.54-0.87; per 10% decrease), prolonged ICU admission (adjusted duration ratio, 1.71; 95% CI, 1.29-2.27), and a higher risk of complications (adjusted odds ratio, 3.00; 95% CI, 1.34-6.72). Development of increased thickness (n = 47; 24%) also predicted prolonged ventilation (adjusted duration ratio, 1.38; 95% CI, 1.00-1.90). Decreasing thickness was related to abnormally low inspiratory effort; increasing thickness was related to excessive effort. Patients with thickening fraction between 15% and 30% (similar to breathing at rest) during the first 3 days had the shortest duration of ventilation.

Conclusion : Diaphragm atrophy developing during mechanical ventilation strongly impacts clinical outcomes. Targeting an inspiratory effort level similar to that of healthy subjects at rest might accelerate liberation from ventilation.

Conclusion (proposition de traduction) : L'atrophie du diaphragme induit par la ventilation mécanique a une forte incidence sur les résultats cliniques. Cibler un niveau d'effort inspiratoire similaire à celui des sujets sains au repos pourrait accélérer le sevrage de la ventilation.

American Journal of Therapeutic

Intravenous Lidocaine for Intractable Renal Colic Unresponsive to Standard Therapy.
Sin B, Cao J, Yang D, Ambert K, Punnapuzha S. | Am J Ther. 2018 Jan 23
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Original article

Introduction : Renal colic is defined as a flank pain radiating to the groin caused by kidney stones in the ureter (urolithiasis). Renal colic is a frequent cause of Emergency Department visits. Most renal colic cases present as acute distress and severe back and/or abdominal pain that require prompt treatment with analgesics.

Discussion : Nonsteroidal anti-inflammatory drugs and opioids are traditionally used for renal colic in the Emergency Department. This trend of practice is based on clinical experience and expert opinion. Consensus guidelines that provide evidence-based approach for the management of renal colic are limited. One consensus guideline from Europe provides a systematic approach for the management of pain with the use of nonsteroidal anti-inflammatory drugss and opioids. However, no guidance is provided on how to manage patients who do not respond to these agents.

Conclusion : Intravenous lidocaine 120 mg in 100 mL normal saline was infused over 10 minutes for pain management for intractable renal colic unresponsive to standard therapy. Three minutes after initiation of lidocaine infusion, the patient reported numeric pain rating scale 1/10. At 5 minutes, the reported numeric pain rating scale was 0/10 and remained for 60 minutes after initiation of lidocaine infusion. No adverse events were reported during or after the infusion, and no subsequent analgesia was required.

Conclusion (proposition de traduction) : On a perfusé 120 mg de lidocaïne par voie intraveineuse dans 100 mL de solution saline normale en 10 minutes pour soulager la douleur en cas de colique néphrétique réfractaire ne répondant pas au traitement standard. Trois minutes après le début de la perfusion de lidocaïne, le patient a fait état d'une échelle numérique d'évaluation de la douleur de 1/10. À 5 minutes, l'échelle numérique d'évaluation de la douleur était de 0/10 et est demeurée pendant 60 minutes après le début de la perfusion de lidocaïne.
Aucun effet indésirable n'a été signalé pendant ou après la perfusion, et aucune analgésie supplémentaire n'a été nécessaire.

Anaesthesia Critical Care & Pain Medicine

Eyes should be taped closed during rapid sequence induction of anaesthesia.
Priebe HJ | Anaesth Crit Care Pain Med. 2018 Jan 5. pii: S2352-5568(17)30378-8
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Letter to the Editor

Editorial : I read with great interest the guidelines on eye protection in anaesthesia and intensive care published by the French Society for Anaesthesia and Intensive Care Medicine, the French Ophthalmology Society, and the French-speaking Intensive Care Society. The authors are to be congratulated for addressing this clinically highly relevant but mostly neglected issue. The only recommendation with which I strongly disagree is the exemption of rapid sequence induction of anaesthesia (RSI) from eyelid occlusion as soon as the ciliary reflex is lost and before tracheal intubation (recommendation 1.2). Unfortunately, the rationale for this exemption is not provided. Most likely, however, it is based on the belief that eye protection will interfere with airway management. This view had been expressed many years ago: "We recommend that all patients should have their eyes taped closed immediately after preoxygenation and intravenous induction of anaesthesia except during rapid sequence intubation when securing the airway takes precedence over eye protection".

Conclusion : -

Anesthesia & Analgesia

Comparison of the Mallampati Classification in Sitting and Supine Position to Predict Difficult Tracheal Intubation: A Prospective Observational Cohort Study.
Hanouz JL, Bonnet V, Buléon C, Simonet T, Radenac D, Zamparini G, Fischer MO, Gérard JL. | Anesth Analg. 2018 Jan;126(1):161-169
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original articles

Introduction : The Mallampati classification (MLPT) is normally evaluated in the sitting position. However, many patients cannot be evaluated in the sitting position for medical reasons. Thus, we compared the MLPT in sitting and supine positions in predicting difficult tracheal intubation (DTI). We hypothesized that the diagnostic accuracy of the MLPT performed in sitting and supine positions would differ.

Méthode : We performed a single-center prospective observational study in adult patients who received general anesthesia and orotracheal intubation for noncardiac surgery. During the preanesthesia consultation, the MLPT in the sitting position was recorded. The day of surgery, the MLPT in the supine position and the difficulty of intubation (DTI) were recorded by an independent observer. The diagnostic performance of the MLPT for the prediction of DTI was evaluated in the sitting and supine positions through the area under the receiver operating characteristic (ROC) curve. The performance of the Naguib score in predicting DTI was calculated with the MLPT in sitting and supine positions.

Résultats : Among the 3036 patients, 157 (5.1%) had DTI. The area under the ROC curve for the MLPT in supine position (0.82 [0.78-0.84]) was greater than that for the MLPT in the sitting position (0.70 [0.66-0.75]; P < .001). The relationship between the sitting and supine MLPTs was moderate (Spearman rank correlation coefficient: 0.50; P < .001). The area under ROC curve for predicting DTI by the Naguib score calculated with the supine MLPT (0.78 [95% confidence interval, 0.74-0.82]) was greater than that for the Naguib score calculated with MLPT in the sitting position (0.69 [95% confidence interval, 0.63-0.74)]; P < .001).

Conclusion : The MLPT performed in the supine position is possibly superior to that performed in the sitting position for predicting difficult intubation in adults.

Conclusion (proposition de traduction) : Le score de Mallampati réalisé en décubitus dorsal est probablement supérieur à sa réalisatrion en position assise pour prédire une intubation difficile chez l'adulte.

Commentaire : Voir l'analyse de l'article sur le site Société de Réanimation de Langue Française (SRLF) : Prédire l’intubation difficile plutôt que la subir !  . Rédigé par le Dr Boris Jung, Réanimation Médicale, CHU de Montpellier, France.

Ultrasound-Guided Dynamic Needle Tip Positioning Technique Versus Palpation Technique for Radial Arterial Cannulation in Adult Surgical Patients: A Randomized Controlled Trial.
Kiberenge RK, Ueda K, Rosauer B. | Anesth Analg. 2018 Jan;126(1):120-126
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Original Clinical Research Report

Introduction : Radial arterial cannulation is most commonly done using palpation, but the use of ultrasound has increased the cannulation success rate. This improvement, albeit significant, has not led to a very high success rate especially in trainees. A modified ultrasound technique for vascular cannulation (dynamic needle tip positioning) has been described for peripheral venous cannulation. We therefore assessed the success rate of this technique compared to the palpation technique for radial artery cannulation in adult surgical patients.

Méthode : We enrolled patients who were having nonemergent operations that required a radial arterial catheter for intraoperative monitoring. Patients were randomized to either palpation or dynamic needle tip positioning technique. Arterial cannulation was performed by anesthesia residents or faculty members. The primary end point was successful cannulation on the first pass. Secondary end points were overall 5-minute success rate and number of attempts within 5 minutes.

Résultats : Two hundred sixty patients were evaluated. The first-pass success rate was 83% in the dynamic needle tip positioning technique group (n = 132) and 48% in the palpation group (n = 128; P < .001); relative risk was 2.5; 95% confidence interval, 1.7-3.6. The overall 5-minute success rate was 89% in the dynamic needle tip positioning technique group compared to 65% in the palpation group (P < .001), relative risk was 2.4; 95% confidence interval, 1.2-1.6. The number of skin puncture attempts was significantly more in the palpation group (P < .001). The median cannulation times and interquartile ranges were 81.5 (61-122) seconds in the dynamic needle tip positioning and 76 (48-175) seconds (P = .7) in the palpation group.

Conclusion : The use of the ultrasound-guided dynamic needle tip positioning technique increased the first and overall success rates compared to palpation in anesthesia residents and faculty members.

Conclusion (proposition de traduction) : L'utilisation de la technique de positionnement dynamique de l'aiguille, guidée par ultrasons, a augmenté les taux de succès initiaux et globaux par rapport à la palpation chez les résidents en anesthésie et les membres du corps professoral.


Central Venous Catheters in Small Infants.
Brasher C, Malbezin S. | Anesthesiology. 2018 Jan;128(1):4-5
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Editorial Views

Editorial : HOW to best insert and maintain central venous catheters in small infants is a question of interest to all health professionals working in the field. The hospitalized small infant population is growing as extremely premature baby survival rates increase.1 In parallel, ultrasound technology is developing rapidly. Smaller vessel and catheter diameters imply increased technical difficulties during both insertion and maintenance when compared with larger children and adults. In this issue of Anesthesiology, Breschan et al.2 describe an experience in Austria with respect to central vein cannulation technique in preterm infants. In 2010, they decided to change their default central venous catheter cannulation technique to in-plane ultrasound-guided cannulation of the brachiocephalic vein in small infants. Their aim was to increase success rates and efficiency, and to reduce complications. One particular advantage of the target brachiocephalic vein is that it relatively maintains its diameter in hypovolemic and shocked patients. The detailed description of the technique, along with the pitfalls to be avoided, is of great potential interest to all anesthesiologists and, indeed, all practitioners inserting central venous catheters in small infants.

Conclusion : Good central venous access is often crucial to quality care in small infants, and we need good-quality evidence to guide practice. This will not be easy to achieve given the patient population and the heterogeneity of approaches developing worldwide. International collaboration, high-quality data registries, and multicenter trials are required to explore opti- mal approaches in securing and maintaining central access in small infants. Articles that share innovative experiences, such as that by Breschan et al., are a step in the right direction.

Conclusion (proposition de traduction) : Un bon accès veineux central est souvent essentiel à la qualité des soins chez les nourrissons de petite taille et nous avons besoin de preuves de bonne qualité pour guider la pratique. Ce ne sera pas facile à réaliser compte tenu de la population de patients et de l'hétérogénéité des approches en développement dans le monde. Une collaboration internationale, des registres de données de haute qualité et des essais multicentres sont nécessaires pour explorer des approches optimales en matière de sécurisation et de maintien de l'accès centralisé chez les petits nourrissons. Les articles qui partagent des expériences novatrices, tels que ceux de Breschan et al., vont dans la bonne direction.

A Retrospective Analysis of the Clinical Effectiveness of Supraclavicular, Ultrasound-guided Brachiocephalic Vein Cannulations in Preterm Infants.
Breschan C, Graf G, Jost R, Stettner H, Feigl G, Neuwersch S, Stadik C, Koestenberger M, Likar R. | Anesthesiology. 2018 Jan;128(1):38-43
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Perioperative Medicine Clinical Science

Introduction : The aim of this retrospective analysis was to evaluate the clinical effectiveness of the supraclavicular ultrasound-guided cannulation of the brachiocephalic vein in preterm infants.

Méthode : The ultrasound probe was placed in the supraclavicular region so as to obtain the optimum sonographic long-axis view of the brachiocephalic vein. By using a strict in-plane approach the brachiocephalic vein was cannulated by advancing a 22- or 24-gauge iv cannula from lateral to medial under the long axis of the ultrasound probe under real-time ultrasound guidance into the vein.

Résultats : One hundred and forty-two cannulations in infants weighing between 0.59 and 2.5 kg (median: 2.1; CI: 2.0 to 2.2) were included. Ultimate success rate was 94% (134 of 142). One cannulation attempt was required in 100 (70%) patients, two attempts in 21 (15%), and three attempts in 13 (9%). The smaller the weight of the infant the more attempts were needed. More attempts also were needed for the right brachiocephalic vein, which was primarily targeted in 75 (53%) neonates. One (1%) inadvertent arterial puncture was noted.

Conclusion : This supraclavicular, in-plane, real-time, ultrasound-guided cannulation of the brachiocephalic vein seems to be a convenient and effective method to insert central venous catheters in preterm infants.

Conclusion (proposition de traduction) : Cette canulation supra-claviculaire de la veine brachiocéphalique, dans le plan, en temps réel, guidée par échographie semble être une méthode pratique et efficace pour poser des cathéters veineux centraux chez les prématurés

Right Ventricular Perfusion: Physiology and Clinical Implications.
Crystal GJ, Pagel PS. | Anesthesiology. 2018 Jan;128(1):202-218
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Education Review Article

Editorial : Regulation of blood flow to the right ventricle differs significantly from that to the left ventricle. The right ventricle develops a lower systolic pressure than the left ventricle, resulting in reduced extravascular compressive forces and myocardial oxygen demand. Right ventricular perfusion has eight major characteristics that distinguish it from left ventricular perfusion: (1) appreciable perfusion throughout the entire cardiac cycle; (2) reduced myocardial oxygen uptake, blood flow, and oxygen extraction; (3) an oxygen extraction reserve that can be recruited to at least partially offset a reduction in coronary blood flow; (4) less effective pressure-flow autoregulation; (5) the ability to downregulate its metabolic demand during coronary hypoperfusion and thereby maintain contractile function and energy stores; (6) a transmurally uniform reduction in myocardial perfusion in the presence of a hemodynamically significant epicardial coronary stenosis; (7) extensive collateral connections from the left coronary circulation; and (8) possible retrograde perfusion from the right ventricular cavity through the Thebesian veins. These differences promote the maintenance of right ventricular oxygen supply-demand balance and provide relative resistance to ischemia-induced contractile dysfunction and infarction, but they may be compromised during acute or chronic increases in right ventricle afterload resulting from pulmonary arterial hypertension. Contractile function of the thin-walled right ventricle is exquisitely sensitive to afterload. Acute increases in pulmonary arterial pressure reduce right ventricular stroke volume and, if sufficiently large and prolonged, result in right ventricular failure. Right ventricular ischemia plays a prominent role in these effects. The risk of right ventricular ischemia is also heightened during chronic elevations in right ventricular afterload because microvascular growth fails to match myocyte hypertrophy and because microvascular dysfunction is present. The right coronary circulation is more sensitive than the left to α-adrenergic-mediated constriction, which may contribute to its greater propensity for coronary vasospasm. This characteristic of the right coronary circulation may increase its vulnerability to coronary vasoconstriction and impaired right ventricular perfusion during administration of α-adrenergic receptor agonists.

Conclusion : Future research in right ventricle hemodynamics should include studies in human subjects. Such research may be facilitated by recent advances in nuclear imaging, allowing an assessment of right ventricle perfusion, metabolism, morphology, and contractile function in a single test session.While having diagnostic and prognostic value, this emerging technology also provides an opportunity for confirming previous find- ings in animal models and for clarifying the role of impaired perfusion in right ventricle disease.

Conclusion (proposition de traduction) : Les futures recherches sur l'hémodynamique du ventricule droit devraient inclure des études sur des sujets humains. De telles recherches pourraient être facilitées par les récents progrès de l’imagerie nucléaire, permettant d’évaluer la perfusion, le métabolisme, la morphologie et la fonction contractile du ventricule droit en une seule étude. Cette technologie, qui a une valeur diagnostique et pronostique, offre également l’occasion de confirmer les résultats chez des modèles animaux et pour clarifier le rôle de la perfusion avec fonction altérée dans la maladie du ventricule droit.

Annals of Emergency Medicine

Low Accuracy of Positive qSOFA Criteria for Predicting 28-Day Mortality in Critically Ill Septic Patients During the Early Period After Emergency Department Presentation.
Hwang SY, Jo IJ, Lee SU, Lee TR, Yoon H, Cha WC, Sim MS, Shin TG. | Ann Emerg Med. 2018 Jan;71(1):1-9.e2
Keywords: Aucun

Infectious Disease

Introduction : We determine the diagnostic performance of positive Quick Sequential Organ Failure Assessment (qSOFA) scores for predicting 28-day mortality among critically ill septic patients during the early period after emergency department (ED) presentation.

Méthode : This was a retrospective cohort study at a tertiary care academic center. We reviewed a registry of adult (≥18 years) patients who received a diagnosis of severe sepsis or septic shock during an ED stay from August 2008 through September 2014. We identified the point at which patients met 2 or more of the 3 qSOFA criteria (indicating a positive qSOFA score) simultaneously during the initial 24 hours. The diagnostic performance of positive qSOFA score for predicting 28-day mortality was assessed (on ED arrival and within 3, 6, and 24 hours after ED presentation).

Résultats : A total of 1,395 patients were included, and the overall 28-day mortality was 15%. For patients with positive qSOFA score, 28-day mortality was 23% (95% confidence interval [CI] 19% to 28%) on ED arrival, 20% (95% CI 17% to 23%) at 3 hours, 20% (95% CI 17% to 22%) at 6 hours, and 17% (95% CI 15% to 20%) at 24 hours. Positive qSOFA score for predicting 28-day mortality had a sensitivity, specificity, and area under the receiver operating curve, respectively, of 39% (95% CI 32% to 46%), 77% (95% CI 75% to 80%), and 0.58 (95% CI 0.55 to 0.62) on ED arrival; 68% (95% CI 62% to 75%), 52% (95% CI 49% to 55%), and 0.60 (95% CI 0.57 to 0.63) within 3 hours; 82% (95% CI 76% to 87%), 41% (95% CI 38% to 44%), and 0.61 (95% CI 0.58 to 0.64) within 6 hours; and 91% (95% CI 86% to 94%), 23% (95% CI 21% to 25%), and 0.57 (95% CI 0.54 to 0.59) within 24 hours.

Conclusion : The diagnostic performance of positive qSOFA score for predicting 28-day mortality was low in critically ill septic patients, particularly during the early period after ED presentation. The study requires further prospective validation because of limitations with its retrospective design and use of single-center data.

Conclusion (proposition de traduction) : La performance diagnostique du score qSOFA positif pour prédire la mortalité à 28 jours était faible chez les patients septicémiques en situation critique, en particulier au début de la période post-admission aux urgences. L'étude nécessite une validation prospective supplémentaire en raison des limites de sa conception rétrospective et de l'utilisation de données monocentriques.

Commentaire : Etude rétrospective monocentrique sur 1395 patients suivi sur 28 jours

What to Do After You Cut: Recommendations for Abscess Management in the Emergency Setting.
Gottlieb M, Schmitz G, Grock A, Mason J. | Ann Emerg Med. 2018 Jan;71(1):31-33
Keywords: Aucun

EM:Rap Commentary

Editorial : Ultrasonography? Helps when there is clinical uncertainty. Needle aspiration? Not as good as standard incision and drainage. Incision size? Large enough for adequate drainage or consider the loop technique. Packing? Jury is still out. Larger trials are needed, although packing is probably not helpful in smaller abscesses. Irrigation? Nope. Antibiotics? Complicated. Benefit of a small, clinically significant improvement in cure rates should be weighed against potential risks of antibiotics such as medication adverse effects and increased antibiotic resistance.

Conclusion : Ultrasonography? Helps when there is clinical uncertainty.
Needle aspiration? Not as good as standard incision and drainage.
Incision size? Large enough for adequate drainage or consider the loop technique.
Packing? Jury is still out. Larger trials are needed, although packing is probably not helpful in smaller abscesses.
Irrigation? Nope.
Antibiotics? Complicated. Benefit of a small, clinically significant improvement in cure rates should be weighed against potential risks of antibiotics such as medication adverse effects and increased antibiotic resistance.

Conclusion (proposition de traduction) : Échographie  ? Aide en cas d'incertitude clinique.
Aspiration de l'aiguille ? Pas aussi bon que l'incision standard et le drainage.
Taille de l'incision ? Assez grand pour un drainage adéquat ou envisagez la technique de la boucle.
Emballage ? Le jury est toujours absent. Des essais plus importants sont nécessaires, bien que l'emballage ne soit probablement pas utile chez les petits abcès.
Irrigation ? Nan.
Antibiotiques ? Compliqué. Les avantages d'une légère amélioration cliniquement significative du taux de guérison devraient être mis en balance avec les risques potentiels d'antibiotiques tels que les effets indésirables des médicaments et l'augmentation de la résistance aux antibiotiques.

Acute Kidney Injury After Computed Tomography: A Meta-analysis.
Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. | Ann Emerg Med. 2018 Jan;71(1):44-53.e4
Keywords: Aucun

Review Articles

Introduction : Computed tomography (CT) is an important imaging modality used in the diagnosis of a variety of disorders. Imaging quality may be improved if intravenous contrast is added, but there is a concern for potential renal injury. Our goal is to perform a meta-analysis to compare the risk of acute kidney injury, need for renal replacement, and total mortality after contrast-enhanced CT versus noncontrast CT.

Méthode : We searched MEDLINE (PubMed), the Cochrane Library, CINAHL, Web of Science, ProQuest, and Academic Search Premier for relevant articles. Included articles specifically compared rates of renal insufficiency, need for renal replacement therapy, or mortality in patients who received intravenous contrast versus those who received no contrast.

Résultats : The database search returned 14,691 articles, inclusive of duplicates. Twenty-six unique articles met our inclusion criteria, with an additional 2 articles found through hand searching. In total, 28 studies involving 107,335 participants were included in the final analysis, all of which were observational. Meta-analysis demonstrated that, compared with noncontrast CT, contrast-enhanced CT was not significantly associated with either acute kidney injury (odds ratio [OR] 0.94; 95% confidence interval [CI] 0.83 to 1.07), need for renal replacement therapy (OR 0.83; 95% CI 0.59 to 1.16), or all-cause mortality (OR 1.0; 95% CI 0.73 to 1.36).

Conclusion : We found no significant differences in our principal study outcomes between patients receiving contrast-enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient- and illness-level factors, rather than the use of contrast material, likely contribute to the development of acute kidney injury.

Conclusion (proposition de traduction) : Nous n'avons trouvé aucune différence significative dans les résultats de notre étude principale entre les patients recevant une TDM avec injection de produit de contraste et ceux recevant une TDM sans. Étant donné les fréquences similaires de lésions rénales aiguës chez les patients bénéficiant d’un scanner sans produit de contraste, d'autres facteurs au niveau du patient et de la maladie, plutôt que l'utilisation de produit de contraste, contribuent probablement au développement de lésions rénales aiguës.

A Randomized Controlled Trial on the Effect of a Double Check on the Detection of Medication Errors.
Douglass AM, Elder J, Watson R, Kallay T, Kirsh D, Robb WG, Kaji AH, Coil CJ. | Ann Emerg Med. 2018 Jan;71(1):74-82.e1
Keywords: Aucun

Original research article

Introduction : The use of a double check by 2 nurses has been advocated as a key error-prevention strategy. This study aims to determine how often a double check is used for high-alert medications and whether it increases error detection.

Méthode : Emergency department and ICU nurses worked in pairs to care for a simulated patient. Nurses were randomized into single- and double-check groups. Errors intentionally introduced into the simulation included weight-based dosage errors and wrong medication vial errors. The evaluator recorded whether a double check was used, whether errors were detected, and observational data about nurse behavior during the simulation.

Résultats : Forty-three pairs of nurses consented to enroll in the study. All nurses randomized to the double-check group used a double check. In the single-check group, 9% of nurses detected the weight-based dosage error compared with 33% of nurses in the double-check group (odds ratio 5.0; 95% confidence interval 0.90 to 27.74). Fifty-four percent of nurses in the single-check group detected the wrong vial error compared with 100% of nurses in the double-check group (odds ratio 19.9; 95% confidence interval 1.0 to 408.5).

Conclusion : Our study demonstrates that nurses use double checks before administering high-alert medications. Use of a double check increases certain error detection rates in some circumstances, but not others. Both techniques missed many errors. In some cases, the second nurse actually dissuaded the first nurse from acting on the error.

Conclusion (proposition de traduction) : Notre étude démontre que les infirmières effectuent des doubles vérifications avant d'administrer des médicaments très actifs. L'utilisation d'une double vérification augmente certains taux de détection d'erreur dans certaines circonstances, mais pas dans d'autres. Les deux techniques ont manqué de nombreuses erreurs. Dans certains cas, la deuxième infirmière a effectivement dissuadé la première infirmière d'agir en fonction de l'erreur.

Safety Considerations and Guideline-Based Safe Use Recommendations for "Bolus-Dose" Vasopressors in the Emergency Department.
Holden D, Ramich J, Timm E, Pauze D, Lesar T. | Ann Emerg Med. 2018 Jan;71(1):83-92
Keywords: Aucun

Patient safety/Concepts

Editorial : The use of intermittently administered doses of vasopressors to correct hypotension in the emergency department (ED), commonly referred to as bolus-dose pressors, push-dose pressors, Neo-sticks, or phenyl sticks, has been widely advocated outside of the traditional printed medical literature. No outcomes data of this practice exist to demonstrate benefits over traditional continuous infusion of vasopressors. Use of bolus-dose vasopressors in the ED setting raises a number of patient safety concerns, and misuse and errors in the preparation and administration of bolus-dose vasopressors may result in patient harm. A systems-based approach should be implemented to maximize safety and patient benefits if bolus-dose vasopressors are used. This article discusses the wide range of issues to consider when evaluating the role of bolus-dose vasopressors in the ED and provides recommendations based on current safe medication practices guidelines.

Conclusion : Despite the apparent common use of bolus-dose vasopressors in the ED setting, no data are available to demonstrate outcome or safety benefits over other patient management strategies. Use of bolus-dose vasopressors in the ED presents a number of safety challenges generally not present in the operating room, where use of these vasopressors is more commonplace. As with all medications, a comprehensive systems-based approach should be used to assess risks and benefits of bolus-dose vasopressors in the ED. The clinical, pharmaceutical, operational, and safety concerns discussed within this article must be considered and addressed by each organization choosing to allow use of bolus-dose vasopressors in the ED. Many of the safety considerations and related concerns with bolus-dose vasopressors can be addressed through application of widely available and accepted safe medication practices.

Conclusion (proposition de traduction) : Malgré l'utilisation apparemment fréquente des vasopresseurs en bolus dans les services d'urgences, aucune donnée n'est disponible pour démontrer les résultats ou les avantages en termes de sécurité par rapport aux autres stratégies d'administration. L'utilisation de vasopresseurs en bolus dans les services d'urgences pose un certain nombre de problèmes de sécurité qui ne sont généralement pas présents en salle d'opération, où l'utilisation de ces vasopresseurs est plus courante. Comme pour tous les médicaments, une approche globale systémique devrait être utilisée pour évaluer les risques et les avantages des vasopresseurs en bolus aux urgences. Les problèmes cliniques, pharmaceutiques, opérationnels et de sécurité abordés dans le présent article doivent être pris en compte et traités par chaque organisation qui choisit de permettre l’utilisation de vasopresseurs en bolus aux urgences. Un grand nombre des considérations de sécurité et des préoccupations associées aux vasopresseurs en bolus peuvent être résolus par l'application de pratiques de médication sans danger largement disponibles et acceptées.

Bolus-Dose Vasopressors in the Emergency Department: First, Do No Harm; Second, More Evidence Is Needed.
Cole JB | Ann Emerg Med. 2018 Jan;71(1):93-95
Keywords: Aucun

Patient safety/Editorial

Editorial : In this issue of Annals, Holden et al introduce safety considerations and guideline-based recommendations for the use of bolus-dose vasopressors in the ED. Although literature on the use of bolus-dose vasopressors in the ED is still in its infancy, they advocate a “systems-based” approach to balance patient safety and benefits. Their article also raises the question of whether social media has encouraged the use of bolus-dose vasopressors in the ED ahead of sufficient supporting evidence.

Conclusion : As it achieves popularity ahead of supporting science and literature, the practice of using bolus-dose vasopressors in the ED needs a framework to keep patients safe. Holden et al offer an approach that takes into account the difficulty of dose calculations and drug dilution under pressure. It is an important first step.

Conclusion (proposition de traduction) : Comme il gagne en popularité avant d'être validé au niveau scientifique et dans la littérature, la pratique consistant à utiliser des vasopresseurs en bolus aux urgences nécessite un cadre pour assurer la sécurité des patients. Holden et al. proposent une approche qui prend en compte la difficulté du calcul de la dose et de la dilution du médicament sous pression. C'est un premier pas important.

Ibutilide Effectiveness and Safety in the Cardioversion of Atrial Fibrillation and Flutter in the Community Emergency Department.
Vinson DR, Lugovskaya N, Warton EM, Rome AM, Stevenson MD, Reed ME, Nagam MR, Ballard DW; Pharm CAFÉ Investigators of the CREST Network. | Ann Emerg Med. 2018 Jan;71(1):96-108.e2
Keywords: Aucun

Original research article

Introduction : Little is known about the use of ibutilide for cardioversion in atrial fibrillation and flutter outside of clinical trials. We seek to describe patient characteristics, ibutilide administration patterns, cardioversion rates, and adverse outcomes in the community emergency department (ED) setting. We also evaluate potential predictors of cardioversion success.

Méthode : Using a retrospective cohort of adults who received ibutilide in 21 community EDs between January 2009 and June 2015, we gathered demographic and clinical variables from electronic health records and structured manual chart review. We calculated rates of cardioversion and frequency of ventricular tachycardia within 4 hours and estimated adjusted odds ratios (aOR) in a multivariate regression model for potential predictors of cardioversion.

Résultats : Among 361 patients, the median age was 61 years (interquartile range 53 to 71 years) and most had recent-onset atrial fibrillation and flutter (98.1%). Five percent of the cohort had a history of heart failure. The initial QTc interval was prolonged (>480 ms) in 29.4% of patients, and 3.1% were hypokalemic (<3.5 mEq/L). The mean ibutilide dose was 1.5 mg (SD 0.5 mg) and the rate of ibutilide-related cardioversion within 4 hours was 54.8% (95% confidence interval [CI] 49.6% to 60.1%), 50.5% for atrial fibrillation and 75.0% for atrial flutter. Two patients experienced ventricular tachycardia (0.6%), both during their second ibutilide infusion. Age (in decades) (aOR 1.3; 95% CI 1.1 to 1.5), atrial flutter (versus atrial fibrillation) (aOR 2.7; 95% CI 1.4 to 5.1), and no history of atrial fibrillation and flutter (aOR 2.0; 95% CI 1.2 to 3.1) were associated with cardioversion.

Conclusion : The effectiveness and safety of ibutilide in this community ED setting were consistent with clinical trial results despite less stringent patient selection criteria.

Conclusion (proposition de traduction) : L'efficacité et l'innocuité de l'ibutilide dans ce contexte d'urgence communautaire étaient concordant avec les résultats des essais cliniques malgré des critères de sélection de patients moins rigoureux

Commentaire : L'ibutilide (CORVERT, réservé à l'usage hospitalier) est un antiarythmique de classe III (comme l'amiodarone). Il est indiqué dans la réduction, en rythme sinusal, de la fibrillation atriale ou du flutter auriculaire récents.

External Defibrillator Damage Associated With Attempted Synchronized Dual-Dose Cardioversion.
Gerstein NS, McLean AR, Stecker EC, Schulman PM. | Ann Emerg Med. 2018 Jan;71(1):109-112
Keywords: Aucun

Cardiology/Case report

Editorial : The simultaneous use of 2 external defibrillators to administer either dual or sequential cardioversion or defibrillation for refractory cardiac arrhythmias is increasing in both the out-of-hospital and inhospital settings. Using 2 defibrillators to administer higher energy levels than can be achieved with a single defibrillator is considered off-label and is currently not part of published advanced cardiac life support guidelines. We report the first case in which the use of dual-dose cardioversion was associated with external defibrillator damage. Because defibrillator damage, especially if undetected, jeopardizes patient safety and off-label medical product use may void the manufacturer's warranty, this case should urge users to proceed with caution when contemplating this technique.

Conclusion : In summary, this case illustrates that the simultaneous use of 2 defibrillators can potentially be associated with defibrillator malfunction or damage. This is an important concern, given the increasing number of reports describing dual-dose cardioversion and defibrillation. Defibrillator damage has both cost and patient safety implications. Because the true efficacy of dual-dose cardioversion or defibrillation has yet to be demonstrated with high-quality evidence and remains an off-label use, hospitals and EMS agencies may wish to develop guidelines to ensure appropriate use of this technique and reliable subsequent device function in the context of manufacturer-specific warranty practices. A protocol for routine device testing to ensure device functionality after each off-label use would be one such option.

Conclusion (proposition de traduction) : En résumé, ce cas montre que l’utilisation simultanée de 2 défibrillateurs peut potentiellement être associée à un dysfonctionnement du défibrillateur ou à des dommages. Ceci est une préoccupation importante, étant donné le nombre croissant de rapports décrivant la cardioversion à double dose et la défibrillation. Les dommages causés par le défibrillateur ont des conséquences en termes de coût et de sécurité des patients. Parce que l'efficacité réelle de la cardioversion ou de la défibrillation à double dose n'a pas encore été démontrée avec des preuves de haute qualité et qu'elle reste une utilisation non conforme, les hôpitaux et les agences de secouristes pourraient souhaiter élaborer des directives pour garantir l'utilisation appropriée de cette technique et une fonction fiable du dispositif dans le contexte des pratiques de garantie spécifiques au fabricant. Un protocole pour les tests de routine des périphériques afin de garantir leur fonctionnalité après chaque utilisation non conforme constituerait l'une de ces options.

What Baseline Clinical Features Are Associated With Survival or Good Neurologic Outcome After Extracorporeal Cardiopulmonary Resuscitation?.
Reynolds JC, Singer B. | Ann Emerg Med. 2018 Jan;71(1):120-121
Keywords: Aucun

Cardiology/Systematic review snapshot

Introduction : Data sources included MEDLINE (2000 to 2016), references of relevant articles and previously published reviews, and experts in the field for article recommendations or unpublished work.

Méthode : Observational and experimental studies (!10 subjects) of extracorporeal CPR during cardiac arrest and a case mix of at least 50% out-of-hospital cardiac arrest were used. Studies comparing extracorporeal CPR and conventional CPR were excluded.

Résultats : Two investigators extracted data after independently assessing each study for methodological quality, using the Quality in Prognosis Studies tool. Using random-effects models, the authors calculated summary estimates of prespecified clinical variables and their association with favorable outcome (favorable neurologic status [or survival for studies that did not assess neurologic status] at the longest available follow-up interval).

Conclusion : In refractory out-of-hospital cardiac arrest patients, initial shockable cardiac rhythm, shorter cardiopulmonary resuscitation (CPR) duration, higher admission arterial pH, and lower admission serum lactate level may help predict favorable outcome after extracorporeal CPR.

Conclusion (proposition de traduction) : Chez les patients en arrêt cardiaque réfractaire en extra-hospitalier, le rythme cardiaque initial, la durée de réanimation cardio-pulmonaire (CPR), le pH artériel à l'admission et le taux sérique de lactate peuvent aider à prédire un résultat favorable après une RCP extracorporelle.

Can a Negative High-Sensitivity Troponin Result Rapidly Rule Out Acute Myocardial Infarction?.
Finnerty NM, Weinstock MB. | Ann Emerg Med. 2018 Jan;71(1):122-124
Keywords: Aucun

Cardiology/Systematic review snapshot

Editorial : A single, undetectable, high-sensitivity, cardiac troponin T (hs-cTnT) test in combination with a nonischemic ECG result may effectively rule out acute myocardial infarction in emergency department (ED) patients presenting greater than 3 hours after symptom onset.

Conclusion (proposition de traduction) : Un résultat de troponine T unique, indétectable et à haute sensibilité associé à un résultat ECG non ischémique peut exclure un infarctus aigu du myocarde chez les patients en service d'urgences se présentant plus de 3 heures après l'apparition des signes cliniques.

Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial.
Barniol C, Dehours E, Mallet J, Houze-Cerfon CH, Lauque D, Charpentier S. | Ann Emerg Med. 2018 Jan;71(1):125-131.e1
Keywords: Aucun

Original research article

Introduction : We evaluate the efficacy of a 4-day course of prednisone added to antihistamine for the management of acute urticaria in an emergency department (ED).

Méthode : In this double-blind randomized clinical trial, patients were eligible for inclusion if aged 18 years or older and with acute urticaria of no more than 24 hours' duration. Patients with anaphylaxis or who had received antihistamines or glucocorticoids during the previous 5 days were not included. In addition to levocetirizine (5 mg orally for 5 days), patients were assigned to receive prednisone (40 mg orally for 4 days) or placebo. The primary endpoint of the study was itching relief 2 days after the ED visit, rated on a numeric scale of 0 to 10. Secondary endpoints were rash resolution, relapses, and adverse events.

Résultats : A total of 100 patients were included, 50 in each group. Seven patients in the prednisone group and 8 in the placebo group discontinued treatment. At 2-day follow-up, 62% of patients in the prednisone group had an itch score of 0 versus 76% of those in the placebo group (Δ 14%; 95% confidence interval -31% to 4%). Thirty percent of patients in the prednisone group and 24% in the placebo group reported relapses (Δ 6%; 95% confidence interval -23% to 11%). Mild adverse events were reported by 12% of patients in the prednisone group and 14% in the placebo group.

Conclusion : The addition of a prednisone burst did not improve the symptomatic and clinical response of acute urticaria to levocetirizine. This study does not support the addition of corticosteroid to H1 antihistamine as first-line treatment of acute urticaria without angioedema.

Conclusion (proposition de traduction) : L'association d'un bolus de prednisone au lévocétirizine n'a pas amélioré la symptomatologie ni la réponse clinique dans l'urticaire aiguë. Cette étude ne recommande pas l' association de corticostéroïdes aux antihistaminiques H1 comme traitement de première intention de l'urticaire aiguë sans angio-œdème.

How Safe Is the Ultrasonographically Guided Peripheral Internal Jugular Line?.
Gottlieb M, Russell FM. | Ann Emerg Med. 2018 Jan;71(1):132-137
Keywords: Aucun

Review article

Editorial : Vascular access is an essential procedure in the emergency department (ED). In patients with difficult intravenous access, alternatives to the traditional blind cannulation should be considered, including cannulation of an external jugular vein, a peripheral vein in the upper or lower extremity with real-time ultrasonographic guidance, or a central vein with ultrasonographic guidance. Intraosseous lines and venous cutdowns may also be considered for unstable patients. However, even with ultrasonographic guidance, peripheral venous cannulation may be unsuccessful and central venous cannulation is both time consuming and associated with potential complications, including infection, thrombosis, pneumothorax, and arterial injury. The peripheral internal jugular line is another option for vascular access that was originally described in 2009. This procedure involves placement of a single-lumen peripheral catheter into the internal jugular vein, using real-time ultrasonographic guidance. The peripheral internal jugular may be safe, quickly placed, and obviate the need for central line placement in patients with difficult intravenous access. However, it is important to ensure that this technique is safe and reliable before routine clinical application. The objective of this article is to provide a summary of the current evidence about the efficacy and safety of placing ultrasonographically-guided peripheral internal jugular venous lines.

Conclusion : -

Are α-Blockers Beneficial for Outpatient Management of Uncomplicated Ureteric Stones?.
Harrison N, Babcock C. | Ann Emerg Med. 2018 Jan;71(1):138-140
Keywords: Aucun

General medicine/Systematic review snapshot

Editorial : a-Blockers may accelerate passage and prevent complications such as hospital admission or surgery when ureteric stones are 5 to 10 mm, but there is no evidence to support their use in stones less than 5 mm. Benefits appear to be similar regardless of location in the ureter.

Conclusion (proposition de traduction) : Les α-bloquants pourraient accélérer l’élimination et prévenir les complications telles que l'hospitalisation ou la chirurgie lorsque les lithiases urinaires mesurent de 5 à 10 mm, mais rien ne prouve leur intérêt pour des calculs de moins de 5 mm. Les avantages semblent similaires quel que soit l'emplacement de la lithiases dans l'uretère.

What Is the Efficacy of Droperidol for the Management of Acute Psychosis-Induced Agitation?.
Gottlieb M, Schiebout J. | Ann Emerg Med. 2018 Jan;71(1):141-143
Keywords: Aucun

General medicine/Systematic review snapshot

Editorial : Droperidol is effective for the treatment of acute psychosis-induced aggression or agitation, with a low risk of adverse events compared with placebo, olanzapine, haloperidol, and midazolam.

Conclusion (proposition de traduction) : Le droperidol est efficace pour le traitement de l'agression ou de l'agitation induite par la psychose aiguë, avec un faible risque d'effets indésirables par rapport au placebo, à l'olanzapine, à l'halopéridol et au midazolam.

BMC Emergency Medicine

Management and outcomes of patients presenting with sepsis and septic shock to the emergency department during nursing handover: a retrospective cohort study.
Alsolamy S, Al-Sabhan A, Alassim N, Sadat M, Qasim EA, Tamim H, Arabi YM. | BMC Emerg Med. 2018 Jan 18;18(1):3
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Research Article

Introduction : Clinical handover is an important process for the transition of patient-care responsibility to the next healthcare provider, but it may divert the attention of the team away from active patients. This is challenging in the Emergency Department (ED) because of highly dynamic patient conditions and is likely relevant in conditions that requires time-sensitive therapies, such as sepsis. We aimed to examine the management and outcomes of patients presenting with sepsis and septic shock to the ED during nursing handover.

Méthode : This retrospective cohort study was conducted at a 115-bed ED and more than 200,000 annual ED visits, within a 900-bed academic tertiary care center. Data on Surviving Sepsis Campaign (SSC) bundle elements and hospital mortality were collected for all ≥14-year-old patients who presented to the ED with a diagnosis of sepsis and septic shock between January 1, 2011 and October 30, 2013. Our primary outcome was time to antibiotics, were other SSC bundle elements and mortality counted as secondary outcomes. Patients were divided into two groups: 1) handover time group, comprising patients who presented an hour before or after the start of handover time (6-8 AM/PM), and 2) non-handover time group, comprising patients who presented over the remaining 20 h.

Résultats : During the study period, 1330 patients presented with sepsis or septic shock (228, handover time group; 1102, non-handover time group). No significant differences were found between the handover time and non-handover time groups, respectively, in median time to antibiotic administration (100 [interquartile range (IQR) 57-172] vs. 95 [IQR 50-190] minutes; P = 0.07), median time to serum lactate result (162 [IQR 108-246] vs. 156 [IQR 180-246] minutes; P = 0.33) and median time to obtain blood culture (54 [IQR 36-119] vs. 52 [IQR 28-103] minutes; P = 0.52), and hospital mortality rate (29.4% vs. 28.9%; P = 0.89).

Conclusion : No significant differences were found in median time of SSC bundle elements or hospital mortality between patients who presented during the handover and non-handover times.

Conclusion (proposition de traduction) : Aucune différence significative n'a été trouvée dans le temps médian de prise en charge du sepsis ou pour la mortalité hospitalière de ces patients, entre ceux qui se sont présentés pendant les périodes de transmission et ceux qui se sont présenté en dehors de celle-ci.

Implementing blended learning in emergency airway management training: a randomized controlled trial.
Kho MHT, Chew KS, Azhar MN, Hamzah ML, Chuah KM, Bustam A, Chan HC. | BMC Emerg Med. 2018 Jan 15;18(1):1
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Keywords: Aucun

Research Article

Introduction : While emergency airway management training is conventionally conducted via face-to-face learning (F2FL) workshops, there are inherent cost, time, place and manpower limitations in running such workshops. Blended learning (BL) refers to the systematic integration of online and face-to-face learning aimed to facilitate complex thinking skills and flexible participation at a reduced financial, time and manpower cost. This study was conducted to evaluate its effectiveness in emergency airway management training.

Méthode : A single-center prospective randomised controlled trial involving 30 doctors from Sarawak General Hospital, Malaysia was conducted from September 2016 to February 2017 to compare the effectiveness of BL versus F2FL for emergency airway management training. Participants in the BL arm were given a period of 12 days to go through the online materials in a learning management system while those in the F2FL arm attended a-day of face-to-face lectures (8 h). Participants from both arms then attended a day of hands-on session consisting of simulation skills training with airway manikins. Pre- and post-tests in knowledge and practical skills were administered. E-learning experience and the perception towards BL among participants in the BL arm were also assessed.

Résultats : Significant improvements in post-test scores as compared to pre-test scores were noted for participants in both BL and F2FL arms for knowledge, practical, and total scores. The degree of increment between the BL group and the F2FL arms for all categories were not significantly different (total scores: 35 marks, inter-quartile range (IQR) 15.0 - 41.0 vs. 31 marks, IQR 24.0 - 41.0, p = 0.690; theory scores: 18 marks, IQR 9 - 24 vs. 19 marks, IQR 15 - 20, p = 0.992; practical scores: 11 marks, IQR 5 -18 vs. 10 marks, IQR 9 - 20, p = 0.461 respectively). The overall perception towards BL was positive.

Conclusion : Blended learning is as effective as face-to-face learning for emergency airway management training of junior doctors, suggesting that blended learning may be a feasible alternative to face-to-face learning for such skill training in emergency departments.

Conclusion (proposition de traduction) : L'apprentissage mixte est aussi efficace que l'apprentissage en face-à-face pour la formation à la gestion des voies respiratoires d'urgence des jeunes médecins, suggérant que l'apprentissage mixte peut être une alternative possible à l'apprentissage en face à face.

Commentaire : Etude mono-centrique randomisée. La formation consiste en une formation en ligne de 12 jours assortie d'une formation en présidentielle de 8 heures. La validation se fait sur mannequin.


Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report.
Irwin RS, French CL, Chang AB, Altman KW; CHEST Expert Cough Panel. | Chest. 2018 Jan;153(1):196-209
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Evidence-Based Medicine

Introduction : We performed systematic reviews using the population, intervention, comparison, outcome (PICO) format to answer the following key clinical question: Are the CHEST 2006 classifications of acute, subacute and chronic cough and associated management algorithms in adults that were based on durations of cough useful?

Méthode : We used the CHEST Expert Cough Panel's protocol for the systematic reviews and the American College of Chest Physicians (CHEST) methodological guidelines and Grading of Recommendations Assessment, Development, and Evaluation framework. Data from the systematic reviews in conjunction with patient values and preferences and the clinical context were used to form recommendations or suggestions. Delphi methodology was used to obtain the final grading.

Résultats : With respect to acute cough (< 3 weeks), only three studies met our criteria for quality assessment, and all had a high risk of bias. As predicted by the 2006 CHEST Cough Guidelines, the most common causes were respiratory infections, most likely of viral cause, followed by exacerbations of underlying diseases such as asthma and COPD and pneumonia. The subjects resided on three continents: North America, Europe, and Asia. With respect to subacute cough (duration, 3-8 weeks), only two studies met our criteria for quality assessment, and both had a high risk of bias. As predicted by the 2006 guidelines, the most common causes were postinfectious cough and exacerbation of underlying diseases such as asthma, COPD, and upper airway cough syndrome (UACS). The subjects resided in countries in Asia. With respect to chronic cough (> 8 weeks), 11 studies met our criteria for quality assessment, and all had a high risk of bias. As predicted by the 2006 guidelines, the most common causes were UACS from rhinosinus conditions, asthma, gastroesophageal reflux disease, nonasthmatic eosinophilic bronchitis, combinations of these four conditions, and, less commonly, a variety of miscellaneous conditions and atopic cough in Asian countries. The subjects resided on four continents: North America, South America, Europe, and Asia.

Conclusion : Although the quality of evidence was low, the published literature since 2006 suggests that CHEST's 2006 Cough Guidelines and management algorithms for acute, subacute, and chronic cough in adults appeared useful in diagnosing and treating patients with cough around the globe. These same algorithms have been updated to reflect the advances in cough management as of 2017.

Conclusion (proposition de traduction) : Bien que la qualité des preuves soit faible, la littérature publiée depuis 2006 suggère que les lignes directrices 2006 de la CHEST et les algorithmes de prise en charge de la toux aiguë, subaiguë et chronique chez les adultes ont semblé utiles pour diagnostiquer et traiter les patients partout dans le monde. Ces mêmes algorithmes ont été mis à jour pour refléter les progrès de la gestion de la toux à partir de 2017.

Better With Ultrasound: Pleural Procedures in Critically Ill Patients.
Millington SJ, Koenig S. | Chest. 2018 Jan;153(1):224-232
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Special Features

Editorial : Procedures designed to drain fluid or air from the pleural spaces can be technically challenging in patients who are critically ill, and are associated with significant complications. Many individual ultrasound techniques have been described, each with the goal of making pleural drainage procedures safer. This article presents a systemic approach for incorporating many of these tools into procedures such as diagnostic thoracentesis, therapeutic drainage, and pleural catheter insertion. A series of illustrative figures and narrated video presentations are included to demonstrate many of the described techniques.

Conclusion (proposition de traduction) : Les procédures conçues pour drainer le liquide ou l'air des espaces pleuraux peuvent être techniquement difficiles chez les patients gravement malades et associées à des complications significatives. De nombreuses techniques d'échographie ont été décrites, chacune dans le but de rendre les procédures de drainage pleural plus sûres. Cet article présente une approche systémique pour incorporer plusieurs de ces outils dans des procédures telles que la thoracocentèse diagnostique, le drainage thérapeutique et la ponction pleurale. Une série de figures illustratives et de présentations vidéo sont incluses pour illustrer bon nombre des techniques décrites.

Commentaire : Belle présentation avec une iconographie de qualité. Une publication supplémentaire sur l'intérêt de l'échographie en médecine au lit du malade, et notamment, en remplacement de la radiographie standard du thorax.

Clinical Practice and Infrastructure Review of Fecal Microbiota Transplantation for Clostridium difficile Infection.
Kelly BJ, Tebas P. | Chest. 2018 Jan;153(1):266-277
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Topics in Practice Management

Editorial : A substantial proportion of Clostridium difficile infection (CDI) cases recur after completion of antibiotic therapy, and antibiotic cure rates diminish with each recurrence of CDI. Fecal microbiota transplantation (FMT) is an effective therapy for recurrent FMT, which otherwise requires prolonged or indefinite antibiotic treatment. FMT is performed by introducing the fecal microbial community obtained from a healthy donor or pool of donors into the stomach, small intestine, or colon of a patient with CDI. Multiple clinical trials support the usefulness of FMT in treating recurrent CDI, and CDI treatment guidelines now include consideration of FMT at the third CDI recurrence. However, there remain challenges to incorporating FMT into clinical practice. First, methods of fecal bacterial community processing vary, as do methods of FMT administration. Second, the optimal dosing strategy and expected benefit of FMT for refractory CDI, particularly for severe and severe complicated cases, are uncertain. Third, the US Food and Drug Administration (FDA) considers FMT an investigational treatment. Fourth, insurance reimbursement for FMT usually falls short of FMT administration costs. In the setting of rising C difficile incidence and growing evidence for FMT efficacy, the demand for FMT has increased. However, uncertainty surrounding optimal FMT preparation and administration methods, FDA oversight, and insurance reimbursement presently limits the clinical practice of FMT.

Conclusion : -


2017 American Heart Association Focused Update on Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Atkins DL, de Caen AR, Berger S, Samson RA, Schexnayder SM, Joyner BL Jr, Bigham BL, Niles DE, Duff JP, Hunt EA, Meaney PA. | Circulation. 2018 Jan 2;137(1):e1-e6
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Clinical Statements and Guidelines

Editorial : This focused update to the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care follows the Pediatric Task Force of the International Liaison Committee on Resuscitation evidence review. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, and updates are published when the International Liaison Committee on Resuscitation completes a literature review based on new science. This update provides the evidence review and treatment recommendation for chest compression-only CPR versus CPR using chest compressions with rescue breaths for children <18 years of age. Four large database studies were available for review, including 2 published after the "2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care." Two demonstrated worse 30-day outcomes with chest compression-only CPR for children 1 through 18 years of age, whereas 2 studies documented no difference between chest compression-only CPR and CPR using chest compressions with rescue breaths. When the results were analyzed for infants <1 year of age, CPR using chest compressions with rescue breaths was better than no CPR but was no different from chest compression-only CPR in 1 study, whereas another study observed no differences among chest compression-only CPR, CPR using chest compressions with rescue breaths, and no CPR. CPR using chest compressions with rescue breaths should be provided for infants and children in cardiac arrest. If bystanders are unwilling or unable to deliver rescue breaths, we recommend that rescuers provide chest compressions for infants and children.

Conclusion : -

Commentaire : Mise à jour également consultable depuis le site Internet de l'ILCOR  

2017 American Heart Association Focused Update on Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care..
Kleinman ME, Goldberger ZD, Rea T, Swor RA, Bobrow BJ, Brennan EE, Terry M, Hemphill R, Gazmuri RJ, Hazinski MF, Travers AH. | Circulation. 2018 Jan 2;137(1):e7-e13
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Clinical Statements and Guidelines

Editorial : Cardiopulmonary resuscitation is a lifesaving technique for victims of sudden cardiac arrest. Despite advances in resuscitation science, basic life support remains a critical factor in determining outcomes. The American Heart Association recommendations for adult basic life support incorporate the most recently published evidence and serve as the basis for education and training for laypeople and healthcare providers who perform cardiopulmonary resuscitation.

Conclusion : -

Commentaire : Attention, erratum in : Correction to: 2017 American Heart Association Focused Update on Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care  .

Confusion Around Therapeutic Temperature Management Hypothermia After In-Hospital Cardiac Arrest?.
Polderman KH, Varon J. | Circulation. 2018 Jan 16;137(3):219-221
Keywords: Aucun


Editorial : Over the past 15 years, therapeutic temperature management (TTM) has become an increasingly important goal of care in critically ill patients with acute brain injury. TTM (initially defined as cooling to 32oC−34oC) was used with increasing frequency to treat patients with postanoxic/hypoxic encephalopathy caused by catastrophic events such as neonatal asphyxia or cardiac arrest (CA). In the case of CA, using TTM was supported by the results of 2 randomized controlled trials and 45 nonrandomized (mostly before/after) studies. Guidelines from the American Heart Association and European Resuscitation Council have recommended the use of TTM for postanoxic injury after witnessed CA since 2003, and after an initially slow uptake, especially in the United States, application and implementation of these guidelines increased significantly in recent years, with growing consensus on the importance of TTM. However, this trend is currently under threat. In 2013, a large randomized controlled trial by Nielsen and coworkers reported that outcomes in patients with CA cooled to 33oC were not better than in patients cooled to 36oC, leading to a highly contentious debate in the TTM field. Strong opinions on this issue range from accepting the results of the Nielsen study and changing the target temperature to 36oC to staying with a target of 32oC−33oC because of perceived problems with the trial. We support the latter view and have criticized the Nielsen study in these pages for possible selection bias, up to 4-hour delays in initiation of cooling, prolonged (average 10 hours) time…

Conclusion : -

Commentaire : Remise en question de la publication de 2013 de Nielsen (Targeted temperature management at 33°C versus 36°C after cardiac arrest  ) sur l'objectif de température à 36° C en post-ACR.

Derivation and Validation of the CREST Model for Very Early Prediction of Circulatory Etiology Death in Patients Without ST-Segment-Elevation Myocardial Infarction After Cardiac Arrest.
Bascom KE, Dziodzio J, Vasaiwala S, Mooney M, Patel N, McPherson J, McMullan P, Unger B, Nielsen N, Friberg H, Riker RR, Kern KB, Duarte CW, Seder DB; International Cardiac Arrest Registry (INTCAR). | Circulation. 2018 Jan 16;137(3):273-282
Keywords: Aucun

Original Research Articles

Introduction : No practical tool quantitates the risk of circulatory-etiology death (CED) immediately after successful cardiopulmonary resuscitation in patients without ST-segment-elevation myocardial infarction. We developed and validated a prediction model to rapidly determine that risk and facilitate triage to individualized treatment pathways.

Méthode : With the use of INTCAR (International Cardiac Arrest Registry), an 87-question data set representing 44 centers in the United States and Europe, patients were classified as having had CED or a combined end point of neurological-etiology death or survival. Demographics and clinical factors were modeled in a derivation cohort, and backward stepwise logistic regression was used to identify factors independently associated with CED. We demonstrated model performance using area under the curve and the Hosmer-Lemeshow test in the derivation and validation cohorts, and assigned a simplified point-scoring system.

Résultats : Among 638 patients in the derivation cohort, 121 (18.9%) had CED. The final model included preexisting coronary artery disease (odds ratio [OR], 2.86; confidence interval [CI], 1.83-4.49; P≤0.001), nonshockable rhythm (OR, 1.75; CI, 1.10-2.77; P=0.017), initial ejection fraction<30% (OR, 2.11; CI, 1.32-3.37; P=0.002), shock at presentation (OR, 2.27; CI, 1.42-3.62; P<0.001), and ischemic time >25 minutes (OR, 1.42; CI, 0.90-2.23; P=0.13). The derivation model area under the curve was 0.73, and Hosmer-Lemeshow test P=0.47. Outcomes were similar in the 318-patient validation cohort (area under the curve 0.68, Hosmer-Lemeshow test P=0.41). When assigned a point for each associated factor in the derivation model, the average predicted versus observed probability of CED with a CREST score (coronary artery disease, initial heart rhythm, low ejection fraction, shock at the time of admission, and ischemic time >25 minutes) of 0 to 5 was: 7.1% versus 10.2%, 9.5% versus 11%, 22.5% versus 19.6%, 32.4% versus 29.6%, 38.5% versus 30%, and 55.7% versus 50%.

Conclusion : The CREST model stratified patients immediately after resuscitation according to risk of a circulatory-etiology death. The tool may allow for estimation of circulatory risk and improve the triage of survivors of cardiac arrest without ST-segment-elevation myocardial infarction at the point of care.

Conclusion (proposition de traduction) : Le modèle CREST a stratifié les patients immédiatement après la réanimation en fonction du risque de décès par étiologie circulatoire. L'outil peut permettre d'estimer le risque circulatoire et d'améliorer le triage des survivants d'un arrêt cardiaque sans infarctus du myocarde avec élévation du segment ST au point d'intervention.

Prognostic Value of High-Sensitivity Troponin T in Chronic Heart Failure.
Aimo A, Januzzi JL Jr, Vergaro G, Ripoli A, Latini R, Masson S, Magnoli M, Anand IS, Cohn JN, Tavazzi L, Tognoni G, Gravning J, Ueland T, Nymo SH, Brunner-La Rocca HP, Bayes-Genis A, Lupón J, de Boer RA, Yoshihisa A, Takeishi Y, Egstrup M, Gustafsson I, Gaggin HK, Eggers KM, Huber K, Tentzeris I, Tang WHW, Grodin J, Passino C, Emdin M. | Circulation. 2018 Jan 16;137(3):286-297
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Systematic Review

Introduction : Most patients with chronic heart failure have detectable troponin concentrations when evaluated by high-sensitivity assays. The prognostic relevance of this finding has not been clearly established so far. We aimed to assess high-sensitivity troponin assay for risk stratification in chronic heart failure through a meta-analysis approach.

Méthode : Medline, EMBASE, Cochrane Library, and Scopus were searched in April 2017 by 2 independent authors. The terms were "troponin" AND "heart failure" OR "cardiac failure" OR "cardiac dysfunction" OR "cardiac insufficiency" OR "left ventricular dysfunction." Inclusion criteria were English language, clinical stability, use of a high-sensitivity troponin assay, follow-up studies, and availability of individual patient data after request to authors. Data retrieved from articles and provided by authors were used in agreement with the PRISMA statement. The end points were all-cause death, cardiovascular death, and hospitalization for cardiovascular cause.

Résultats : Ten studies were included, reporting data on 11 cohorts and 9289 patients (age 66±12 years, 77% men, 60% ischemic heart failure, 85% with left ventricular ejection fraction <40%). High-sensitivity troponin T data were available for all patients, whereas only 209 patients also had high-sensitivity troponin I assayed. When added to a prognostic model including established risk markers (sex, age, ischemic versus nonischemic etiology, left ventricular ejection fraction, estimated glomerular filtration rate, and N-terminal fraction of pro-B-type natriuretic peptide), high-sensitivity troponin T remained independently associated with all-cause mortality (hazard ratio, 1.48; 95% confidence interval, 1.41-1.55), cardiovascular mortality (hazard ratio, 1.40; 95% confidence interval, 1.33-1.48), and cardiovascular hospitalization (hazard ratio, 1.42; 95% confidence interval, 1.36-1.49), over a median 2.4-year follow-up (all P<0.001). High-sensitivity troponin T significantly improved risk prediction when added to a prognostic model including the variables above. It also displayed an independent prognostic value for all outcomes in almost all population subgroups. The area under the curve-derived 18 ng/L cutoff yielded independent prognostic value for the 3 end points in both men and women, patients with either ischemic or nonischemic etiology, and across categories of renal dysfunction.

Conclusion : In chronic heart failure, high-sensitivity troponin T is a strong and independent predictor of all-cause and cardiovascular mortality, and of hospitalization for cardiovascular causes, as well. This biomarker then represents an additional tool for prognostic stratification.

Conclusion (proposition de traduction) : ans l'insuffisance cardiaque chronique, la troponine T ultra-sensible est un paramètre prédictif fort et indépendant de la mortalité toutes causes confondues, et en particulier, de la mortalité cardiovasculaire, ainsi que du recours à l'hospitalisation pour des causes cardiovasculaires. Ce biomarqueur représente alors un outil supplémentaire de stratification pronostique.

Routine Oxygen Supplementation in Acute Cardiovascular Disease: The End of a Paradigm?.
Hofmann R, James SK. | Circulation. 2018 Jan 23;137(4):320-322
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Editorial : In summary, we believe a paradigm shift is indicated abolishing the recommendation for general oxygen supplementation in the unselected population with acute MI or stroke without hypoxemia at baseline. Experts already call for a change of clinical practice to reflect this new evidence.5 However, future RCTs need to clarify remaining questions, such as the optimal lower limit for initiation, dosage, duration, method for delivery, and patient category with the best risk-benefit ratio. Other common cardiovascular conditions, such as congestive heart failure, are already under investigation, and it seems reasonable to assume that the number of patients MONA should greet at the door will further diminish.

Conclusion (proposition de traduction) : En résumé, nous croyons qu'un changement de paradigme est nécessaire pour supprimer de la pratique la supplémentation en oxygène systématique dans la population des patients présentant un IM aigu ou un AVC quand elle n’est pas motivée c’est-à-dire sans hypoxémie initiale. Les experts préconisent déjà un changement de pratique clinique pour prendre en compte ces nouvelles données. Cependant, de futurs études cliniques randomisées devont clarifier les questions restantes, telles que la limite inférieure optimale d'initiation de l’oxygénothérapie, le débit, la durée, le mode d'administration et la typologie des patients pour un meilleur bénéfice/risque. D'autres affections cardiovasculaires courantes, telles que l'insuffisance cardiaque congestive, sont déjà à l'étude, et il semble raisonnable de supposer que le nombre de patients concernés par le moyen mnémotechnique MONA (dans l’infarctus du myocarde : Morphine, Oxygène, Nitroglycerine et Aspirine) devrait encore diminuer.

Commentaire : Je vous propose de vous rapporter aux recommandations 2017 de l'ESC (European Society of Cardiology) sur la prise en charge du syndrome coronarien aigu avec sus-décalage du segment ST : Acute Myocardial Infarction in patients presenting with ST-segment elevation (Management of)  , page 127 en ce qui concerne la recommandation sur l'oxygénothérapie.

Impact of Regionalization of ST-Segment-Elevation Myocardial Infarction Care on Treatment Times and Outcomes for Emergency Medical Services-Transported Patients Presenting to Hospitals With Percutaneous Coronary Intervention: Mission: Lifeline Accelerator-2.
Jollis JG, Al-Khalidi HR, Roettig ML, Berger PB, Corbett CC, Doerfler SM, Fordyce CB, Henry TD, Hollowell L, Magdon-Ismail Z, Kochar A, McCarthy JJ, Monk L, O'Brien P, Rea TD, Shavadia J, Tamis-Holland J, Wilson BH, Ziada KM1, Granger CB. | Circulation. 2018 Jan 23;137(4):376-387
Keywords: Aucun

Original Research Articles

Introduction : Regional variations in reperfusion times and mortality in patients with ST-segment-elevation myocardial infarction are influenced by differences in coordinating care between emergency medical services (EMS) and hospitals. Building on the Accelerator-1 Project, we hypothesized that time to reperfusion could be further reduced with enhanced regional efforts.

Méthode : Between April 2015 and March 2017, we worked with 12 metropolitan regions across the United States with 132 percutaneous coronary intervention-capable hospitals and 946 EMS agencies. Data were collected in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network)-Get With The Guidelines Registry for quarterly Mission: Lifeline reports. The primary end point was the change in the proportion of EMS-transported patients with first medical contact to device time ≤90 minutes from baseline to final quarter. We also compared treatment times and mortality with patients treated in hospitals not participating in the project during the corresponding time period.

Résultats : During the study period, 10 730 patients were transported to percutaneous coronary intervention-capable hospitals, including 974 in the baseline quarter and 972 in the final quarter who met inclusion criteria. Median age was 61 years; 27% were women, 6% had cardiac arrest, and 6% had shock on admission; 10% were black, 12% were Latino, and 10% were uninsured. By the end of the intervention, all process measures reflecting coordination between EMS and hospitals had improved, including the proportion of patients with a first medical contact to device time of ≤90 minutes (67%-74%; P<0.002), a first medical contact to device time to catheterization laboratory activation of ≤20 minutes (38%-56%; P<0.0001), and emergency department dwell time of ≤20 minutes (33%-43%; P<0.0001). Of the 12 regions, 9 regions reduced first medical contact to device time, and 8 met or exceeded the national goal of 75% of patients treated in ≤90 minutes. Improvements in treatment times corresponded with a significant reduction in mortality (in-hospital death, 4.4%-2.3%; P=0.001) that was not apparent in hospitals not participating in the project during the same time period.

Conclusion : Organization of care among EMS and hospitals in 12 regions was associated with significant reductions in time to reperfusion in patients with ST-segment-elevation myocardial infarction as well as in in-hospital mortality. These findings support a more intensive regional approach to emergency care for patients with ST-segment-elevation myocardial infarction.

Conclusion (proposition de traduction) : L'organisation des soins dans les services d’urgence et les hôpitaux de 12 régions a été associée à des réductions significatives du temps de reperfusion chez les patients présentant un infarctus du myocarde avec sus-décalage du segment ST ainsi que pour la mortalité hospitalière. Ces résultats penche pour une approche régionale plus intensive des soins d'urgence pour les patients atteints d'un infarctus du myocarde avec sus-décalage du segment ST.

Commentaire : A comparer avec l'organisation des GHT en France...

High-Sensitivity Cardiac Troponin and the Risk Stratification of Patients With Renal Impairment Presenting With Suspected Acute Coronary Syndrome.
Miller-Hodges E, Anand A1, Shah ASV, Chapman AR, Gallacher P, Lee KK, Farrah T, Halbesma N, Blackmur JP, Newby DE, Mills NL, Dhaun N. | Circulation. 2018 Jan 30;137(5):425-435
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Keywords: Aucun

Original Research Articles

Introduction : High-sensitivity cardiac troponin testing may improve the risk stratification and diagnosis of myocardial infarction, but concentrations can be challenging to interpret in patients with renal impairment, and the effectiveness of testing in this group is uncertain.

Méthode : In a prospective multicenter study of consecutive patients with suspected acute coronary syndrome, we evaluated the performance of high-sensitivity cardiac troponin I in those with and without renal impairment (estimated glomerular filtration rate <60mL/min/1.73m2). The negative predictive value and sensitivity of troponin concentrations below the risk stratification threshold (5 ng/L) at presentation were reported for a primary outcome of index type 1 myocardial infarction, or type 1 myocardial infarction or cardiac death at 30 days. The positive predictive value and specificity at the 99th centile diagnostic threshold (16 ng/L in women, 34 ng/L in men) was determined for index type 1 myocardial infarction. Subsequent type 1 myocardial infarction and cardiac death were reported at 1 year.

Résultats : Of 4726 patients identified, 904 (19%) had renal impairment. Troponin concentrations <5 ng/L at presentation identified 17% of patients with renal impairment as low risk for the primary outcome (negative predictive value, 98.4%; 95% confidence interval [CI], 96.0%-99.7%; sensitivity 98.9%; 95%CI, 97.5%-99.9%), in comparison with 56% without renal impairment (P<0.001) with similar performance (negative predictive value, 99.7%; 95% CI, 99.4%-99.9%; sensitivity 98.4%; 95% CI, 97.2%-99.4%). The positive predictive value and specificity at the 99th centile were lower in patients with renal impairment at 50.0% (95% CI, 45.2%-54.8%) and 70.9% (95% CI, 67.5%-74.2%), respectively, in comparison with 62.4% (95% CI, 58.8%-65.9%) and 92.1% (95% CI, 91.2%-93.0%) in those without. At 1 year, patients with troponin concentrations >99th centile and renal impairment were at greater risk of subsequent myocardial infarction or cardiac death than those with normal renal function (24% versus 10%; adjusted hazard ratio, 2.19; 95% CI, 1.54-3.11).

Conclusion : In suspected acute coronary syndrome, high-sensitivity cardiac troponin identified fewer patients with renal impairment as low risk and more as high risk, but with lower specificity for type 1 myocardial infarction. Irrespective of diagnosis, patients with renal impairment and elevated cardiac troponin concentrations had a 2-fold greater risk of a major cardiac event than those with normal renal function, and should be considered for further investigation and treatment.

Conclusion (proposition de traduction) : En cas de suspicion de syndrome coronarien aigu, la troponine ultra-sensible identifie moins de patients présentant une insuffisance rénale, avec un risque faible et plus élevé, mais avec une spécificité inférieure pour l'infarctus du myocarde de type 1. Indépendamment du diagnostic, les patients présentant une insuffisance rénale et des concentrations élevées de troponine cardiaque avaient un risque deux fois plus élevé d'un événement cardiaque majeur que ceux ayant une fonction rénale normale, et devraient être considérés pour un examen plus invasif et un traitement.

0/1-Hour Triage Algorithm for Myocardial Infarction in Patients With Renal Dysfunction.
Twerenbold R, Badertscher P, Boeddinghaus J, Nestelberger T, Wildi K, Puelacher C, Sabti Z, Rubini Gimenez M, Tschirky S, du Fay de Lavallaz J, Kozhuharov N, Sazgary L, Mueller D, Breidthardt T, Strebel I, Flores Widmer D, Shrestha S, Miró Ò, Martín-Sánchez FJ, Morawiec B, Parenica J, Geigy N, Keller D, Rentsch K, von Eckardstein A, Osswald S, Reichlin T, Mueller C. | Circulation. 2018 Jan 30;137(5):436-451
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Keywords: Aucun

Original Research Articles

Introduction : The European Society of Cardiology recommends a 0/1-hour algorithm for rapid rule-out and rule-in of non-ST-segment elevation myocardial infarction using high-sensitivity cardiac troponin (hs-cTn) concentrations irrespective of renal function. Because patients with renal dysfunction (RD) frequently present with increased hs-cTn concentrations even in the absence of non-ST-segment elevation myocardial infarction, concern has been raised regarding the performance of the 0/1-hour algorithm in RD.

Méthode : In a prospective multicenter diagnostic study enrolling unselected patients presenting with suspected non-ST-segment elevation myocardial infarction to the emergency department, we assessed the diagnostic performance of the European Society of Cardiology 0/1-hour algorithm using hs-cTnT and hs-cTnI in patients with RD, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2, and compared it to patients with normal renal function. The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including cardiac imaging. Safety was quantified as sensitivity in the rule-out zone, accuracy as the specificity in the rule-in zone, and efficacy as the proportion of the overall cohort assigned to either rule-out or rule-in based on the 0- and 1-hour sample.

Résultats : Among 3254 patients, RD was present in 487 patients (15%). The prevalence of non-ST-segment elevation myocardial infarction was substantially higher in patients with RD compared with patients with normal renal function (31% versus 13%, P<0.001). Using hs-cTnT, patients with RD had comparable sensitivity of rule-out (100.0% [95% confidence interval {CI}, 97.6-100.0] versus 99.2% [95% CI, 97.6-99.8]; P=0.559), lower specificity of rule-in (88.7% [95% CI, 84.8-91.9] versus 96.5% [95% CI, 95.7-97.2]; P<0.001), and lower overall efficacy (51% versus 81%, P<0.001), mainly driven by a much lower percentage of patients eligible for rule-out (18% versus 68%, P<0.001) compared with patients with normal renal function. Using hs-cTnI, patients with RD had comparable sensitivity of rule-out (98.6% [95% CI, 95.0-99.8] versus 98.5% [95% CI, 96.5-99.5]; P=1.0), lower specificity of rule-in (84.4% [95% CI, 79.9-88.3] versus 91.7% [95% CI, 90.5-92.9]; P<0.001), and lower overall efficacy (54% versus 76%, P<0.001; proportion ruled out, 18% versus 58%, P<0.001) compared with patients with normal renal function.

Conclusion : In patients with RD, the safety of the European Society of Cardiology 0/1-hour algorithm is high, but specificity of rule-in and overall efficacy are decreased. Modifications of the rule-in and rule-out thresholds did not improve the safety or overall efficacy of the 0/1-hour algorithm.

Conclusion (proposition de traduction) : Chez les patients présentant un dysfonctionnement rénal, l'innocuité de l'algorithme 0/1 heure de la Société européenne de cardiologie est élevée, mais la spécificité des règles et l'efficacité globale sont réduites. Les modifications des seuils d’instauration et d’exclusion n’ont pas amélioré la sécurité ou l’efficacité globale de l’algorithme de 0/1 heure.

Commentaire : A propose de la validation du protocole de European Society of Cardiology (ESC), voir l'article de Twerenbold R and al. dans J Am Coll Cardiol. 2018 Aug 7;72(6):620-632  . Prospective Validation of the 0/1-h Algorithm for Early Diagnosis of Myocardial Infarction.

Clinical Infectious Diseases

Impact of Systemic Antibiotics on Staphylococcus aureus Colonization and Recurrent Skin Infection.
Hogan PG, Rodriguez M, Spenner AM, Brenneisen JM, Boyle MG, Sullivan ML, Fritz SA. | Clin Infect Dis. 2018 Jan 6;66(2):191-197
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Keywords: SSTI; Staphylococcus aureus; colonization; systemic antibiotics

Articles and commentaries

Introduction : Staphylococcus aureus colonization poses risk for subsequent skin and soft tissue infection (SSTI). We hypothesized that including systemic antibiotics in the management of S. aureus SSTI, in conjunction with incision and drainage, would reduce S. aureus colonization and incidence of recurrent infection.

Méthode : We prospectively evaluated 383 children with S. aureus SSTI requiring incision and drainage and S. aureus colonization in the anterior nares, axillae, or inguinal folds at baseline screening. Systemic antibiotic prescribing at the point of care was recorded. Repeat colonization sampling was performed within 3 months (median, 38 days; interquartile range, 22-50 days) in 357 participants. Incidence of recurrent infection was ascertained for up to 1 year.

Résultats : Participants prescribed guideline-recommended empiric antibiotics for purulent SSTI were less likely to remain colonized at follow-up sampling (adjusted hazard ratio [aHR], 0.49; 95% confidence interval [CI], .30-.79) and less likely to have recurrent SSTI (aHR, 0.57; 95% CI, .34-.94) than those not receiving guideline-recommended empiric antibiotics for their SSTI. Additionally, participants remaining colonized at repeat sampling were more likely to report a recurrent infection over 12 months (aHR, 2.37; 95% CI, 1.69-3.31). Clindamycin was more effective than trimethoprim-sulfamethoxazole (TMP-SMX) in eradicating S. aureus colonization (44% vs 57% remained colonized, P = .03) and preventing recurrent SSTI (31% vs 47% experienced recurrence, P = .008).

Conclusion : Systemic antibiotics, as part of acute SSTI management, impact S. aureus colonization, contributing to a decreased incidence of recurrent SSTI. The mechanism by which clindamycin differentially affects colonization and recurrent SSTI compared to TMP-SMX warrants further study.

Conclusion (proposition de traduction) : Les antibiotiques systémiques, dans le cadre de la gestion de l'infection aiguë de la peau et des tissus mous, ont un impact sur la colonisation de S. aureus, contribuant à une diminution de l'incidence des infections récidivantes de la peau et des tissus mous. Le mécanisme par lequel la clindamycine affecte différemment la colonisation et l'infection récurrente de la peau et des tissus mous par rapport au triméthoprime-sulfaméthoxazole justifie une étude plus poussée.

Commentaire : Cette étude comporte des limites, notamment son caractère observationnel avec de multiples biais potentiels, et le faible effectif du groupe « sans antibiotique » (n=26). Néanmoins, les résultats sont superposables à ceux obtenus par Daum RS et al. au cours d’une étude randomisée de haut niveau méthodologique portant sur les abcès sous cutané à S. aureus de taille < 5 cm (N Engl J Med 2017; 376:2545-2555  ) : les 2 antibiothérapies évaluées (clindamycine et cotrimoxazole) étaient supérieures au placebo, avec là aussi une supériorité de la clindamycine sur le cotrimoxazole en ce qui concerne le risque de récidive.
Des résultats inattendus, qui pourraient remettre en cause la non-indication d’antibiothérapie pour les abcès sous-cutanés drainés. Cependant, il faut souligner la particularité du contexte épidémiologique des Etats-Unis : 70 % des souches de cette étude sont des SARM communautaires, dont on connaît la virulence, liée à la toxine PVL. Le bénéfice de l’antibiothérapie observé ici n’est pas forcément extrapolable au contexte français, où ces souches sont rares (Rédigé par : Pr Pierre Tattevin   pour info-atbvac).

Cochrane Database of Systematic Reviews

Probiotics for preventing acute otitis media in children.
Scott AM , Beller EM, Clark J, Roos K, Grimwood K, Little P, Del Mar CB. | Cochrane Database Syst Revs. 2018 jan 31;1: CD012941
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Keywords: Aucun

Intervention Protocols

Editorial : This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of probiotics to prevent the occurrence and reduce the severity of acute otitis media in children.

Conclusion (proposition de traduction) : Évaluer les effets des probiotiques pour prévenir l'apparition et réduire la gravité de l'otite moyenne aiguë chez les enfants.

Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome.
Schumann J, Henrich EC, Strobl H, Prondzinsky R, Weiche S, Thiele H, Werdan K, Frantz S, Unverzagt S. | Cochrane Database Syst Rev. 2018 Jan 29;1:CD009669
Keywords: Aucun

Intervention Reviews

Introduction : Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) as complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery are life-threatening conditions. While there is a broad body of evidence for the treatment of people with acute coronary syndrome under stable haemodynamic conditions, the treatment strategies for people who become haemodynamically unstable or develop CS remain less clear. We have therefore summarised here the evidence on the treatment of people with CS or LCOS with different inotropic agents and vasodilative drugs. This is the first update of a Cochrane review originally published in 2014.

Méthode : To assess efficacy and safety of cardiac care with positive inotropic agents and vasodilator strategies in people with CS or LCOS due to AMI, HF or cardiac surgery.
SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in June 2017. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied.
SELECTION CRITERIA: Randomised controlled trials in people with myocardial infarction, heart failure or cardiac surgery complicated by cardiogenic shock or LCOS.
DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane.

Résultats : We identified 13 eligible studies with 2001 participants (mean or median age range 58 to 73 years) and two ongoing studies. We categorised studies into eight comparisons, all against cardiac care and additional other active drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo, epinephrine versus norepinephrine-dobutamine, amrinone versus dobutamine, dopexamine versus dopamine, enoximone versus dopamine and nitric oxide versus placebo.All trials were published in peer-reviewed journals, and analysis was done by the intention-to-treat (ITT) principle. Twelve of 13 trials were small with few included participants. Acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements emerged in five of 13 trials. In general, confidence in the results of analysed studies was reduced due to serious study limitations, very serious imprecision or indirectness. Domains of concern, which show a high risk of more than 50%, include performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events.Levosimendan may reduce short-term mortality compared to a therapy with dobutamine (RR 0.60, 95% CI 0.37 to 0.95; 6 studies; 1776 participants; low-quality evidence; NNT: 16 (patients with moderate risk), NNT: 5 (patients with CS)). This initial short-term survival benefit with levosimendan vs. dobutamine is not confirmed on long-term follow up. There is uncertainty (due to lack of statistical power) as to the effect of levosimendan compared to therapy with placebo (RR 0.48, 95% CI 0.12 to 1.94; 2 studies; 55 participants, very low-quality evidence) or enoximone (RR 0.50, 95% CI 0.22 to 1.14; 1 study; 32 participants, very low-quality evidence).All comparisons comparing other positive inotropic, inodilative or vasodilative drugs presented uncertainty on their effect on short-term mortality with very low-quality evidence and based on only one RCT. These single studies compared epinephrine with norepinephrine-dobutamine (RR 1.25, 95% CI 0.41 to 3.77; 30 participants), amrinone with dobutamine (RR 0.33, 95% CI 0.04 to 2.85; 30 participants), dopexamine with dopamine (no in-hospital deaths from 70 participants), enoximone with dobutamine (two deaths from 40 participants) and nitric oxide with placebo (one death from three participants).

Conclusion : Apart from low quality of evidence data suggesting a short-term mortality benefit of levosimendan compared with dobutamine, at present there are no robust and convincing data to support a distinct inotropic or vasodilator drug-based therapy as a superior solution to reduce mortality in haemodynamically unstable people with cardiogenic shock or LCOS. Considering the limited evidence derived from the present data due to a generally high risk of bias and imprecision, it should be emphasised that there remains a great need for large, well-designed randomised trials on this topic to close the gap between daily practice in critical care medicine and the available evidence. It seems to be useful to apply the concept of 'early goal-directed therapy' in cardiogenic shock and LCOS with early haemodynamic stabilisation within predefined timelines. Future clinical trials should therefore investigate whether such a therapeutic concept would influence survival rates much more than looking for the 'best' drug for haemodynamic support.

Conclusion (proposition de traduction) : Outre la faible qualité des données probantes suggérant un bénéfice sur la mortalité à court terme du lévosimendan par rapport à la dobutamine, il n’existe actuellement pas de données solides et convaincantes pour proposer une thérapeutique médicamenteuse inotrope ou vasodilatatrice distincte en tant que solution supérieure pour réduire la mortalité des patients en choc cardiogénique ou présentant un syndrome de faible débit cardiaque.
Compte tenu des preuves limitées issues des données actuelles en raison d'un risque généralement élevé de biais et d'imprécision, il convient de souligner la nécessité de mener des essais randomisés de grande envergure et bien conçus pour combler l'écart entre la pratique quotidienne en médecine de soins intensifs et les preuves disponibles. Il semble utile d’appliquer le concept de « thérapeutique précoce ciblée » dans le choc cardiogénique et le syndrome du faible débit cardiaque avec une stabilisation hémodynamique précoce dans des délais prédéfinis.
Les futurs essais cliniques devraient donc rechercher, si un tel concept thérapeutique influencait beaucoup plus les taux de survie que la recherche, le « meilleur » médicament pour le soutien hémodynamique.

Anticoagulation for the initial treatment of venous thromboembolism in people with cancer.
Hakoum MB, Kahale LA, Tsolakian IG, Matar CF, Yosuico VE, Terrenato I, Sperati F, Barba M, Schünemann H, Akl EA. | Cochrane Database Syst Rev. 2018 Jan 24;1:CD006649
Keywords: Aucun

Intervention Reviews

Introduction : Compared with people without cancer, people with cancer who receive anticoagulant treatment for venous thromboembolism (VTE) are more likely to develop recurrent VTE. OBJECTIVES: To compare the efficacy and safety of three types of parenteral anticoagulants (i.e. fixed-dose low molecular weight heparin (LMWH), adjusted-dose unfractionated heparin (UFH), and fondaparinux) for the initial treatment of VTE in people with cancer.

Méthode : A comprehensive search included a major electronic search of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (2018, Issue 1), MEDLINE (via Ovid) and Embase (via Ovid); handsearching of conference proceedings; checking of references of included studies; use of the 'related citation' feature in PubMed; and a search for ongoing studies. This update of the systematic review was based on the findings of a literature search conducted on 14 January 2018.
SELECTION CRITERIA: Randomized controlled trials (RCTs) assessing the benefits and harms of LMWH, UFH, and fondaparinux in people with cancer and objectively confirmed VTE.
DATA COLLECTION AND ANALYSIS: Using a standardized form, we extracted data in duplicate on study design, participants, interventions outcomes of interest, and risk of bias. Outcomes of interested included all-cause mortality, symptomatic VTE, major bleeding, minor bleeding, postphlebitic syndrome, quality of life, and thrombocytopenia. We assessed the certainty of evidence for each outcome using the GRADE approach.

Résultats : Of 15440 identified citations, 7387 unique citations, 15 RCTs fulfilled the eligibility criteria. These trials enrolled 1615 participants with cancer and VTE: 13 compared LMWH with UFH enrolling 1025 participants, one compared fondaparinux with UFH and LMWH enrolling 477 participants, and one compared dalteparin with tinzaparin enrolling 113 participants. The meta-analysis of mortality at three months included 418 participants from five studies and that of recurrent VTE included 422 participants from 3 studies. The findings showed that LMWH likely decreases mortality at three months compared to UFH (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.40 to 1.10; risk difference (RD) 57 fewer per 1000, 95% CI 101 fewer to 17 more; moderate certainty evidence), but did not rule out a clinically significant increase or decrease in VTE recurrence (RR 0.69, 95% CI 0.27 to 1.76; RD 30 fewer per 1000, 95% CI 70 fewer to 73 more; moderate certainty evidence).The study comparing fondaparinux with heparin (UFH or LMWH) did not exclude a beneficial or detrimental effect of fondaparinux on mortality at three months (RR 1.25, 95% CI 0.86 to 1.81; RD 43 more per 1000, 95% CI 24 fewer to 139 more; moderate certainty evidence), recurrent VTE (RR 0.93, 95% CI 0.56 to 1.54; RD 8 fewer per 1000, 95% CI 52 fewer to 63 more; moderate certainty evidence), major bleeding (RR 0.82, 95% CI 0.40 to 1.66; RD 12 fewer per 1000, 95% CI 40 fewer to 44 more; moderate certainty evidence), or minor bleeding (RR 1.53, 95% CI 0.88 to 2.66; RD 42 more per 1000, 95% CI 10 fewer to 132 more; moderate certainty evidence)The study comparing dalteparin with tinzaparin did not exclude a beneficial or detrimental effect of dalteparin on mortality (RR 0.86, 95% CI 0.43 to 1.73; RD 33 fewer per 1000, 95% CI 135 fewer to 173 more; low certainty evidence), recurrent VTE (RR 0.44, 95% CI 0.09 to 2.16; RD 47 fewer per 1000, 95% CI 77 fewer to 98 more; low certainty evidence), major bleeding (RR 2.19, 95% CI 0.20 to 23.42; RD 20 more per 1000, 95% CI 14 fewer to 380 more; low certainty evidence), or minor bleeding (RR 0.82, 95% CI 0.30 to 2.21; RD 24 fewer per 1000, 95% CI 95 fewer to 164 more; low certainty evidence).

Conclusion : LMWH is possibly superior to UFH in the initial treatment of VTE in people with cancer. Additional trials focusing on patient-important outcomes will further inform the questions addressed in this review. The decision for a person with cancer to start LMWH therapy should balance the benefits and harms and consider the person's values and preferences.

Conclusion (proposition de traduction) : Les HBPM sont probablement supérieures à l'HNF dans le traitement initial de la TEVP chez les patients porteurs de cancer. Des essais cliniques supplémentaires avec des objectifs de résultats plus importants pour les patients pourraient répondre aux questions abordées dans cette revue. La décision de traiter un patient porteur d'un cancer en commençant par un traitement par HBPM devrait faire de poser la question du bénéfice/risque attendu et tenir compte des choix et des préférences du patient.

Antibiotic therapy for preventing infections in people with acute stroke.
Vermeij JD, Westendorp WF, Dippel DW, van de Beek D, Nederkoorn PJ. | Cochrane Database Syst Rev. 2018 Jan 22;1:CD00853
Keywords: Aucun

Intervention Reviews

Introduction : Stroke is the main cause of disability in high-income countries and ranks second as a cause of death worldwide. Infections occur frequently after stroke and may adversely affect outcome. Preventive antibiotic therapy in the acute phase of stroke may reduce the incidence of infections and improve outcome. In the previous version of this Cochrane Review, published in 2012, we found that antibiotics did reduce the risk of infection but did not reduce the number of dependent or deceased patients. However, included studies were small and heterogeneous. In 2015, two large clinical trials were published, warranting an update of this Review. OBJECTIVES: To assess the effectiveness and safety of preventive antibiotic therapy in people with ischaemic or haemorrhagic stroke. We wished to determine whether preventive antibiotic therapy in people with acute stroke:• reduces the risk of a poor functional outcome (dependency and/or death) at follow-up;• reduces the occurrence of infections in the acute phase of stroke;• reduces the occurrence of elevated body temperature (temperature ≥ 38° C) in the acute phase of stroke;• reduces length of hospital stay; or• leads to an increased rate of serious adverse events, such as anaphylactic shock, skin rash, or colonisation with antibiotic-resistant micro-organisms.

Méthode : We searched the Cochrane Stroke Group Trials Register (25 June 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 5; 25 June 2017) in the Cochrane Library; MEDLINE Ovid (1950 to 11 May 2017), and Embase Ovid (1980 to 11 May 2017). In an effort to identify further published, unpublished, and ongoing trials, we searched trials and research registers, scanned reference lists, and contacted trial authors, colleagues, and researchers in the field.
SELECTION CRITERIA: Randomised controlled trials (RCTs) of preventive antibiotic therapy versus control (placebo or open control) in people with acute ischaemic or haemorrhagic stroke.
DATA COLLECTION AND ANALYSIS: Two review authors independently selected articles and extracted data; we discussed and resolved discrepancies at a consensus meeting with a third review author. We contacted study authors to obtain missing data when required. An independent review author assessed risk of bias using the Cochrane 'Risk of bias' tool. We calculated risk ratios (RRs) for dichotomous outcomes, assessed heterogeneity amongst included studies, and performed subgroup analyses on study quality.

Résultats : We included eight studies involving 4488 participants. Regarding quality of evidence, trials showed differences in study population, study design, type of antibiotic, and definition of infection; however, primary outcomes among the included studies were consistent. Mortality rate in the preventive antibiotic group was not significantly different from that in the control group (373/2208 (17%) vs 360/2214 (16%); RR 1.03, 95% confidence interval (CI) 0.87 to 1.21; high-quality evidence). The number of participants with a poor functional outcome (death or dependency) in the preventive antibiotic therapy group was also not significantly different from that in the control group (1158/2168 (53%) vs 1182/2164 (55%); RR 0.99, 95% CI 0.89 to 1.10; moderate-quality evidence). However, preventive antibiotic therapy did significantly reduce the incidence of 'overall' infections in participants with acute stroke from 26% to 19% (408/2161 (19%) vs 558/2156 (26%); RR 0.71, 95% CI 0.58 to 0.88; high-quality evidence). This finding was highly significant for urinary tract infections (81/2131 (4%) vs 204/2126 (10%); RR 0.40, 95% CI 0.32 to 0.51; high-quality evidence), whereas no preventive effect for pneumonia was found (222/2131 (10%) vs 235/2126 (11%); RR 0.95, 95% CI 0.80 to 1.13; high-quality evidence). No major side effects of preventive antibiotic therapy were reported. Only two studies qualitatively assessed the occurrence of elevated body temperature; therefore, these results could not be pooled. Only one study reported length of hospital stay.

Conclusion : Preventive antibiotics had no effect on functional outcome or mortality, but significantly reduced the risk of 'overall' infections. This reduction was driven mainly by prevention of urinary tract infection; no effect for pneumonia was found.

Conclusion (proposition de traduction) : Une antibioprophylaxie n'avaient aucun effet sur les résultats fonctionnels ou la mortalité de l'AVC, mais réduiraient significativement le risque d'infections « globale s». Cette réduction était principalement due à la prévention des infections urinaires; aucun effet pour la pneumopathie n'a été trouvé.

Drug management for acute tonic‐clonic convulsions including convulsive status epilepticus in children.
McTague A, Martland T, Appleton R. | Cochrane Database Syst Rev. 2018 Jan 10;1:CD001905
Keywords: Aucun

Intervention Reviews

Introduction : Tonic-clonic convulsions and convulsive status epilepticus (currently defined as a tonic-clonic convulsion lasting at least 30 minutes) are medical emergencies and require urgent and appropriate anticonvulsant treatment. International consensus is that an anticonvulsant drug should be administered for any tonic-clonic convulsion that has been continuing for at least five minutes. Benzodiazepines (diazepam, lorazepam, midazolam) are traditionally regarded as first-line drugs and phenobarbital, phenytoin and paraldehyde as second-line drugs. This is an update of a Cochrane Review first published in 2002 and updated in 2008.OBJECTIVES:To evaluate the effectiveness and safety of anticonvulsant drugs used to treat any acute tonic-clonic convulsion of any duration, including established convulsive (tonic-clonic) status epilepticus in children who present to a hospital or emergency medical department.

Méthode : For the latest update we searched the Cochrane Epilepsy Group's Specialised Register (23 May 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 23 May 2017), MEDLINE (Ovid, 1946 to 23 May 2017), (23 May 2017), and the WHO International Clinical Trials Registry Platform (ICTRP, 23 May 2017).
SELECTION CRITERIA: Randomised and quasi-randomised trials comparing any anticonvulsant drugs used for the treatment of an acute tonic-clonic convulsion including convulsive status epilepticus in children.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and extracted data. We contacted study authors for additional information.

Résultats : The review includes 18 randomised trials involving 2199 participants, and a range of drug treatment options, doses and routes of administration (rectal, buccal, nasal, intramuscular and intravenous). The studies vary by design, setting and population, both in terms of their ages and also in their clinical situation. We have made many comparisons of drugs and of routes of administration of drugs in this review; our key findings are as follows:(1) This review provides only low- to very low-quality evidence comparing buccal midazolam with rectal diazepam for the treatment of acute tonic-clonic convulsions (risk ratio (RR) for seizure cessation 1.25, 95% confidence interval (CI) 1.13 to 1.38; 4 trials; 690 children). However, there is uncertainty about the effect and therefore insufficient evidence to support its use. There were no included studies which compare intranasal and buccal midazolam.(2) Buccal and intranasal anticonvulsants were shown to lead to similar rates of seizure cessation as intravenous anticonvulsants, e.g. intranasal lorazepam appears to be as effective as intravenous lorazepam (RR 0.96, 95% CI 0.82 to 1.13; 1 trial; 141 children; high-quality evidence) and intranasal midazolam was equivalent to intravenous diazepam (RR 0.98, 95% CI 0.91 to 1.06; 2 trials; 122 children; moderate-quality evidence).(3) Intramuscular midazolam also showed a similar rate of seizure cessation to intravenous diazepam (RR 0.97, 95% CI 0.87 to 1.09; 2 trials; 105 children; low-quality evidence).(4) For intravenous routes of administration, lorazepam appears to be as effective as diazepam in stopping acute tonic clonic convulsions: RR 1.04, 95% CI 0.94 to 1.16; 3 trials; 414 children; low-quality evidence. Furthermore, we found no statistically significant or clinically important differences between intravenous midazolam and diazepam (RR for seizure cessation 1.08, 95% CI 0.97 to 1.21; 1 trial; 80 children; moderate-quality evidence) or intravenous midazolam and lorazepam (RR for seizure cessation 0.98, 95% CI 0.91 to 1.04; 1 trial; 80 children; moderate-quality evidence)...

Conclusion : We have not identified any new high-quality evidence on the efficacy or safety of an anticonvulsant in stopping an acute tonic-clonic convulsion that would inform clinical practice. There appears to be a very low risk of adverse events, specifically respiratory depression. Intravenous lorazepam and diazepam appear to be associated with similar rates of seizure cessation and respiratory depression. Although intravenous lorazepam and intravenous diazepam lead to more rapid seizure cessation, the time taken to obtain intravenous access may undermine this effect. In the absence of intravenous access, buccal midazolam or rectal diazepam are therefore acceptable first-line anticonvulsants for the treatment of an acute tonic-clonic convulsion that has lasted at least five minutes. There is no evidence provided by this review to support the use of intranasal midazolam or lorazepam as alternatives to buccal midazolam or rectal diazepam.

Conclusion (proposition de traduction) : Nous n'avons identifié aucune nouvelle preuve de haute qualité sur l'efficacité ou l'innocuité d'un anticonvulsivant dans l'arrêt d'une convulsion tonico-clonique aiguë susceptible de modifier la pratique clinique.
Il semble y avoir un très faible risque d'effets indésirables, en particulier de dépression respiratoire. Le lorazépam et le diazépam par voie intraveineuse semblent être associés à des taux similaires d'arrêt des crises et de dépression respiratoire. Bien que le lorazépam par voie intraveineuse et le diazépam par voie intraveineuse entraînent un arrêt plus rapide des crises, le temps nécessaire pour mettre en place l'accès veineux peut compromettre cet effet. En l'absence d'accès veineuse, le midazolam buccal ou le diazépam par voie rectale sont donc des anticonvulsivants de première intention acceptables pour le traitement d'une convulsion tonico-clonique aiguë d'au moins cinq minutes.
Cette revue ne fournit aucune preuve à l'appui de l'utilisation du midazolam ou du lorazépam par voie intranasale en tant qu'alternatives au midazolam buccal ou au diazépam rectal.

Commentaire : Pas de nouveauté...

Critical Care

Cerebral metabolic effects of strict versus conventional glycaemic targets following severe traumatic brain injury.
Plummer MP, Notkina 2, Timofeev I, Hutchinson PJ, Finnis ME, Gupta AK. | Crit Care. 2018 Jan 25;22(1):16
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Keywords: Aucun


Introduction : Optimal glycaemic targets for patients with severe traumatic brain injury remain unclear. The primary objective of this microdialysis study was to compare cerebral metabolism with strict versus conventional glycaemic control.

Méthode : We performed a prospective single-centre randomised controlled within-subject crossover study of 20 adult patients admitted to an academic neurointensive care unit with severe traumatic brain injury. Patients underwent randomised, consecutive 24-h periods of strict (4-7 mmol/L; 72-126 mg/dl) and conventional (<10 mmol/L; 180 mg/dl) glycaemic control with microdialysis measurements performed hourly. The first 12 h of each study period was designated as a 'washout' period, with the subsequent 12 h being the period of interest.

Résultats : Cerebral glucose was lower during strict glycaemia than with conventional control (mean 1.05 [95% CI 0.58-1.51] mmol/L versus 1.28 [0.81-1.74] mmol/L; P = 0.03), as was lactate (3.07 [2.44-3.70] versus 3.56 [2.81-4.30]; P < 0.001). There were no significant differences in pyruvate or the lactate/pyruvate ratio between treatment phases. Strict glycaemia increased the frequency of low cerebral glucose (< 0.8 mmol/L; OR 1.91 [95% CI 1.01-3.65]; P < 0.05); however, there were no differences in the frequency of critically low glucose (< 0.2 mmol/L) or critically elevated lactate/pyruvate ratio between phases.

Conclusion : Compared with conventional glycaemic targets, strict blood glucose control was associated with lower mean levels of cerebral glucose and an increased frequency of abnormally low glucose levels. These data support conventional glycaemic targets following traumatic brain injury.

Conclusion (proposition de traduction) : Comparativement au contrôle glycémique conventionnel, un contrôle strict de la glycémie était associé à des niveaux moyens plus bas de glucose cérébral et à une fréquence accrue de taux de glucose anormalement bas. Ces données nous font proposer un contrôle glycémique conventionnelles chez le traumatisé crânien grave.

Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials.
Cabrini L, Landoni G1,2, Baiardo Radaelli M, Saleh O, Votta CD, Fominskiy E, Putzu A, Snak de Souza CD, Antonelli M, Bellomo R, Pelosi P, Zangrillo A. | Crit Care. 2018 Jan 20;22(1):6
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Keywords: Aucun


Introduction : We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill.

Méthode : We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation-based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration's Risk of Bias tool.

Résultats : We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study). Pre-oxygenation with non-invasive ventilation (NIV) and/or high-flow nasal cannula (HFNC) showed a possible beneficial role. Post-intubation recruitment improved oxygenation, while ramped position increased the number of intubation attempts and thiopental had negative hemodynamic effects. No effect was found for use of a checklist, apneic oxygenation (on oxygenation and hemodynamics), videolaryngoscopy (on number and length of intubation attempts), sedatives and neuromuscular blockers (on hemodynamics). Finally, videolaryngoscopy was associated with severe adverse effects in multiple trials.

Conclusion : The limited available evidence supports a beneficial role of pre-oxygenation with NIV and HFNC before intubation of critically ill patients. Recruitment maneuvers may increase post-intubation oxygenation. Ramped position increased the number of intubation attempts; thiopental had negative hemodynamic effects and videolaryngoscopy might favor adverse events.

Conclusion (proposition de traduction) : Les preuves disponibles limitées sont en faveur du rôle bénéfique de la pré-oxygénation par VNI et HFNC avant l'intubation des patients en soins intensifs. Les manœuvres de recrutement peuvent augmenter l'oxygénation post-intubation. La position modifiée de Jackson (Ramped ou sniff position) a augmenté le nombre de tentatives d'intubation ; le thiopental avait des effets hémodynamiques négatifs et la vidéolaryngoscopie pourrait favoriser la survenue d'événements indésirables.

Emergency department hyperoxia is associated with increased mortality in mechanically ventilated patients: a cohort study.
Page D, Ablordeppey E, Wessman BT, Mohr NM, Trzeciak S, Kollef MH, Roberts BW, Fuller BM. | Crit Care. 2018 Jan 18;22(1):9
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Keywords: Emergency department; Hyperoxia; Mechanical ventilation


Introduction : Providing supplemental oxygen is fundamental in the management of mechanically ventilated patients. Increasing amounts of data show worse clinical outcomes associated with hyperoxia. However, these previous data in the critically ill have not focused on outcomes associated with brief hyperoxia exposure immediately after endotracheal intubation. Therefore, the objectives of this study were to evaluate the impact of isolated early hyperoxia exposure in the emergency department (ED) on clinical outcomes among mechanically ventilated patients with subsequent normoxia in the intensive care unit (ICU).

Méthode : This was an observational cohort study conducted in the ED and ICUs of an academic center in the USA. Mechanically ventilated normoxic (partial pressure of arterial oxygen (PaO2) 60-120 mm Hg) ICU patients with mechanical ventilation initiated in the ED were studied. The cohort was categorized into three oxygen exposure groups based on PaO2 values obtained after ED intubation: hypoxia, normoxia, and hyperoxia (defined as PaO2 < 60 mmHg, PaO2 60-120 mm Hg, and PaO2 > 120 mm Hg, respectively, based on previous literature).

Résultats : A total of 688 patients were included. ED normoxia occurred in 350 (50.9%) patients, and 300 (43.6%) had exposure to ED hyperoxia. The ED hyperoxia group had a median (IQR) ED PaO2 of 189 mm Hg (146-249), compared to an ED PaO2 of 88 mm Hg (76-101) in the normoxia group, P < 0.001. Patients with ED hyperoxia had greater hospital mortality (29.7%), when compared to those with normoxia (19.4%) and hypoxia (13.2%). After multivariable logistic regression analysis, ED hyperoxia was an independent predictor of hospital mortality (adjusted OR 1.95 (1.34-2.85)).

Conclusion : ED exposure to hyperoxia is common and associated with increased mortality in mechanically ventilated patients achieving normoxia after admission. This suggests that hyperoxia in the immediate post-intubation period could be particularly injurious, and targeting normoxia from initiation of mechanical ventilation may improve outcome.

Conclusion (proposition de traduction) : L’exposition à l’hyperoxie est fréquente et associée à une augmentation de la mortalité chez les patients sous ventilation mécanique qui obtiennent une normoxie après leur admission. Ceci suggère que l'hyperoxie immédiatement après l'intubation pourrait être particulièrement préjudiciable et que cibler la normoxie dès le début de la ventilation mécanique pourrait améliorer les résultats.

Critical Care Medicine

Technological Distractions (Part 2): A Summary of Approaches to Manage Clinical Alarms With Intent to Reduce Alarm Fatigue.
Winters BD, Cvach MM, Bonafide CP, Hu X, Konkani A, O'Connor MF, Rothschild JM, Selby NM, Pelter MM, McLean B, Kane-Gill SL; Society for Critical Care Medicine Alarm and Alert Fatigue Task Force. | Crit Care Med. 2018 Jan;46(1):130-137
Keywords: Aucun

Review Articles

Introduction : Alarm fatigue is a widely recognized safety and quality problem where exposure to high rates of clinical alarms results in desensitization leading to dismissal of or slowed response to alarms. Nonactionable alarms are thought to be especially problematic. Despite these concerns, the number of clinical alarm signals has been increasing as an everincreasing number of medical technologies are added to the clinical care environment.

Méthode : DATA SOURCES: PubMed, SCOPUS, Embase, and CINAHL.
STUDY SELECTION: We performed a systematic review of the literature focused on clinical alarms. We asked a primary key question; "what interventions have been attempted and resulted in the success of reducing alarm fatigue?" and 3-secondary key questions; "what are the negative effects on patients/families; what are the balancing outcomes (unintended consequences of interventions); and what human factor approaches apply to making an effective alarm?"
DATA EXTRACTION: Articles relevant to the Key Questions were selected through an iterative review process and relevant data was extracted using a standardized tool.

Résultats : We found 62 articles that had relevant and usable data for at least one key question. We found that no study used/developed a clear definition of "alarm fatigue." For our primary key question 1, the relevant studies focused on three main areas: quality improvement/bundled activities; intervention comparisons; and analysis of algorithm-based false and total alarm suppression. All sought to reduce the number of total alarms and/or false alarms to improve the positive predictive value. Most studies were successful to varying degrees. None measured alarm fatigue directly.

Conclusion : There is no agreed upon valid metric(s) for alarm fatigue, and the current methods are mostly indirect. Assuming that reducing the number of alarms and/or improving positive predictive value can reduce alarm fatigue, there are promising avenues to address patient safety and quality problem. Further investment is warranted not only in interventions that may reduce alarm fatigue but also in defining how to best measure it.

Conclusion (proposition de traduction) : Il n'y a pas de mesure(s) valide(s) pour quantifier la fatigue générée par les alarmes pour les soignants, et les méthodes actuelles sont pour la plupart indirectes. En supposant que la réduction du nombre d'alarmes et/ou l'amélioration de la valeur prédictive positive peuvent réduire la fatigue générée par les alarmes, il existe des voies prometteuses pour résoudre les problèmes posés par la sécurité et la qualité des patients. Des investissements supplémentaires sont justifiés non seulement dans les interventions susceptibles de réduire la fatigue générée par les alarmes, mais aussi améliorer la définition de la meilleure manière de les mesurer.

Commentaire : PM : Technologic Distractions (Part 1): Summary of Approaches to Manage Alert Quantity With Intent to Reduce Alert Fatigue and Suggestions for Alert Fatigue Metrics 

Acute Systemic Complications of Convulsive Status Epilepticus-A Systematic Review.
Sutter R, Dittrich T, Semmlack S, Rüegg S, Marsch S, Kaplan PW. | Crit Care Med. 2018 Jan;46(1):138-145
Keywords: Aucun

Review Articles

Introduction : Status epilepticus is a neurologic emergency with high morbidity and mortality requiring neurointensive care and treatment of systemic complications. This systematic review compiles the current literature on acute systemic complications of generalized convulsive status epilepticus in adults and their immediate clinical impact along with recommendations for optimal neurointensive care.

Méthode : DATA SOURCES: We searched PubMed, Medline, Embase, and the Cochrane library for articles published between 1960 and 2016 and reporting on systemic complications of convulsive status epilepticus.
STUDY SELECTION: All identified studies were screened for eligibility by two independent reviewers.
DATA EXTRACTION: Key data were extracted using standardized data collection forms.

Résultats : Thirty-two of 3,046 screened articles were included. Acute manifestations and complications reported in association with generalized convulsive status epilepticus can affect all organ systems fueling complex cascades and multiple organ interactions. Most reported complications result from generalized excessive muscle contractions that increase body temperature and serum potassium levels and may interfere with proper and coordinated function of respiratory muscles followed by hypoxia and respiratory acidosis. Increased plasma catecholamines can cause a decay of skeletal muscle cells and cardiac function, including stress cardiomyopathy. Systemic complications are often underestimated or misinterpreted as they may mimic underlying causes of generalized convulsive status epilepticus or treatment-related adverse events.

Conclusion : Management of generalized convulsive status epilepticus should center on the administration of antiseizure drugs, treatment of the underlying causes, and the attendant systemic consequences to prevent secondary seizure-related injuries. Heightened awareness, systematic clinical assessment, and diagnostic workup and management based on the proposed algorithm are advocated as they are keys to optimal outcome.

Conclusion (proposition de traduction) : La prise en charge de la crise convulsive généralisée devrait être centrée sur l'administration de médicaments antiépileptiques, le traitement des causes sous-jacentes et les conséquences systémiques qui en découlent pour prévenir les lésions secondaires liées aux crises convulsives. Une prise de conscience accrue, une évaluation clinique systématique, et un diagnostic et une gestion basés sur l'algorithme proposé, sont préconisés car ils sont la clé d'un résultat optimal.

qSOFA performance in infected patients varies across comorbidity burden.
Taylor S, Schmidt M, Hetherington T, Chou SH, Taylor B, Runyon M, Karvestski C, Heffner A, Russo M, Singh J, McCall A, McWilliams A. | Crit Care Med. 2018 Jan;46(1):1,
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Keywords: Aucun

Congress abstracts

Introduction : Although quick Sepsis-related Organ Failure Assessment (qSOFA) score has been suggested to identify patients at high risk of organ failure and mortality, validation of qSOFA has been mixed. The performance of qSOFA across levels of comorbidity burden is not well studied. We evaluated the performance of qSOFA calculated in the Emergency Department (ED) for patients with varying comorbidity burden.

Méthode : We studied patients presenting with suspected infection to any of 19 EDs within Carolinas Healthcare System between November 2006 until July 2017. Medical records were reviewed to calculate qSOFA score from the first documentation of respiratory rate, systolic blood pressure, and Glasgow coma scale. 30- and 90-day mortality were assessed with vital statistics. Charlson comorbidity index scores were captured at the time of admission.

Résultats : 38,102 patients were admitted from the ED for infection during the study period. 4.5% were missing data for one or more qSOFA parameters, leaving 36,387 for analysis. 23.6% died within 30 days, and 28.9% died within 90 days of ED admission. 20.9% of patients had qSOFA ≥ 2.The mean Charlson comorbidity index was greater for patients with a qSOFA score ≥ 2 than for patients with qSOFA < 2 (7.4 vs 6.5; p < 0.001). qSOFA score ≥ 2 had an AUROC of 0.61 for 30-day mortality and AUROC of 0.60 for 90-day mortality. Compared to qSOFA alone, adding the Charlson score to the qSOFA score resulted in improved discrimination (AUROC 0.74 and 0.75 for 30- and 90-day mortality). As Charlson comorbidity index decreased, there was a linear increase in the AUROC for qSOFA ≥ 2 to predict mortality at both 30-days and 90-days. Finally, in two multivariable logistical regression models for 30- and 90-day mortality, the interaction between qSOFA and Charlson comorbitidy scores was significant (p < 0.001) after adjusting for age, gender, race, facility, time to qSOFA capture, and race.

Conclusion : The performance of qSOFA may diminish with increasing comorbidity burden. This may be because patients with certain comorbidities have baseline abnormalities in systolic blood pressure, respiratory rate, or mental status that preclude adequate discrimination by qSOFA. Additional research is needed to better understand the performance of qSOFA across different comorbid conditions with consideration of assessing change from baseline rather than absolute value.

Conclusion (proposition de traduction) : La performance de qSOFA peut diminuer avec l'augmentation du nombre de comorbidité. Cela peut être dû au fait que les patients présentant certaines comorbidités présentent des anomalies initiales de la pression artérielle systolique, de la fréquence respiratoire ou de l’état mental qui empêchent toute discrimination adéquate par le biais du qSOFA.
Des recherches supplémentaires sont nécessaires pour mieux comprendre la performance du qSOFA dans différentes conditions de comorbidité, en envisageant d'évaluer les changements par rapport aux valeurs initiales plutôt qu'absolues.

Critical Ultrasound Journal

Emergency physician use of tissue Doppler bedside echocardiography in detecting diastolic dysfunction: an exploratory study.
Del Rios M, Colla J, Kotini-Shah P, Briller J, Gerber B, Prendergast H. | Crit Ultrasound J. 2018 Jan 25;10(1):4
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Keywords: Aucun

Short communication

Introduction : This study evaluates the agreement between emergency physician (EP) assessment of diastolic dysfunction (DD) by a simplified approach using average peak mitral excursion velocity (e'A) and an independent cardiologist's diagnosis of DD by estimating left atrial (LA) pressure using American Society of Echocardiography (ASE) guidelines.

Méthode : This was a secondary analysis of 48 limited bedside echocardiograms (LBE) performed as a part of a research study of patients presenting to the Emergency Department (ED) with elevated blood pressure but without decompensated heart failure. EPs diagnosed DD based on e'A < 9 cm/s alone. A blinded board-certified cardiologist reviewed LBEs to estimate LA filling pressures following ASE guidelines. An unweighted kappa measure was calculated to determine agreement between EP and cardiologist.

Résultats : Six LBEs were deemed indeterminate by the cardiologist and excluded from the analysis. Agreement was reached in 41 out of 48 cases (85.4%). The unweighted kappa coefficient was 0.74 (95% CI 0.57-0.92). EPs identified 18 out of 20 LBEs diagnosed with diastolic dysfunction by the cardiologist.

Conclusion : There is a good agreement between (e'A) by EP and cardiologist interpretation of LBEs. Future studies should investigate this simplified approach as a one-step method of screening for LV diastolic dysfunction in the ED.

Conclusion (proposition de traduction) : Il y a une bonne concordance entre le flux mitral (E/A) mesuré par l'urgentiste et l'interprétation du cardiologue des limites au lit du malade. Les études futures devraient étudier cette approche simplifiée comme une méthode en une seule étape de dépistage de la dysfonction diastolique VG aux urgences.

Ultrasound evaluation of the airway in the ED: a feasibility study.
Hall EA, Showaihi I, Shofer FS, Panebianco NL, Dean AJ. | Crit Ultrasound J. 2018 Jan 18;10(1):3
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Keywords: Aucun

Original article

Editorial : Recognition of the difficult airway is a critical element of emergency practice. Mallampati score and body mass index (BMI) are not always predictive and they may be unavailable in critically ill patients. Ultrasonography provides high-resolution images that are rapidly obtainable, mobile, and non-invasive. Studies have shown correlation of ultrasound measurements with difficult laryngoscopy; however, none have been performed in the Emergency Department (ED) using a consistent scanning protocol.

Introduction : This study seeks to determine the feasibility of ultrasound measurements of the upper airway performed in the ED by emergency physicians, the inter-rater reliability of such measurements, and their relationship with Mallampati score and BMI.

Méthode : A convenience sample of volunteer ED patients and healthy volunteers with no known airway issues, aged > 18 years, had images taken of their airway using a standardized ultrasound scanning protocol by two EM ultrasound fellowship trained physicians. Measurements consisted of tongue base, tongue base-to-skin, epiglottic width and thickness, and pre-epiglottic space. Mean and standard deviation (SD) were used to summarize measurements. Inter-rater reliability was assessed by intraclass correlation coefficients (ICCs). Analysis of variance with linear contrasts was used to compare measurements with Mallampati scores and linear regression with BMI.

Résultats : Of 39 participants, 50% were female, 50% white, 42% black, with median age 32.5 years (range 19-90), and BMI 26.0 (range 19-47). Mean ± SD for each measurement (mm) was as follows: tongue base (44.6 ± 5.1), tongue base-to-skin (60.9 ± 5.3), epiglottic width (15.0 ± 2.8) and thickness (2.0 ± 0.37), and pre-epiglottic space (11.4 ± 2.4). ICCs ranged from 0.76 to 0.88 for all measurements except epiglottis thickness (ICC = 0.57). Tongue base and tongue base-to-skin thickness were found to increase with increasing Mallampati score (p = .04, .01), whereas only tongue-to-skin thickness was loosely correlated with BMI (r = .38).

Conclusion : A standardized ultrasound scanning protocol demonstrates that the airway can be measured by emergency sonologists with good inter-operator reliability in all but epiglottic thickness. The measurements correlate with Mallampati score but not with BMI. Future investigation might focus on ultrasound evaluation of the airway in patients receiving airway management to determine whether ultrasound can predict challenging or abnormal airway anatomy prior to laryngoscopy.

Conclusion (proposition de traduction) : Un protocole d'échographique standardisé démontre que les voies aériennes peuvent être mesurées par des médecins urgentistes formés avec une bonne fiabilité inter-opérateur à tous les étages thoraciques sauf au niveau épiglottique.
Les mesures sont en corrélation avec le score de Mallampati mais pas avec l'IMC.
L'étude future pourrait se concentrer sur l'évaluation échographique des voies respiratoires chez les patients nécessitant une prise en charge des voies respiratoires afin de déterminer si l'échographie peut prédire une intubation difficile ou anormale avant la laryngoscopie.


Accuracy of Neck stiffness, Kernig, Brudzinski, and Jolt Accentuation of Headache Signs in Early Detection of Meningitis.
Ala A, Farzad Rahmani F, Abdollahi S, Parsian Z. | Emergency. 2018 jan 20;6(1):e8
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Keywords: Aucun

Original/Research Article

Introduction : The diagnostic value of clinical signs in early diagnosis of meningitis has been evaluated but the existing results are contradicting. The present study aimed to evaluate the accuracy of Kernig, Brudzinski, neck stiffness, and Jolt Accentuation of Headache (JAH) signs in this regard.

Méthode : In this diagnostic accuracy study, patients with suspected meningitis who were referred to the emergency department were examined regarding presence or absence of the mentioned clinical signs and screening performance characteristics of the signs were calculated. Cerebrospinal fluid analysis was used as the reference test.

Résultats : 120 cases with mean age of 48.79 § 21.68 years (18 – 93) were studied (63.3% male). Diagnosis of meningitis was confirmed for 45 (37.5%) cases. Neck stiffness (p < 0.001), Kernig (p < 0.001), Brudzinski (p < 0.001), and JAH (p < 0.001) had significantly higher frequency among patients with meningitis. The accuracy of neck stiffness, Kernig, Brudzinski, and JAH signs in early detection of meningitis were 0.676 (95% CI: 0.575-0.776), 0.667 (95% CI: 0.552-0.782), 0.720 (95% CI: 0.619-0.821), 0.749 (95% CI: 0.659-839), respectively.

Conclusion : It seems that diagnostic value of JAH is higher than other clinical signs but the accuracy of all signs is in poor to fair range. JAH had the highest sensitivity and Kernig and Brudzinski had the highest specificity.

Conclusion (proposition de traduction) : Il semble que la valeur diagnostique de l'augmentation d'intensité des céphalées soit plus élevée que pour les autres signes cliniques, mais que la précision de tous les signes est faible à passable. L'augmentation d'intensité des céphalées avait la sensibilité la plus élevée et le signe de Kernig et Brudzinski avaient la plus haute spécificité.

Emergency Department Bedside Ultrasonography for Diagnosis of Acute Cholecystitis; a Diagnostic Accuracy Study.
Shekarchi1 B, Hejripour Rafsanjani SZ, Riz Fomani NS, Chahardoli M. | Emergency. 2018 Jan 15;6(1):e11
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Keywords: Aucun

Original research

Introduction : Using bedside ultrasound in diagnosing acute cholecystitis in the emergency department (ED) can save time, help the decision making process and allocate resources wisely. This study aimed to evaluate the diagnostic accuracy of bedside right upper quadrant (RUQ) ultrasonography in detection of acute cholecystitis.

Méthode : In this diagnostic accuracy study, patients presenting to ED, suffering from RUQ pain in favor of acute cholecystitis underwent RUQ ultrasonography in emergency and radiology departments and interrater agreement between reports was calculated.

Résultats : 342 patients with the mean age of 53.92 § 11.18 (20 – 83) years were studied (63.2% female). The number of patients with at least one sonographic finding of acute cholecystitis were 53 (15.50%) and 48 (14.00%) based on ED and radiology reports (Kappa = 0.826). Sensitivity, specificity, positive and negative predictive values, as well as positive and negative likelihood ratios of bedside sonography were 89.58 (95%CI: 76.55 – 96.10), 96.59 (95%CI: 93.63 – 98.29), 81.13 (95%CI: 67.58 – 90.11), 98.26 (95%CI: 95.77 – 99.36), 4.30 (95%CI: 2.42 – 7.62) and 0.017 (95%CI: 0.007 – 0.041), respectively.

Conclusion : There was a very good agreement between ED and radiology departments’ sonography reports regarding the presence or absence of acute cholecystitis. Sensitivity and specificity of bedside RUQ sonography were 89.58 and 96.59, respectively.

Conclusion (proposition de traduction) : Il y avait une très bonne concordance entre les rapports échographiques des services d'urgence et de radiologie concernant la présence ou l'absence de cholécystite aiguë. La sensibilité et la spécificité de l'échographie au lit du patient étaient de 89,58 et 96,59, respectivement.

Pro-BNP versus MEDS Score in Determining the Prognosis of Sepsis Patients; a Diagnostic Accuracy Study.
Shojaee M, Safari S, Sabzghabaei A, Alavi-Moghaddam M, Dolatabadi AA, Kariman H, Soltani1 S. | Emergency. 2018 Jan;6(1):e4
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Keywords: Aucun

Original Research

Introduction : Pro-brain natriuretic peptide (Pro-BNP) can act as an independent predictor of mortality in septic patients. This study aimed to compare the diagnostic accuracy of pro-BNP and Mortality in Emergency Department Sepsis (MEDS) score in this regard.

Méthode : This cross-sectional study was conducted on > 14 years old sepsis patients of an emergency department (ED), during 2 years. The level of Pro-BNP and MEDS score were measured for all eligible patients and considering one month mortality as reference, screening performance characteristics of the two tests were compared using SPSS 21 and STATS 11.

Résultats : 121 patients with the mean age of 75.87±11.82 years were studied (55.4% male). 85 (70.25%) patients had moderate to high probability of mortality according to MEDS score. The mean Pro-BNP levels of survivor and non-survivor patients were 489.69 ± 327.47 and 3954.98 ± 2717.85 pg/ml, respectively (p < 0.0001). Sensitivity and specificity of Pro-BNP (in 1000 pg/ml cut off ) and MEDS score (in level 3) in prediction of 1-month mortality were 93.6 (83.7-97.9), 94.8 (84.7-98.6), 65.0 (51.9-76.3), and 98.2 (89.5-99.9), respectively. Area under the ROC curve of the two tests were 97.36 (95% CI: 92.92-94.48) and 92.31 (95% CI: 86.35-96.53), respectively (p = 0.0543).

Conclusion : Pro-BNP and MEDS score both have excellent diagnostic accuracy in predicting 1-month mortality of sepsis patients. However, considering the higher sensitivity as well as availability and ease of calculation, it seems that Pro-BNP can be considered an appropriate tool for screening patients with high risk of mortality following sepsis in ED.

Conclusion (proposition de traduction) : Les taux de Pro-BNP et le score Mortality in Emergency Department Sepsis (MEDS) sont tous deux d'une excellente précision diagnostique pour prédire la mortalité à un mois des patients présentant un sepsis. Toutefois, compte tenu de la sensibilité plus élevée ainsi que de la disponibilité et de la facilité de calcul, il semble que le taux ce Pro-BNP puisse être considéré comme un outil approprié pour le dépistage des patients présentant un risque élevé de mortalité à la suite d'un sepsis aux urgences.

Applications of End-Tidal Carbon Dioxide (ETCO2) Monitoring in Emergency Department; a Narrative Review.
Aminiahidashti H, Aminiahidashti H, Shafiee S, Kiasari AZ, Sazgar M. | Emergency. 2018 jan 15;6(1):e5
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Keywords: Aucun

Review Article

Editorial : Capnograph is an indispensable tool for monitoring metabolic and respiratory function. In this study, the aim was to review the applications of end-tidal carbon dioxide (ETCO2) monitoring in emergency department, multiple databases were comprehensively searched with combination of following keywords: “ETCO2”, “emergency department monitoring”, and “critical monitoring” in PubMed, Google Scholar, Scopus, Index Copernicus, EBSCO and Cochrane Database.

Conclusion (proposition de traduction) : La capnographie est un outil indispensable pour surveiller la fonction métabolique et respiratoire.
Dans cette étude, l'objectif était de revoir les applications de la surveillance de l'ETCO2 dans les services d'urgence. De multiples bases de données ont été consultées en combinant les mots clés suivants : "ETCO2, surveillance des urgences et surveillance critique" dans PubMed, Google Scholar, Scopus, Index Copernicus, EBSCO et base de données Cochrane.

Emergency Medicine Journal

Early prediction of hospital admission for emergency department patients: a comparison between patients younger or older than 70 years.
Lucke JA, de Gelder J, Clarijs F, Heringhaus C, de Craen AJM, Fogteloo AJ, Blauw GJ, Groot B, Mooijaart SP. | Emerg Med J. 2018 Jan;35(1):18-2
Keywords: Aucun


Introduction : The aim of this study was to develop models that predict hospital admission to ED of patients younger and older than 70 and compare their performance.

Méthode : Prediction models were derived in a retrospective observational study of all patients≥18 years old visiting the ED of a university hospital during the first 6 months of 2012. Patients were stratified into two age groups (<70 years old and ≥70 years old). Multivariable logistic regression analysis was used to identify predictors of hospital admission among factors available immediately after patient arrival to the ED. Validation of the prediction models was performed on patients presenting to the ED during the second half of the year 2012.

Résultats : 10 807 patients were included in the derivation and 10 480 in the validation cohorts. The strongest independent predictors of hospital admission among the 8728 patients <70 years old were age, sex, triage category, mode of arrival, performance of blood tests, chief complaint, ED revisit, type of specialist, phlebotomised blood sample and all vital signs. The area under the curve (AUC) of the validation cohort for those <70 years old was 0.86 (95% CI 0.85 to 0.87). Among the 2079 patients ≥70 years, the same factors were predictive, except for gender, type of specialist and heart rate; the AUC was 0.77 (95% CI 0.75 to 0.79). The prediction models could identify a group of 10% of patients with the highest risk in whom hospital admission was predicted at ED triage, with a positive predictive value (PPV) of 71% (95% CI 68% to 74%) in younger patients and PPV of 87% (95% CI 81% to 92%) in older patients.

Conclusion : Demographic and clinical factors readily available early in the ED visit can be useful in identifying patients who are likely to be admitted to the hospital. While the model for the younger patients had a higher AUC, the model for older patients had a higher PPV in identifying the patients at highest risk for admission. Of note, heart rate was not a useful predictor in the older patients.

Conclusion (proposition de traduction) : Les informations démographiques et cliniques facilement recueillis à l'entrée aux urgences peuvent être utiles pour identifier les patients susceptibles d'être admis à l'hôpital. Alors que le modèle pour les patients plus jeunes avait une aire sous la courbe plus élevée, le modèle pour les patients plus âgés avait une valeur prédictive positive plus élevé pour l'identification des patients les plus à risque d'admission. A noter, la fréquence cardiaque n'était pas un critère prédictif utile chez les patients les plus âgés.

Can an observational pain assessment tool improve time to analgesia for cognitively impaired older persons? A cluster randomised controlled trial.
Fry M, Chenoweth L, Arendts G. | Emerg Med J. 2018 Jan;35(1):33-38
Keywords: Aucun


Introduction : The primary objective of the study was to measure the impact of an observational pain assessment dementia tool on time from ED arrival to first dose of analgesic medicine.

Méthode : A multisite cluster randomised controlled trial was conducted to test the Pain Assessment in Advanced Dementia (PAINAD) tool. Patients aged 65 years or older suspected of a long bone fracture were screened for cognitive impairment using the Six-Item Screening (SIS) tool. Patients scoring 4 or less on SIS (intervention sites) were assessed for pain using PAINAD. Control sites, assessed pain using standard methods. The primary outcome was time to first dose of analgesia and was analysed on an intention-to-treat basis with a sensitivity analysis.

Résultats : We enrolled 602 patients, of which 323 (54%) were at intervention sites (n=4). The median time to analgesia was 82 min (IQR 45-151 min). There was no statistically significant difference in median time to analgesia for intervention 83 (IQR 48-158 min) and non-intervention 82 min (IQR 41-147 min) sites (p=0.414). After adjusting for age, fracture type, arrival mode and triage category, there remained no significant difference in time to analgesia (HR 0.97, 95% CI 0.80 to 1.17, p=0.74). Of the 602 patients enrolled, 273 actually had cognitive impairment. A sensitivity analysis demonstrated patients at intervention sites received analgesia 13 min sooner (90 vs 103 min, p=0.91).

Conclusion : Use of the PAINAD was not associated with a shorter time to analgesia, although there was a clinically important but non-significant improvement in the cognitively impaired patient group. Further research is needed to address this clinically important and complex issue.

Conclusion (proposition de traduction) : L'utilisation du PAINAD (Pain Assessment in Advanced Dementia - Évaluation de la douleur dans la démence avancée) n'a pas été associée à un délai plus court de prise en charge de la douleur, bien qu'il y ait eu une amélioration cliniquement importante mais non significative dans le groupe de patients ayant une déficience cognitive. Des recherches supplémentaires sont nécessaires pour traiter ce problème cliniquement important et complexe.

Impact of Physician Navigators on productivity indicators in the ED.
Leung AK1, Puri G, Chen BE, Gong Z, Chan E, Feng E, Duic M. | Emerg Med J. 2018 Jan;35(1):5-11
Keywords: Aucun

Original article

Introduction : We created Physician Navigators in our ED to help improve emergency physician (EP) productivity. We aimed to quantify the effect of Physician Navigators on measures of EP productivity: patient seen per hour (Pt/hr), and turn-around time (TAT) to discharge. Secondary objectives included examining their impact on measures of ED throughput for non-resuscitative patients: ED length of stay (LOS), door-to-physician time and left-without-being-seen rates (LWBS).

Méthode : In this retrospective study, 6845 clinical shifts worked by 20 EPs at a community ED in Newmarket, Canada from 1 January 2012 to 31 March 2015 were evaluated. Using a clustered design, we compared productivity measures between shifts with and without Physician Navigators, by physician. We used a linear mixed model to examine mean changes in Pt/hr and TAT to discharge for EPs who employed Physician Navigators. For secondary objectives, autoregressive modelling was performed to compare ED throughput metrics before and after the implementation of Physician Navigators for non-resuscitative patients.

Résultats : Patient volumes increased by 20 patients per day (p<0.001). Mean Pt/hr increased by 1.07 patients per hour (0.98 to 1.16, p<0.001). The mean TAT to discharge decreased by 10.6 min (−13.2 to −8.0, p<0.001). After implementation of the Physician Navigator programme, overall mean LOS for non-resuscitative patients decreased by 2.6 min (p=0.007), and mean door-to-physician time decreased by 7.4 min (p<0.001). LBWS rates decreased from 1.13% to 0.63% of daily patient volume (p<0.001).

Conclusion : Despite an ED volume increase, the use of a Physician Navigator was associated with significant improvements in EP productivity, and significant reductions in ED throughput times.

Conclusion (proposition de traduction) : Malgré l'augmentation du nombre de passage au service d'urgence, l'utilisation de médecins navigateurs a été associée à des améliorations significatives de la productivité des médecins urgentistes et à des réductions significatives des temps de traitement des urgences.

Commentaire : Le retour des médecins d'accueil et d'orientation (MAO) ?

Skin and soft tissue infection management failure in the emergency department observation unit: a systematic review.
Abetz JW, Adams NG, Mitra B. | Emerg Med J. 2018 Jan;35(1):56-61
Keywords: Aucun


Introduction : Skin and soft tissue infections (SSTIs) are commonly treated in ED observation units (EDOUs). The management failure rate in this setting is high, as evidenced by a large proportion of patients requiring inpatient admission. This systematic review sought to quantify the management failure rate and identify risk factors associated with management failure.

Méthode : Searches of six databases and grey literature were conducted with no limits on publication year or language. Manuscripts describing patients admitted to an EDOU setting (≤24 hours planned admission to EDOU) with a primary diagnosis of cellulitis or other SSTIs were included. Variables associated with failure of management, defined as inpatient admission, stay >28 hours (4 hours in ED, 24 hours in EDOU) or death, were extracted. A narrative description of variables associated with failure of EDOU admission was conducted.

Résultats : There were 1119 unique articles identified through the literature search. Following assessment, 10 studies were included in the final systematic review, 9 of which reported the management failure rate (range 15%-38%). The presence of fever, a high total white blood cell count and known methicillin-resistant Staphylococcus aureus exposure were the most commonly reported variables associated with management failure.

Conclusion : A higher rate of EDOU management failure in SSTIs than the generally accepted rate of 15% was observed in most studies identified by this review. Risk factors identified were varied, but presence of a fever and elevated inflammatory markers were commonly associated with failure of EDOU admission by multiple studies. Recognition of risk factors and the increased application of clinical decision tools may help to improve disposition of patients at high risk for clinical deterioration or management failure.

Conclusion (proposition de traduction) : Un taux plus élevé d'échec de la prise en charge dans l’unité d’observation des urgences des infection de la peau et des tissus mous, que le taux généralement accepté de 15 %, a été observé dans la plupart des études identifiées dans cette revue de la littérature. Les facteurs de risque identifiés étaient variés, mais la présence d'une fièvre et de marqueurs inflammatoires élevés était fréquemment associée avec l'échec dans de multiples études.
La reconnaissance de facteurs de risque et l'application plus importante d'outils de décision cliniques peuvent aider à améliorer l’état clinique de patients exposés au risque élevé de complication infectieuse ou l’échec de la prise en charge.

Waveform capnography: an alternative to physician gestalt in determining optimal intubating conditions after administration of paralytic agents.
Scoccimarro A, West JR, Kanter M, Caputo ND. | Emerg Med J. 2018 Jan;35(1):62-64
Keywords: Aucun

Short report

Introduction : We sought to evaluate the utility of waveform capnography (WC) in detecting paralysis, by using apnoea as a surrogate determinant, as compared with clinical gestalt during rapid sequence intubation. Additionally, we sought to determine if this improves the time to intubation and first pass success rates through more consistent and expedient means of detecting optimal intubating conditions (ie, paralysis).

Méthode : A prospective observational cohort study of consecutively enrolled patients was conducted from April to June 2016 at an academic, urban, level 1 trauma centre in New York City. Nasal cannula WC was used to determine the presence of apnoea as a surrogate measure of paralysis versus physician gestalt (ie, blink test, mandible relaxation, and so on).

Résultats : One hundred patients were enrolled (50 in the WC group and 50 in the gestalt group). There were higher proportions of failure to determine optimal intubating conditions (ie, paralysis) in the gestalt group (32%, n=16) versus the WC group (6%, n=3), absolute difference 26, 95% CI 10 to 40. Time to intubation was longer in the gestalt group versus the WC group (136 seconds vs 116 seconds, absolute difference 20 seconds 95% CI 14 to 26). First pass success rates were higher in the WC group verses the gestalt group (92%, 95% CI 85 to 97 vs 88%, 95% CI 88 to 95, absolute difference 4%, 95% CI 1 to 8).

Conclusion : These preliminary results demonstrate WC may be a useful objective measure to determine the presence of paralysis and optimal in tubating conditions in RSI.

Conclusion (proposition de traduction) : Ces résultats préliminaires démontrent que la capnographie (courbe et mesure) peut être une technique objective utile pour déterminer le moment de la paralysie induite par le curare et la présence des conditions optimales d'intubation.

Commentaire : Une autre utilisation du capnographe (courbe et mesure) dans l'intubation...

BET 1: Continuous flow insufflation of oxygen in out-of-hospital cardiac arrest.
LeBlanc PA, Nadeau A. | Emerg Med J. 2018 Jan;35(1):65-66
Keywords: Aucun

Best evidence topic reports

Editorial : A short cut review was carried out to establish whether continuous flow insufflation of oxygen (CFIO) is better than standard ventilation strategies at improving outcome in adults who have suffered an out-of-hospital cardiac arrest (OHCA). Papers were found in Medline and Embase using the reported searches of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that CFIO does not improve survival or return of spontaneous circulation compared with standard ventilation strategies in OHCA.

Conclusion : Continuous flow insufflation of oxygen does not improve survival nor return of spontaneous circulation compared with standard bag-mask ventilation or endotracheal intubation and mechanical ventilation in patients with out-of-hospital cardiac arrest in different emergency medical service systems

Conclusion (proposition de traduction) : L'insufflation continue d'oxygène (sonde de Boussignac ou B-card) n'améliore pas la survie ni le retour à une circulation spontanée (RACS) par rapport à la ventilation par masque facial au ballon auto-remplisseur standard ou à l'intubation endotrachéale et la ventilation mécanique chez les patients avec arrêt cardiaque extra-hospitalier dans différents systèmes de services médicaux d'urgence.

NSAIs and chickenpox.
Stone K, Tackley E1, Weir S. | Emerg Med J. 2018 Jan;35(1):66-68
Keywords: Aucun

Best evidence topic reports

Editorial : A shortcut review was carried out to establish whether non-steroidal anti-inflammatory drugs (NSAIDs) is safe to prescribe in patients with chicken pox. 66 unique papers were found in CINAHL, Medline, Embase and Cochrane using the reported searches of which 6 presented the best evidence to answer the clinical question. The author, date and country of publication; patient group studied; study type; relevant outcomes; results and study weaknesses of these best papers are tabulated. It is concluded that, pending further research, it is advisable to avoid NSAID use in cases of primary varicella due to the potential increased risk of severe bacterial skin infections. Paracetamol should be given instead.

Conclusion : Until further research is performed it is advisable to avoid non-steroidal anti-inflammatory drug use in cases of primary varicella due to the potential increased risk of severe bacterial skin infections. Paracetamol should be given instead.

Conclusion (proposition de traduction) : Jusqu'à ce que d'autres recherches soient effectuées, il est conseillé d'éviter l'utilisation de médicaments anti-inflammatoires non stéroïdiens dans les cas de varicelle primaire en raison du risque accru d'infections bactériennes graves de la peau. Le paracétamol devrait être proposé à la place.

European Heart Journal

2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranckx P, Widimský P; ESC Scientific Document Group. | Eur Heart J. 2018 Jan 7;39(2):119-177
DOI:  | Télécharger l'article au format  
Keywords: Guidelines, Acute coronary syndromes, Acute myocardial infarction, Antithrombotic therapy, Antithrombotics, Emergency medical system, Evidence, Fibrinolysis, Ischaemic heart disease, Primary percutaneous coronary intervention, Quality indicators, MINOCA, Reperfusion therapy, Risk assessment, Secondary prevention, ST-segment elevation

Article Original

Editorial : Updates on the management of patients presenting with ST-segment elevation myocardial infarction (STEMI) should be based on sound evidence, derived from well-conducted clinical trials whenever possible, or motivated expert opinion when needed. It must be recognized that, even when excellent clinical trials have been undertaken, the results are open to interpretation and treatments may need to be adapted to take account of clinical circumstances and resources. The present Task Force has made an important effort to be as aligned as possible with the other ESC Guidelines and consensus documents, including the simultaneously published update on dual antiplatelet therapy (DAPT), for consistency in the ESC Guidelines strategy. The levels of evidence and the strengths of recommendation of particular treatment options were weighed and graded . according to pre-defined scales, as outlined in Tables 1 and 2. Despite . recommendations with a level of evidence being based on expert . opinion, this Task Force decided to add references to guide the . reader regarding data that were taken into consideration for these . decisions in some cases.

Conclusion : Guideline

Conclusion (proposition de traduction) : Recommandations

European Respiratory Journal

Risk factors for recurrent venous thromboembolism after unprovoked pulmonary embolism: the PADIS-PE randomised trial.
Tromeur C, and al. PADIS-PE Investigators. | Eur Respir J. 2018 Jan 4;51(1)
Keywords: Aucun

Pulmonary vascular disease

Editorial : We aimed to identify risk factors for recurrent venous thromboembolism (VTE) after unprovoked pulmonary embolism.Analyses were based on the double-blind randomised PADIS-PE trial, which included 371 patients with a first unprovoked pulmonary embolism initially treated during 6 months who were randomised to receive an additional 18 months of warfarin or placebo and followed up for 2 years after study treatment discontinuation. All patients had ventilation/perfusion lung scan at inclusion (i.e. at 6 months of anticoagulation).During a median follow-up of 41 months, recurrent VTE occurred in 67 out of 371 patients (6.8 events per 100 person-years). In main multivariate analysis, the hazard ratio for recurrence was 3.65 (95% CI 1.33-9.99) for age 50-65 years, 4.70 (95% CI 1.78-12.40) for age >65 years, 2.06 (95% CI 1.14-3.72) for patients with pulmonary vascular obstruction index (PVOI) ≥5% at 6 months and 2.38 (95% CI 1.15-4.89) for patients with antiphospholipid antibodies. When considering that PVOI at 6 months would not be available in practice, PVOI ≥40% at pulmonary embolism diagnosis (present in 40% of patients) was also associated with a 2-fold increased risk of recurrence.After a first unprovoked pulmonary embolism, age, PVOI at pulmonary embolism diagnosis or after 6 months of anticoagulation and antiphospholipid antibodies were found to be independent predictors for recurrence.

Conclusion (proposition de traduction) : Après une première embolie pulmonaire sans facteur de risque qui aurait entraîné cette embolie pulmonaire initiale, l'âge, l'index d'obstruction vasculaire pulmonaire lors du diagnostic d'embolie pulmonaire ou après 6 mois d'anticoagulation et la présence d'anticorps antiphospholipides se sont avérés être des prédicteurs indépendants de récidive.

Intensive Care Medicine

Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock.
Lamontagne F, Day AG, Meade MO, Cook DJ, Guyatt GH, Hylands M, Radermacher P, Chrétien JM, Beaudoin N, Hébert P, D'Aragon F, Meziani F, Asfar P. | Intensive Care Med. 2018 Jan;44(1):12-21
Keywords: Aucun

Systematic Review

Introduction : Guidelines for shock recommend mean arterial pressure (MAP) targets for vasopressor therapy of at least 65 mmHg and, until recently, suggested that patients with underlying chronic hypertension and atherosclerosis may benefit from higher targets. We conducted an individual patient-data meta-analysis of recent trials to determine if patient variables modify the effect of different MAP targets.

Méthode : We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials for randomized controlled trials of higher versus lower blood pressure targets for vasopressor therapy in adult patients in shock (until November 2017). After obtaining individual patient data from both eligible trials, we used a modified version of the Cochrane Collaboration's instrument to assess the risk of bias of included trials. The primary outcome was 28-day mortality.

Résultats : Included trials enrolled 894 patients. Controlling for trial and site, the OR for 28-day mortality for the higher versus lower MAP targets was 1.15 (95% CI 0.87-1.52). Treatment effect varied by duration of vasopressors before randomization (interaction p = 0.017), but not by chronic hypertension, congestive heart failure or age. Risk of death increased in higher MAP groups among patients on vasopressors > 6 h before randomization (OR 3.00, 95% CI 1.33-6.74).

Conclusion : Targeting higher blood pressure targets may increase mortality in patients who have been treated with vasopressors for more than 6 h. Lower blood pressure targets were not associated with patient-important adverse events in any subgroup, including chronically hypertensive patients.

Conclusion (proposition de traduction) : Cibler des pression artérielle plus élevées (qu’une PAM de 65 mmHg) peut augmenter la mortalité chez les patients qui ont bénéficiés de médicaments vasopresseurs pendant plus de 6 h. Les cibles de pression artérielle plus basses n'étaient associées à aucun événements indésirables importants chez le patient de tous les sous-groupes, y compris les patients chroniquement hypertendus.

Commentaire : Conclusions intéressantes notamment chez les patients hypertendus...

Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections.
van der Kooi T, and al. PROHIBIT consortium. | Intensive Care Med. 2018 Jan;44(1):48-60
Keywords: Aucun


Introduction : To test the effectiveness of a central venous catheter (CVC) insertion strategy and a hand hygiene (HH) improvement strategy to prevent central venous catheter-related bloodstream infections (CRBSI) in European intensive care units (ICUs), measuring both process and outcome indicators.

Méthode : Adult ICUs from 14 hospitals in 11 European countries participated in this stepped-wedge cluster randomised controlled multicentre intervention study. After a 6 month baseline, three hospitals were randomised to one of three interventions every quarter: (1) CVC insertion strategy (CVCi); (2) HH promotion strategy (HHi); and (3) both interventions combined (COMBi). Primary outcome was prospective CRBSI incidence density. Secondary outcomes were a CVC insertion score and HH compliance.

Résultats : Overall 25,348 patients with 35,831 CVCs were included. CRBSI incidence density decreased from 2.4/1000 CVC-days at baseline to 0.9/1000 (p < 0.0001). When adjusted for patient and CVC characteristics all three interventions significantly reduced CRBSI incidence density. When additionally adjusted for the baseline decreasing trend, the HHi and COMBi arms were still effective. CVC insertion scores and HH compliance increased significantly with all three interventions.

Conclusion : This study demonstrates that multimodal prevention strategies aiming at improving CVC insertion practice and HH reduce CRBSI in diverse European ICUs. Compliance explained CRBSI reduction and future quality improvement studies should encourage measuring process indicators.

Conclusion (proposition de traduction) : Cette étude démontre que les stratégies de prévention multimodales visant à améliorer les pratiques d'insertion des cathéters veineux centraux et l'hygiène des mains réduisent les infections sanguines liées aux cathéters dans diverses unités de soins intensifs européennes. La conformité a expliqué la réduction des infections sanguines liées aux cathéters et les futures études d'amélioration de la qualité devraient encourager la mesure des indicateurs de processus.

Commentaire : Prevention of Hospital Infections by Intervention and Training - PROHIBIT   et Prévenir les infections associées aux soins liées aux cathéters intravasculaires centraux  

Ultrasound-guided or landmark techniques for central venous catheter placement in critically ill children.
Oulego-Erroz I, and al. RECANVA collaborative study. | Intensive Care Med. 2018 Jan;44(1):61-72
Keywords: Aucun

Pediatric Original

Introduction : To assess whether ultrasound guidance improves central venous catheter placement outcomes compared to the landmark technique in critically ill children.

Méthode : A prospective multicentre observational study was carried out in 26 paediatric intensive care units over 6 months. Children 0-18 years old who received a temporary central venous catheter, inserted using either ultrasound or landmark techniques, were eligible. The primary outcome was the first-attempt success rate. Secondary outcomes included overall placement success, number of puncture attempts, number of procedures requiring multiple punctures (> 3 punctures), number of procedures requiring punctures at more than one vein site and immediate mechanical complications. To account for potential confounding factors, we used propensity scores. Our primary analysis was based on 1:1 propensity score matching. The association between cannulation technique and outcomes in the matched cohort was estimated using generalized estimating equations and mixed-effects models to account for patient-level and hospital-level confounders.

Résultats : Five hundred central venous catheter-placement procedures involving 354 patients were included. Ultrasound was used for 323 procedures, and the landmark technique was used for 177. Two hundred and sixty-six procedures were matched (133 in the ultrasound group and 133 in the landmark group). Ultrasound was associated with an increase in the first-attempt success rate [46.6 vs. 30%, odds ratio 2.09 (1.26-3.46); p < 0.001], a reduced number of puncture attempts [2 (1-3) vs. 2 (1-4), B coefficient - 0.51 (95% confidence interval - 1.01 to - 0.03), p = 0.035], and fewer overall mechanical complications [12 vs. 22.5%, odds ratio 0.47 (95% confidence interval 0.24-0.91), p = 0.025] in the matched cohort. The number of puncture attempts was the main factor associated with overall complications.

Conclusion : Compared with the landmark technique, ultrasound guidance was associated with an increased first-attempt success rate, a reduced number of puncture attempts, and fewer complications during central venous catheter placement in critically ill children.

Conclusion (proposition de traduction) : Comparé à la technique par repérage anatomique, le guidage échographique était associé à une augmentation du taux de succès à la première tentative, un nombre réduit de tentatives de ponction et moins de complications lors de la pose du cathéter veineux central chez les enfants en soins intensifs.

Commentaire : Etude prospective multi-centrique chez 354 patients (266 procédures appareillées) qui confirme les résultats connus chez l'adulte et qui renvoi à la recommandation de la SFAR sur « l'utilisation de l'échographie lors de la mise en place des accès vasculaires »  

Ten ineffective interventions to prevent ventilator-associated pneumonia.
Makris D, Luna C, Nseir S. | Intensive Care Med. 2018 Jan;44(1):83-86
Keywords: Aucun

What's New in Intensive Care

Editorial : In spite of important progress in the eld of ventilator- associated pneumonia (VAP) pathophysiology and pre- vention, this infection is still commonly diagnosed in critically ill patients requiring invasive mechanical venti- lation. Recognizing ine ective measures for VAP preven- tion is helpful to avoid side e ects of these interventions and to reduce associated costs and workload in the inten- sive care unit (ICU).

Résultats : 1. Residual gastric volume measurement
2. Parenteral nutrition
3. Stress ulcer prophylaxis
4. Systemic or inhaled antibiotic therapy
5. Statins
6. Closed tracheal suctioning system
7. Improved tracheal cuff
8. Early tracheostomy
9. Kinetic beds
10. Prone positioning

Conclusion : On the basis of the current literature, the measures discussed above are not effective and should not be used for VAP prevention (Table 1). However, some measures, such as inhaled antimicrobials, closed tracheal suctioning system, and kinetic beds should be further investigated to draw de nite conclusions. In addition, some inffective measures, such as prone positioning or closed tracheal suctioning system, could be used in the critically ill patients for purposes other than VAP prevention.

Conclusion (proposition de traduction) : Sur la base de la littérature actuelle, les mesures discutées ci-dessus ne sont pas efficaces et ne devraient pas être utilisées pour la prévention des pneumopathies acquises sous respirateur (Tableau 1).
Cependant, certaines mesures, telles que les antimicrobiens inhalés, le système d'aspiration trachéale fermée et les lits cinétiques devraient faire l'objet d'études plus poussées afin de tirer des conclusions définitives. En outre, certaines mesures inefficaces, telles que le positionnement sur le ventre ou le système d'aspiration trachéale fermée, pourraient être utilisées chez les patients de soins intensifs à des fins autres que la prévention des pneumopathies acquises sous respirateur.

Understanding blood gas analysis.
Gattinoni L, Pesenti A, Matthay M. | Intensive Care Med. 2018 Jan;44(1):91-93
Keywords: Aucun

Understanding the Disease

Editorial : Blood gas analysis is probably the most common diag- nostic tool used in intensive care. In fact, a proper under- standing and use of arterial and pulmonary/central venous blood gas and electrolytes analysis makes it pos- sible to correctly interpret most of the respiratory, circu- latory and metabolic derangements which may occur in critically ill patients.

Conclusion (proposition de traduction) : L'analyse des gaz du sang est probablement l'outil diagnostique le plus commun utilisé en soins intensifs. En fait, une bonne compréhension et utilisation des analyses des gaz du sang veineux artériel et pulmonaire/central et des électrolytes permet d'interpréter correctement la plupart des troubles respiratoires, circulatoires et métaboliques qui peuvent survenir chez les patients de soins intensifs.

Journal of Critical Care

Current practices and safety of medication use during rapid sequence intubation.
Groth CM, Acquisto NM, Khadem T. | J Crit Care. 2018 Jan 30;45:65-70
Keywords: Adverse effects; Emergency department; Intensive Care Unit (ICU); Medications; Rapid sequence intubation (RSI)

Original article

Introduction : Characterize medication practices during and immediately after rapid sequence intubation (RSI) by provider/location and evaluate adverse drug events.

Méthode : This was a multicenter, observational, cross-sectional study of adult and pediatric intensive care unit and emergency department patients over a 24-h period surrounding first intubation.

Résultats : A total of 404 patients from 34 geographically diverse institutions were included (mean age 58 ± 22 years, males 59%, pediatric 8%). During RSI, 21%, 87%, and 77% received pre-induction, induction, and paralysis, respectively. Significant differences in medication use by provider type were seen. Etomidate was administered to 58% with sepsis, but was not associated with adrenal insufficiency. Ketamine was associated with hypotension post-RSI [RR = 1.78 (1.36-2.35)] and use was low with traumatic brain injury/stroke (1.5%). Succinylcholine was given to 67% of patients with baseline bradycardia and was significantly associated with bradycardia post-RSI [RR = 1.81 (1.11-2.94)]. An additional 13% given succinylcholine had contraindications. Sedation practices post-RSI were not consistent with current practice guidelines and most receiving a non-depolarizing paralytic did not receive adequate sedation post-RSI.

Conclusion : Medication practices during RSI vary amongst provider and medications are often used inappropriately. There is opportunity for optimization of medication use during RSI.

Conclusion (proposition de traduction) : Les pratiques médicamenteuses au cours de l'ISR varient d'un service à l'autre et les médicaments sont souvent utilisés de façon inappropriée. Il est possible d'optimiser l'utilisation des médicaments pendant le ISR.

Accuracy of SOFA, qSOFA, and SIRS scores for mortality in cancer patients admitted to an intensive care unit with suspected infection.
Costa RT, Nassar AP Jr, Caruso P. | J Crit Care. 2018 Jan 4;45:52-57
Keywords: Cancer; Intensive care unit; Mortality; Organ dysfunction; Sepsis

Original article

Introduction : To compare the prognostic accuracy of Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) with systemic inflammatory response syndrome (SIRS) criteria in critically ill cancer patients with suspected infection.

Méthode : Data for 450 cancer patients admitted to an intensive care unit (ICU) in 2014 with a suspected infection were retrospectively analyzed. Sensitivity, specificity, and area under the receiver operating curve (AUC) values for SOFA, qSOFA, and SIRS criteria for ICU and hospital mortalities were calculated. Mortalities according to Sepsis-2 stratification (e.g., sepsis, severe sepsis, and septic shock) and Sepsis-3 stratification (e.g., infection, sepsis, and septic shock) were also compared.

Résultats : SOFA outperformed SIRS in predicting mortalities for ICU [(AUC, 0.76; 95% confidence interval (CI) 95%, 0.71-0.81) vs. (AUC, 0.62; 95% CI, 0.56-0.67), p < .01] and hospital [(AUC, 0.69; 95% CI, 0.65-0.74) vs. (AUC, 0.58; 95% CI, 0.52-0.63), p < .01)] patients. Similarly, qSOFA outperformed SIRS for both settings [(AUC, 0.71; 95% CI, 0.65-0.76, p = .02) vs. (AUC, 0.69; 95% CI, 0.64-0.74; p < .01), respectively].

Conclusion : SOFA and qSOFA were more sensitive and accurate than SIRS in predicting ICU and hospital mortality for critically ill cancer patients with suspected infection.

Conclusion (proposition de traduction) : Le SOFA et qSOFA étaient plus sensibles et plus précis que le SIRS dans la prédiction de la mortalité en soins intensifs et à l'hôpital pour les patients atteints de cancer avec une suspicion d'infection en soins intensifs.

Journal of the American College of Cardiology

1-Year Outcomes of Patients Undergoing Primary Angioplasty for Myocardial Infarction Treated With Prasugrel Versus Ticagrelor.
Motovska Z, and al; PRAGUE-18 Study Group.. | J Am Coll Cardiol. 2018 Jan 30;71(4):371-381
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : Early outcomes of patients in the PRAGUE-18 (Comparison of Prasugrel and Ticagrelor in the Treatment of Acute Myocardial Infarction) study did not find any significant differences between 2 potent P2Y12 inhibitors.
OBJECTIVES: The 1-year follow-up of the PRAGUE-18 study focused on: 1) a comparison of efficacy and safety between prasugrel and ticagrelor; and 2) the risk of major ischemic events related to an economically motivated post-discharge switch to clopidogrel.

Méthode : A total of 1,230 patients with acute myocardial infarction (MI) treated with primary percutaneous coronary intervention were randomized to prasugrel or ticagrelor with an intended treatment duration of 12 months. The combined endpoint was cardiovascular death, MI, or stroke at 1 year. Because patients had to cover the costs of study medication after hospital discharge, some patients decided to switch to clopidogrel.

Résultats : The endpoint occurred in 6.6% of prasugrel patients and in 5.7% of ticagrelor patients (hazard ratio: 1.167; 95% confidence interval: 0.742 to 1.835; p = 0.503). No significant differences were found in: cardiovascular death (3.3% vs. 3.0%; p = 0.769), MI (3.0% vs. 2.5%; p = 0.611), stroke (1.1% vs. 0.7%; p = 0.423), all-cause death (4.7% vs. 4.2%; p = 0.654), definite stent thrombosis (1.1% vs. 1.5%; p = 0.535), all bleeding (10.9% vs. 11.1%; p = 0.999), and TIMI (Thrombolysis In Myocardial Infarction) major bleeding (0.9% vs. 0.7%; p = 0.754). The percentage of patients who switched to clopidogrel for economic reasons was 34.1% (n = 216) for prasugrel and 44.4% (n = 265) for ticagrelor (p = 0.003). Patients who were economically motivated to switch to clopidogrel had (compared with patients who continued the study medications) a lower risk of major cardiovascular events; however, they also had lower ischemic risk.

Conclusion : Prasugrel and ticagrelor are similarly effective during the first year after MI. Economically motivated early post-discharge switches to clopidogrel were not associated with an increased risk of ischemic events.

Conclusion (proposition de traduction) : Le prasugrel et le ticagrelor sont également efficaces au cours de la première année suivant l'infarctus du myocarde. Les substitutions post-interventionnelles précoces par du clopidogrel, motivées par des raisons économiques, n'étaient pas associées à un risque accru d'événements ischémiques.

Trends in Survival After In-Hospital Cardiac Arrest During Nights and Weekends.
Ofoma UR, Basnet S, Berger A, Kirchner HL, Girotra S; American Heart Association Get With the Guidelines – Resuscitation Investigators. | J Am Coll Cardiol. 2018 Jan 30;71(4):402-411
Keywords: Aucun

Original Investigation

Introduction : Survival after in-hospital cardiac arrest (IHCA) is lower during nights and weekends (off-hours) compared with daytime during weekdays (on-hours). As overall IHCA survival has improved over time, it remains unknown whether survival differences between on-hours and off-hours have changed.
OBJECTIVES: This study sought to examine temporal trends in survival differences between on-hours and off-hours IHCA.

Méthode : We identified 151,071 adults at 470 U.S. hospitals in the Get with the Guidelines-Resuscitation registry during 2000 to 2014. Using multivariable logistic regression with generalized estimating equations, we examined whether survival trends in IHCA differed during on-hours (Monday to Friday 7:00 am to 10:59 pm) versus off-hours (Monday to Friday 11:00 pm to 6:59 am, and Saturday to Sunday, all day).

Résultats : Among 151,071 participants, 79,091 (52.4%) had an IHCA during off-hours. Risk-adjusted survival improved over time in both groups (on-hours: 16.0% in 2000, 25.2% in 2014; off-hours: 11.9% in 2000, 21.9% in 2014; p for trend <0.001 for both). However, there was no significant change in the survival difference over time between on-hours and off-hours, either on an absolute (p = 0.75) or a relative scale (p = 0.059). Acute resuscitation survival improved significantly in both groups (on-hours: 56.1% in 2000, 71% in 2014; off-hours: 46.9% in 2000, 68.2% in 2014; p for trend <0.001 for both) and the difference between on-hours and off-hours narrowed over time (p = 0.02 absolute scale, p < 0.001 relative scale). In contrast, although post-resuscitation survival also improved over time in both groups (p for trend < 0.001 for both), the absolute and relative difference persisted.

Conclusion : Despite an overall improvement in survival, lower survival in IHCA during off-hours compared with on-hours persists.

Conclusion (proposition de traduction) : Malgré une amélioration globale de la survie, on constate une survie plus faible après un arrêt cardiaque à l'hôpital, en dehors des heures de travail, par rapport aux heures d'ouverture persiste.

2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways.
Yancy CW, Januzzi JL Jr., Allen LA, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Jessup M, Lindenfeld J, Maddox TM, Masoudi FA, Motiwala SR, Patterson JH, Walsh MN, Wasserman A. | J Am Coll Cardiol. 2018 Jan 16;71(2):201-230
Keywords: Aucun

Expert Consensus Decision Pathway

Introduction : The prevalence of HF is escalating rapidly. Compounding this, HF is an illness that consumes significant health care resources, inflicts significant morbidity and mortality, and greatly impacts quality of life. Important breakthroughs have redefined opportunities to change the natural history of the disease with a broad range of medical therapies, devices, and care strategies, including readmission reduction programs and ambulatory outpatient disease management for those with more advanced disease.

Conclusion : Management of HFrEF often involves multidisciplinary care, may require complex decision making, and benefits from a solid foundation of knowledge to manage these occasionally fragile patients. HF is a major public health concern, one in which broader clinician experience in GDMT would be expected to significantly benefit affected patients. With recent changes in available diagnostics and therapeutics for HFrEF along with evolution in recommended management strategies for affected patients, many questions have emerged regarding optimal deployment of these newer approaches to patient care. Additionally, clinical practice guidelines continue to evolve. In this context, we have highlighted important literature citations explaining the rationale for this changing picture in HFrEF care, candidate best practices, and, where evidence or best practices are lacking, templates for clinical decision making to rationally manage patients. As more evidence emerges, many topics will be clarified.

Conclusion (proposition de traduction) : La prise en charge de l'insuffisance cardiaque avec une fraction d'éjection altérée implique souvent des soins multidisciplinaires, peut nécessiter une prise de décision complexe et bénéficie d'une solide base de connaissances pour prendre en charge ces patients parfois fragiles. L'insuffisance cardiaque est un problème de santé publique majeur, pour lequel on s'attendrait à ce qu'une expérience clinique plus vaste en matière de recommandation médicale thérapeutiques soit très bénéfique pour les patients atteints. Avec les changements récents dans les diagnostics et les traitements disponibles pour l'insuffisance cardiaque avec une fraction d'éjection altérée et l'évolution des stratégies de gestion recommandées pour les patients atteints, de nombreuses questions sont apparues concernant le déploiement optimal de ces nouvelles approches de soins aux patients. De plus, les recommandations de pratique clinique continuent d'évoluer.
Dans ce contexte, nous avons mis en évidence d'importantes citations de la littérature expliquant la raison d'être de ce tableau évoluant de l'insuffisance cardiaque avec une fraction d'éjection altérée, les meilleures pratiques à retenir et, lorsque les données probantes ou les meilleures pratiques font défaut, des modèles de prise de décision clinique pour la prise en charge rationnelle des patients. Au fur et à mesure que d'autres preuves émergeront, de nombreux sujets seront clarifiés.

Commentaire : Ten Principles for Successful Treatment of Heart Failure 

Obesity: Pathophysiology and Management.
Gadde KM, Martin CK, Berthoud HR, Heymsfield SB. | J Am Coll Cardiol. 2018 Jan 2;71(1):69-84
Keywords: Aucun

State-of-the-Art Review

Editorial : Obesity continues to be among the top health concerns across the globe. Despite our failure to contain the high prevalence of obesity, we now have a better understanding of its pathophysiology, and how excess adiposity leads to type 2 diabetes, hypertension, and cardiovascular disease. Lifestyle modification is recommended as the cornerstone of obesity management, but many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. Fortunately, 5 drug therapies-orlistat, lorcaserin, liraglutide, phentermine/topiramate, and naltrexone/bupropion-are available for long-term weight management. Additionally, several medical devices are available for short-term and long-term use. Bariatric surgery yields substantial and sustained weight loss with resolution of type 2 diabetes, although due to the high cost and a small risk of serious complications, it is generally recommended for patients with severe obesity. Benefit-to-risk balance should guide treatment decisions.

Conclusion : Obesity, besides impairing quality of life, is associated with numerous chronic diseases. Fortunately, weight reduction improves management of many of these diseases, especially T2D. Although global obesity prevalence has not decreased, more therapeutic op- tions are available today, thus improving management of patients with obesity and related comorbidities.

Conclusion (proposition de traduction) : L'obésité, en plus de nuire à la qualité de vie, est associée à de nombreuses maladies chroniques. Heureusement, la réduction du poids améliore la gestion de nombre de ces maladies, en particulier le diabète de type 2. Bien que la prévalence mondiale de l'obésité n'ait pas diminué, il existe aujourd'hui davantage d'options thérapeutiques, ce qui permet d'améliorer la prise en charge des patients souffrant d'obésité et de comorbidités connexes.

Journal of the American Medical Association

Diagnosis and Treatment of Hypertension in the 2017 ACC/AHA Guidelines and in the Real World.
Ioannidis JPA | JAMA. 2018 Jan 9;319(2):115-116
Keywords: Aucun


Editorial : The recently released American College of Cardiology/American Heart Association (ACC/AHA) guidelines1 promote radical changes in the management of hypertension. First, given the change in the definition of the condition (blood pressure >130/80 mm Hg instead of >140/90 mm Hg), the proportion of adults in the United States labeled as having hypertension has suddenly increased from 32% to 46%.2 Second, the new blood pressure target of treatment is also accordingly lower. Third, use of antihypertensive drugs is to be guided by blood pressure as well as by the presence of cardiovascular disease (CVD), diabetes, or a more than 10% 10-year risk of developing CVD. Fourth, the guidelines put more emphasis on monitoring blood pressure at home and on team-based systems for managing hypertension.

Conclusion : Guideline

Diagnosis and Treatment of Hypertension in the 2017 ACC/AHA Guidelines and in the Real World.
Ioannidis JPA | JAMA. 2018 Jan 9;319(2):115-116
Keywords: Aucun


Editorial : The recently released American College of Cardiology/American Heart Association (ACC/AHA) guidelines1 promote radical changes in the management of hypertension. First, given the change in the definition of the condition (blood pressure >130/80 mm Hg instead of >140/90 mm Hg), the proportion of adults in the United States labeled as having hypertension has suddenly increased from 32% to 46%.2 Second, the new blood pressure target of treatment is also accordingly lower. Third, use of antihypertensive drugs is to be guided by blood pressure as well as by the presence of cardiovascular disease (CVD), diabetes, or a more than 10% 10-year risk of developing CVD. Fourth, the guidelines put more emphasis on monitoring blood pressure at home and on team-based systems for managing hypertension.

Conclusion : The wish to reap every benefit possible from blood pressure control, even for relatively low-risk patients, is welcome. However, clinicians should not forget that many high-risk patients remain undiagnosed even with very high blood pressure. Many others receive suboptimal treatment, even according to more conservative definitions of hypertension. The new guidelines promote team-based system approaches for better diagnosis and management of hypertension and, indeed, there is evidence that team-based systems can offer substantial gains on these fronts.10 The ability to generalize these gains across diverse settings in clinical practice and to use limited resources wisely remains an open challenge.

Conclusion (proposition de traduction) : The wish to reap every benefit possible from blood pressure control, even for relatively low-risk patients, is welcome. However, clinicians should not forget that many high-risk patients remain undiagnosed even with very high blood pressure. Many others receive suboptimal treatment, even according to more conservative definitions of hypertension. The new guidelines promote team-based system approaches for better diagnosis and management of hypertension and, indeed, there is evidence that team-based systems can offer substantial gains on these fronts.10 The ability to generalize these gains across diverse settings in clinical practice and to use limited resources wisely remains an open challenge.

Association Between Handover of Anesthesia Care and Adverse Postoperative Outcomes Among Patients Undergoing Major Surgery.
Jones PM, Cherry RA, Allen BN, Jenkyn KMB, Shariff SZ, Flier S, Vogt KN, Wijeysundera DN. | JAMA. 2018 Jan 9;319(2):143-153
Keywords: Aucun

Original Investigation

Introduction : Handing over the care of a patient from one anesthesiologist to another occurs during some surgeries and might increase the risk of adverse outcomes.
OBJECTIVE: To assess whether complete handover of intraoperative anesthesia care is associated with higher likelihood of mortality or major complications compared with no handover of care.

Méthode : A retrospective population-based cohort study (April 1, 2009-March 31, 2015 set in the Canadian province of Ontario) of adult patients aged 18 years and older undergoing major surgeries expected to last at least 2 hours and requiring a hospital stay of at least 1 night.
EXPOSURE: Complete intraoperative handover of anesthesia care from one physician anesthesiologist to another compared with no handover of anesthesia care.

Résultats : Of the 313 066 patients in the cohort, 56% were women; the mean (SD) age was 60 (16) years; 49% of surgeries were performed in academic centers; 72% of surgeries were elective; and the median duration of surgery was 182 minutes (interquartile [IQR] range, 124-255). A total of 5941 (1.9%) patients underwent surgery with complete handover of anesthesia care. The percentage of patients undergoing surgery with a handover of anesthesiology care progressively increased each year of the study, reaching 2.9% in 2015. In the unweighted sample, the primary outcome occurred in 44% of the complete handover group compared with 29% of the no handover group. After adjustment, complete handovers were statistically significantly associated with an increased risk of the primary outcome (adjusted risk difference [aRD], 6.8% [95% CI, 4.5% to 9.1%]; P < .001), all-cause death (aRD, 1.2% [95% CI, 0.5% to 2%]; P = .002), and major complications (aRD, 5.8% [95% CI, 3.6% to 7.9%]; P < .001), but not with hospital readmission within 30 days of surgery (aRD, 1.2% [95% CI, -0.3% to 2.7%]; P = .11).

Conclusion : Among adults undergoing major surgery, complete handover of intraoperative anesthesia care compared with no handover was associated with a higher risk of adverse postoperative outcomes. These findings may support limiting complete anesthesia handovers.

Conclusion (proposition de traduction) : Chez les adultes bénéficiant d'une intervention chirurgicale lourde, les transmissions de la prise en charge des soins anesthésiques peropératoires par rapport à l'absence de transmission ont été associées à un risque plus élevé d'événements indésirables postopératoires. Ces observations peuvent contribuer à justifier la limitation les transmissions de la prise en charge des soins anesthésiques peropératoires.

Commentaire : Les transmissions au bloc opératoire favorisent la survenue d'évènements indésirables pour les anesthésistes. Quant est-il pour les jonctions entres équipes SMUR, les transmissions entre équipes aux urgences… ?
Commentaires de l'article dans la revue JAMA : Handovers During Anesthesia Care: Patient Safety Risk or Opportunity for Improvement?  

What This Computer Needs Is a Physician: Humanism and Artificial Intelligence.
Verghese A, Shah NH, Harrington RA. | JAMA. 2018 Jan 2;319(1):19-20
Keywords: Aucun


Editorial : he recent challenges to the Affordable Care Act (ACA), which has increased the number of individuals with health insurance in the United States but has had little effect on cost, has revived the debate about a single-payer health care system.1 Whether a single-payer system is the answer or not depends on what question is being asked and what form single payer will take. Single payer can take many forms, and many questions can be asked. This Viewpoint considers 3 problems of US health care: the uninsured, poor health outcomes (relative to other high-income countries), and high cost. In discussing cost, it will be critical to consider the form that a single-payer health care system might take.

Conclusion : In the care of the sick, there is a key function played by physi- cians, referred to by Tinsley Harrison as the “priestly function of the physician.” Human intelligence working with artificial intelligence— a well-informed, empathetic clinician armed with good predictive tools and unburdened from clerical drudgery—can bring physicians closer to fulfilling Peabody’s maxim that the secret of care is in “caring for the patient.”

Conclusion (proposition de traduction) : Dans le soin aux malades, il y a une fonction clé jouée par les médecins, que Tinsley Harrison appelle la « fonction sacerdotale du médecin ». L'intelligence humaine travaille avec l'intelligence artificielle - un clinicien bien informé et empathique, armé de bons outils prédictifs et libérés des corvées cléricales - peuvent rapprocher les médecins de la maxime de Peabody selon laquelle le secret des soins consiste à « prendre soin du patient ».

Pediatric Emergency Care

A Survey of Return Visits to the Pediatric Emergency Department: The Caretakers' Perspective.
Augustine EM, Bekker TD, Goel A, Breslin KA, Chamberlain JM. | Pediatr Emerg Care. 2018 Jan;34(1):27-32
Keywords: Aucun

Original Articles

Introduction : Approximately 5% of children return to the emergency department within 72 hours of a first evaluation. Previous literature has focused on healthcare utilization and the use of return visits as a quality metric. The goal of this study was to quantify reasons for return visits from the caretaker perspective.

Méthode : Caretaker surveys were developed based on previously identified themes from focus groups. When considering reasons for return, multiple answers were allowed. Surveys were administered to a convenience sample of eligible caretakers who returned to the emergency department within 72 hours between June and August 2013. Caretakers were excluded if the return was scheduled or for an unrelated complaint.

Résultats : Of the 306 eligible caretakers, 83 (27%) participated. A majority returned because of continued (92%) or worsening symptoms (70%). More than half returned because they did not know how to help their child at home (60%), they did not understand their child's illness (59%), and/or they did not expect the persistence of symptoms (58%). Overall, caretakers felt more testing (55%), treatments (45%), medications (41%), and information (28%) should have been provided at the initial visit. Caretakers of children admitted at the second visit were significantly more dissatisfied with care at the first visit (P = 0.05).

Conclusion : The most commonly reported reasons for pediatric return visits were continued symptoms and lack of illness understanding. We plan to use these data to develop targeted interventions to decrease the perceived need for return visits.

Conclusion (proposition de traduction) : Les motifs les plus fréquemment rapportés pour les ré-hospitalisations dans le service des urgences pédiatriques étaient la persistance des signes et l'absence de compréhension de la maladie.
Nous prévoyons utiliser ces données pour élaborer des actions ciblées afin de réduire les motifs de ré-hospitalisation.

Effect of Intravenous Ondansetron on the QT Interval of Patients' Electrocardiograms.
Krammes SK, Jacobs T, Clark JM, Lutes RE. | Pediatr Emerg Care. 2018 Jan;34(1):38-41
Keywords: Aucun

Original Articles

Introduction : Ondansetron improves the success of oral rehydration in children with gastroenteritis. In postoperative adults, ondansetron has been shown to prolong the corrected QT (QTc). The aim of the study was to evaluate the effect of ondansetron on the QT at peak effect and at 1-hour postpeak effect in pediatric patients.

Méthode : This was an observational study looking at patients aged 6 months to 18 years receiving intravenous ondansetron for nausea, vomiting, or the inability to take fluids in the emergency department. Patients had electrocardiogram performed at baseline, at ondansetron's peak effect, and 1 hour postpeak effect. A paired samples Student t test compared QTc change at peak effect to zero. Peak effect of intravenous ondansetron is 3 minutes.

Résultats : One hundred patients were included. Fifty-five percent of patients were female with a mean age of 8.3 years. The mean (range) baseline QTc was 435 (388 to 501) milliseconds. The mean (range) change in QTc at peak effect of ondansetron was 3 (-40 to 65) milliseconds (P = 0.072). The change in QTc 1-hour postpeak effect of ondansetron was 3 (-43 to 45) milliseconds (P = 0.082). No change at peak effect or 1-hour postpeak effect was clinically significant.

Conclusion : Ondansetron does not affect the QTc of pediatric patients receiving the medication for nausea, vomiting, or inability to take fluids in the emergency department. No changes in the QTc are clinically significant. To date, there have been no studies evaluating the effect of ondansetron in this acutely ill population; therefore, a larger study should be completed to confirm these data.

Conclusion (proposition de traduction) : L'ondansétron ne modifie pas l'intervalle QTc des patients de pédiatrie qui bénéficient de ce traitement pour nausées, vomissements ou l'impossibilité de prise de liquides dans le service des urgences. Aucune modification de l'intervalle QTc n'était cliniquement significatif.
À ce jour, aucune étude n'a évalué l'effet de l'ondansétron dans cette population d'enfant malade nécessitant un traitement ; par conséquent, une étude de plus grande envergure devrait être réalisée pour confirmer ces données.


Comparison of Treatment Persistence with Dabigatran or Rivaroxaban versus Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation Patients: A Competing Risk Analysis in the French National Health Care Databases.
Maura G, Billionnet C, Alla F, Gagne JJ, Pariente A. | Pharmacotherapy. 2018 Jan;38(1):6-18
DOI:  | Télécharger l'article au format  
Keywords: atrial fibrillation; bleeding; health data; oral anticoagulant; persistence

Original Research Article

Introduction : Direct oral anticoagulants (DOACs) have been proposed as a more convenient alternative to vitamin K antagonists (VKAs), which are commonly associated with poor treatment persistence in non-valvular atrial fibrillation (nv-AF).

Méthode : Using data from the French national health care databases (Régime Général, 50 million beneficiaries), a cohort study was conducted to compare the 1-year non-persistence rates in nv-AF patients initiating dabigatran (N=11,141) or rivaroxaban (N=11,126) versus VKA (N=11,998). Treatment discontinuation was defined as a switch between oral anticoagulant (OAC) classes or a 60-day gap with no medication coverage, with the additional criterion of no reimbursement for international normalized ratio monitoring during this gap for VKA patients. Considering death as a competing risk, differences between 1-year discontinuation rates were used to compare each DOAC versus VKA. The 95% confidence intervals (CIs) were estimated via bootstrapping. Baseline patient characteristics were adjusted using inverse probability of treatment weighting. Subgroup analyses considered DOAC dose at initiation, age, risk of stroke, and bleeding.

Résultats : Adjusted 1-year discontinuation rates were higher for dabigatran than for VKA new users (36.8% vs 30.2%; difference: 6.6% [95% CI, 5.5-7.6]) and for rivaroxaban versus VKA new users (33.4% vs 30.4%; 3.0% [1.9-4.1]). Similar differences were found in all subgroup analyses, except in dabigatran and rivaroxaban patients <75 years (dabigatran vs VKA: 0.3% [-1.4 to 1.8]; rivaroxaban vs VKA: -2.6% [-4.3 to -0.9]) and dabigatran 150 mg new users (-1.1% [-3.1 to 0.7]). Consistent results were obtained when considering both switches between OAC classes and death as competing risks of treatment discontinuation.

Conclusion : Results from this nationwide cohort study showed high non-persistence levels with all OACs and suggest that persistence with both dabigatran and rivaroxaban therapy is not better than persistence with VKA therapy. Hospitalizations for bleeding among non-persistent patients were unlikely to explain these high non-persistence rates.

Conclusion (proposition de traduction) : Les résultats de cette étude de cohorte à l'échelle nationale ont montré des taux élevés de non-observance avec tous les anticoagulants oraux et suggèrent que l'observance avec le dabigatran et le rivaroxaban n'est pas meilleure que l'observance avec le traitement avec les AVK. Les hospitalisations dues à des saignements chez les patients non observants étaient peu susceptibles d'expliquer ces taux élevés de non-observance.

Commentaire : Voir l'analyse de l'article sur le site Medscape : FA et observance thérapeutique : les AOD ne font pas mieux que les AVK - Medscape - 5 oct 2018  . Rédigé par Aude Lecrubier.

Prehospital Emergency Care

Procedural Sedation and Analgesia in Trauma Patients in an Out-of-Hospital Emergency Setting: A Prospective Multicenter Observational Study.
Galinski M, Hoffman L, Bregeaud D, Kamboua M, Ageron FX, Rouanet C, Hubert JC, Istria J, Ruscev M, Tazarourte K, Pevirieri F, Lapostolle F, Adnet F. | Prehosp Emerg Care. 2018 Jan 31:1-9
Keywords: Aucun

Original articles

Introduction : The quality of procedural analgesia and sedation among trauma patients has not been studied much in the prehospital setting. The main objective of this study was to characterize the quality of procedural analgesia sedation practices in prehospital settings in trauma patients.

Méthode : This was an open-label observational prospective multicenter study (January 01, 2012-December 31, 2013). We included all consecutive trauma victims undergoing a potentially painful procedure on the accident scene. The primary endpoint was the procedural pain intensity.

Résultats : Data for 210 patients aged 11 to 98 years were analyzed. The most common lesions were limb fractures or dislocations. The most common procedures were limb realignment and splinting. Overall, 25 different drug combinations [with paracetamol [acetaminophen], non-steroidal anti-inflammatory drugs, nefopam, opioids, loco-regional anesthesia, Equimolar Mixture of Oxygen/Nitrous Oxide (EMONO), sedative drugs] were used by the emergency medical services (EMS). One hundred seventeen patients (55%) received either one or two sedative drugs (among ketamine, propofol, and midazolam), 171 patients (81%) received morphine that was combined with a sedative drug in 54% of cases. During the procedure, 95 patients, 45% [95% Confidence Interval (CI) 39-52] experienced intense to severe pain. Among patients who received sedative drugs, 27% (32/117) had intense to severe pain vs. 68% (63/93) in patients who did not, that is, 40% difference [95% CI 33.8-47.0]. Seventeen patients (8%) experienced 18 adverse events of which 6 were respiratory adverse events. A deep sedation occurred in 17 patients. No center had any specific protocols for procedural sedation analgesia.

Conclusion : Procedural sedation-analgesia was inadequate in almost half of the trauma patients in the out-of-hospital setting. The reasons of these failures were probably multiple. The non-administration of a sedative drug despite an indication or non-adapted doses, in the context of a lack of specific protocols, was certainly one of them.

Conclusion (proposition de traduction) : La sédation-analgésie procédurale était inadéquate chez près de la moitié des patients traumatisés extra-hospitalier. Les raisons de ces échecs étaient probablement multiples. La non-administration d'un médicament sédatif malgré une indication ou bien des doses de médicament non adaptées, dans le contexte d'un manque de protocoles spécifiques, en faisait certainement partie.

Commentaire : La conclusion est sans appel...


Frequency and significance of qSOFA criteria during adult rapid response team reviews: A prospective cohort study.
LeGuen M, Ballueer Y, McKay R, Eastwood G, Bellomo R, Jones D; Austin Health RRT qSOFA investigators. | Resuscitation. 2018 Jan;122:13-18
Keywords: Infection; RRT call; SOFA; Sepsis; qSOFA

Original research article

Introduction : A new definition of sepsis released by an international task-force has introduced the concept of quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA). This study aimed to measure the proportion of patients who fulfilled qSOFA criteria during a Rapid Response Team (RRT) review and to assess their associated outcomes.

Méthode : We conducted a prospective study of adult RRT reviews over a one month period between 6th June and 10th July 2016 in a large tertiary hospital in Melbourne Australia.

Résultats : Over a one-month period, there were 282 RRT reviews, 258 of which were included. One hundred out of 258 (38.8%) RRT review patients fulfilled qSOFA criteria. qSOFA positive patients were more likely to be admitted to the intensive care unit (29% vs 18%, P=0.04), to have repeat RRT reviews (27% vs 13%; p=0.007) and die in hospital (31% vs 10%, P<0.001). qSOFA positive patients with suspected infection were more likely to be admitted to the intensive care unit compared to patients with infection alone (37% vs 15%, P=0.002). Eleven of 42 patients (26%) who had infection and qSOFA died whilst in hospital, compared to 8/55 (15%) of patients with infection alone (P=0.2).

Conclusion : Adult patients who are qSOFA positive at the time of their RRT review are at increased risk of in-hospital mortality. The assessment of qSOFA may be a useful triage tool during a RRT review.

Conclusion (proposition de traduction) : Les patients adultes qui ont un qSOFA ≥ 2 au moment de l'examen par l’équipe médicale des urgences sont exposés à un risque accru de mortalité intra-hospitalière. L'évaluation du qSOFA peut être un outil de triage utile lors d'un examen par l’équipe médicale des urgences.

Commentaire : Etudes sur l'intérêt du score qSOFA très tendance mais résultats peu probants en ce qui concerne spécifiquement la gravité ou le diagnostic d'un sepsis. Il semble qu'il soit plutôt utile comme un score de « gravité ».
Le qSOFA permet de suspecter un sepsis dès la phase initiale de prise en charge, en réanimation (pas de validation dans un service d'urgence). C'est un score simple qui doit être répété. Son utilisation comporte 3 critères dont 2 sont nécessaires pour suspecter un sepsis. Attention, le qSOFA est un score pronostic de mortalité, PAS une test diagnostic de septicémie. Rhodes A and al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock  : 2016 Crit Care Med. 2017 Mar;45(3):486-552.

Predicting ROSC in out-of-hospital cardiac arrest using expiratory carbon dioxide concentration: Is trend-detection instead of absolute threshold values the key?.
Brinkrolf P, Borowski 2, Metelmann C, Lukas RP, Pidde-Küllenberg L, Bohn A. | Resuscitation. 2018 Jan;122:19-24
Keywords: Out of hospital cardiac arrest; Real-time; Repeated median regression; Return of spontaneous circulation (ROSC); Trend detection

Original research article

Introduction : Guidelines recommend detecting return of spontaneous circulation (ROSC) by a rising concentration of carbon dioxide in the exhalation air. As CO2 is influenced by numerous factors, no absolute cut-off values of CO2 to detect ROSC are agreed on so far. As trends in CO2 might be less affected by influencing factors, we investigated an approach which is based on detecting CO2-trends in real-time.

Méthode : We conducted a retrospective case-control study on 169 CO2 time series from out of hospital cardiac arrests resuscitated by Muenster City Ambulance-Service, Germany. A recently developed statistical method for real-time trend-detection (SCARM) was applied to each time series. For each series, the percentage of time points with detected positive and negative trends was determined.

Résultats : ROSC time series had larger percentages of positive trends than No-ROSC time series (p=0.003). The median percentage of positive trends was 15% in the ROSC time series (IQR: 5% to 23%) and 7% in the No-ROSC time series (IQR: 3% to 14%). A receiver operating characteristic (ROC) analysis yielded an optimal threshold of 13% to differentiate between ROSC and No-ROSC cases with a specificity of 58.4% and sensitivity of 73.9%; the area under the curve was 63.5%.

Conclusion : Patients with ROSC differed from patients without ROSC as to the percentage of detected CO2 trends, indicating the potential of our real-time trend-detection approach. Since the study was designed as a proof of principle and its calculated specificity and sensitivity are low, more research is required to implement CO2-trend-detection into clinical use.

Conclusion (proposition de traduction) : Les patients avec RACS différaient des patients sans RACS quant au pourcentage de tendances d'EtCO2 détectées, indiquant le potentiel de notre approche de détection de tendance en temps réel. Étant donné que l'étude a été conçue comme une preuve de principe et que sa spécificité et sa sensibilité calculées sont faibles, d'autres recherches sont nécessaires pour mettre en œuvre la détection des tendances d'EtCO2 en clinique.

Long-term survival in patients with acute myocardial infarction and out-of-hospital cardiac arrest: A prospective cohort study.
Kvakkestad KM, Sandvik L, Andersen GØ, Sunde K, Halvorsen S. | Resuscitation. 2018 Jan;122:41-47
DOI:  | Télécharger l'article au format  
Keywords: Acute myocardial infarction; Long-term survival; Out-of-hospital cardiac arrest

Original research article

Introduction : To compare short- and long-term survival in patients admitted to hospital after acute myocardial infarction (AMI) with and without out-of-hospital cardiac arrest (OHCA).

Méthode : Prospective cohort study of all AMI patients admitted to Oslo University Hospital Ulleval from September 1, 2005 to December 31, 2011. All-cause mortality was obtained from the Norwegian Cause of Death Registry with censoring date December 31, 2013. Cumulative survival was assessed with the Kaplan-Meier and the Life-table method. Logistic- and Cox regression were used for risk comparisons.

Résultats : We identified 404 AMI patients with OHCA and 9425 AMI patients without. AMI patients without OHCA were categorized as ST-elevation myocardial infarction (STEMI, n=4522) or non-STEMI (NSTEMI, n=4903). Mean age was 63.6±standard deviation (SD) 12.5, 63.8±13.1 and 69.7±13.6 years in OHCA, STEMI and NSTEMI, respectively. Coronary angiography with subsequent percutaneous coronary intervention if indicated, was performed in 87% of OHCA, 97% of STEMI and 80% of NSTEMI patients. Thirty-day survival was 63%, 94% and 94%, and 8-year survival was 49%, 74%, and 57%, respectively. Among patients surviving the first 30days, no significant difference in risk during long-term follow-up was found (adjusted Hazard Ratio (aHR)OHCAvsSTEMI 1.15 [95% CI 0.82-1.60], aHROHCAvsNSTEMI 0.89 [95% CI 0.64-1.24]).

Conclusion : Long-term survival after OHCA due to AMI was good, with 49% of admitted patients being alive after eight years. Although short-term mortality remained high, OHCA patients alive after 30days had similar long-term risk as AMI patients without OHCA.

Conclusion (proposition de traduction) : La survie à long terme après un arrêt cardiaque extra-hospitalier sur infarctus aigu du myocarde était bonne, 49 % des patients admis étant vivants après huit ans. Bien que la mortalité à court terme reste élevée, les patients vivants après 30 jours dans les suites d'un arrêt cardiaque extra-hospitalier présentaient un risque à long terme similaire à celui des patients présentant un infarctus aigu du myocarde sans arrêt cardiaque extra-hospitalier.

An assessment of ventilation and perfusion markers in out-of-hospital cardiac arrest patients receiving mechanical CPR with endotracheal or supraglottic airways..
Becker TK, Berning AW, Prabhu A, Callaway CW, Guyette FX, Martin-Gill C. | Resuscitation. 2018 Jan;122:61-64
Keywords: Airway management; Cardiopulmonary resuscitation; Emergency medical services; Intubation, intratracheal; Out-of-hospital cardiac arrest

Original research article

Introduction : Mechanical chest compression (MCPR) devices are considered equivalent to manual compressions in patient outcomes in out-of-hospital cardiac arrest (OHCA). However, recent data suggest possible harm in patients with a supraglottic airway device (SGA) during MCPR. The aim of this study was to evaluate differences in direct and indirect markers of ventilation and perfusion in patients with cardiac arrest receiving MCPR and who had their airway managed with an endotracheal tube (ETT) or SGA.

Méthode : We retrospectively reviewed Emergency Medical Services (EMS) agencies and emergency department (ED) records over a two-year period. We included patients with OHCA who underwent MCPR and who had an advanced airway placed. The primary outcome was differences in intra-arrest end-tidal carbon dioxide (etCO2) measurements. Secondary outcomes included intra-arrest ventilation rates, rates of prehospital return of spontaneous circulation (ROSC), blood pressure upon prehospital ROSC, and 24-h survival.

Résultats : Valid data sets were available for 126 patients. Eighty-four (66.7%) had an ETT placed, and 42 (33.3%) had a SGA placed. Twenty-eight (22.6%) achieved prehospital ROSC. Twenty-four-hour survival data were available for 13 (10.3%) of these patients. There were no significant differences in primary or secondary outcomes.

Conclusion : In this retrospective study, we found no evidence of differences in markers of ventilation, perfusion or prehospital ROSC and survival in patients with OHCA who had their airway managed with either an ETT or SGA while receiving MCPR.

Conclusion (proposition de traduction) : Dans cette étude rétrospective, nous n'avons trouvé aucune différence dans les marqueurs de ventilation, de perfusion, de RACS pré-hospitaliers et de survie chez les patients en arrêt cardiaque extra-hospitalier qui ont bénéficié de la gestion de leurs voies respiratoires par intubation ou dispositif supraglottique tout en bénéficiant d'un massage cardiaque mécanique.

She's sort of breathing': What linguistic factors determine call-taker recognition of agonal breathing in emergency calls for cardiac arrest?.
Riou M, Ball S, Williams TA, Whiteside A, Cameron P, Fatovich DM, Perkins GD, Smith K, Bray J, Inoue M, O'Halloran KL, Bailey P, Brink D, Finn J. | Resuscitation. 2018 Jan;122:92-98
Keywords: Agonal breathing; Communication; Conversation analysis; Dispatch; Emergency calls; Emergency medical services; Out-of-hospital cardiac arrest; Recognition

Original research article

Introduction : In emergency ambulance calls, agonal breathing remains a barrier to the recognition of out-of-hospital cardiac arrest (OHCA), initiation of cardiopulmonary resuscitation, and rapid dispatch. We aimed to explore whether the language used by callers to describe breathing had an impact on call-taker recognition of agonal breathing and hence cardiac arrest.

Méthode : We analysed 176 calls of paramedic-confirmed OHCA, stratified by recognition of OHCA (89 cases recognised, 87 cases not recognised). We investigated the linguistic features of callers' response to the question "is s/he breathing?" and examined the impact on subsequent coding by call-takers.

Résultats : Among all cases (recognised and non-recognised), 64% (113/176) of callers said that the patients were breathing (yes-answers). We identified two categories of yes-answers: 56% (63/113) were plain answers, confirming that the patient was breathing ("he's breathing"); and 44% (50/113) were qualified answers, containing additional information ("yes but gasping"). Qualified yes-answers were suggestive of agonal breathing. Yet these answers were often not pursued and most (32/50) of these calls were not recognised as OHCA at dispatch.

Conclusion : There is potential for improved recognition of agonal breathing if call-takers are trained to be alert to any qualification following a confirmation that the patient is breathing.

Conclusion (proposition de traduction) : Il existe un potentiel d'amélioration de la reconnaissance de la respiration agonale si les preneurs d'appel sont formés pour être attentifs à toute qualification suite à une confirmation que le patient respire.

Liver lacerations as a complication of CPR during pregnancy.
Cox TR, Crimmins SD, Shannon AM, Atkins KL, Tesoriero R, Malinow AM. | Resuscitation. 2018 Jan;122:121-125
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Complications (CPR); Liver injury; Liver laceration; Obstetrics; Pregnancy

Original research article

Introduction : Cardiac arrest in peripartum patients is a rare but devastating event; reported rates in the literature range from 0.019% to 0.0085%. In the general population, a well-described complication of cardiopulmonary resuscitation (CPR), liver laceration and injury, is reported at a rate of between 0.5-2.9% after CPR. Liver laceration rate among peripartum patients receiving CPR has not been well-studied. We sought to find the rate of liver lacerations in the peripartum population associated with CPR, with the hypothesis that the rate would be higher than in the general population.

Méthode : We identified pregnancies complicated by cardiac arrest by performing a retrospective medical record review from 2011 to 2016 at a single tertiary referral hospital. We then compared the rate of liver lacerations in this group to the rate in the general population as found in the literature.

Résultats : Eleven of 9408 women in the peripartum period suffered cardiac arrest. Return of spontaneous circulation occurred in seven of eleven (64%) women. Three of these seven women suffered clinically significant liver laceration (43%). Overall mortality rate among women suffering cardiac arrest was 82% (9/11).Even after return of spontaneous circulation, the mortality rate was 72%(5/7) including two of three women suffering liver laceration.

Conclusion : Based on a small retrospective study, liver lacerations requiring intervention occurred in 43% of gravidas patients that survived CPR, and is significantly higher than published rates (0.6-2.1%) for the general patient population. Further studies are indicated to determine the incidence of liver injury after peripartum CPR.

Conclusion (proposition de traduction) : Sur la base d'une petite étude rétrospective, des lacérations hépatiques nécessitant une intervention sont survenues chez 43 % des patients gravides qui ont survécu à la RCP et sont significativement plus élevées que les taux publiés (0,6-2,1 %) pour la population générale des patients. D'autres études sont indiquées pour déterminer l'incidence des lésions hépatiques après une RCP périnatale.

Conventional versus chest-compression-only cardiopulmonary resuscitation by bystanders for children with out-of-hospital cardiac arrest.
Goto Y, Funada A, Goto Y. | Resuscitation. 2018 Jan;122:126-134
Keywords: Cardiopulmonary resuscitation; Children; Epidemiology; Infant; Out-of-hospital cardiac arrest

Original research article

Introduction : It is unclear whether chest-compression-only cardiopulmonary resuscitation (CC-CPR) is therapeutically equivalent to conventional CPR for children with out-of-hospital cardiac arrest (OHCA). We aimed to determine the association of CC-CPR and conventional CPR with outcomes in discrete child patient populations with OHCA.

Méthode : We analysed 6810 children (aged <18years) using Japanese registry from 2007 to 2014. Main outcomes measure was 30-day neurologically intact survival after OHCA, defined as Glasgow-Pittsburgh cerebral performance categories 1 or 2.

Résultats : In propensity score-matched children aged 1-17 years (n=2682), overall neurologically intact survival rate was significantly higher after conventional CPR than after CC-CPR (9.4% vs. 6.0%, P=0.001). However, there was no significant difference between the two CPR modalities in patients with cardiac aetiology (14.2% vs. 11.8%, P=0.32), initial shockable rhythm (35.3% vs. 31.7%, P=0.59), or age ≥8 years (12.4% vs. 9.8%, P=0.13). For matched infants (n=1994), no significant differences were observed in overall neurological intact survival between conventional CPR and CC-CPR (2.2% vs. 1.3%, P=0.17). In infant subgroup analyses, neurologically intact survival was similar between the CPR modalities for cardiac aetiology (0.3% vs. 1.0%; P=0.37) and for witnessed arrest (6.2% vs. 6.0%; P=0.98).

Conclusion : In the majority of the paediatric subgroups, conventional CPR was associated with improved outcomes compared to CC-CPR. CC-CPR was associated with 30-day neurologically intact survival similar to conventional CPR for children with OHCA aged ≥8 years, for children aged 1-17 years with cardiac aetiology or initial shockable rhythm, and for infants with cardiac aetiology or witnessed arrest.

Conclusion (proposition de traduction) : Dans la majorité des sous-groupes pédiatriques, la réanimation cardiorespiratoire conventionnelle était associée à de meilleurs résultats que les compressions thoraciques seules. Les compressions thoraciques seules était associée à une survie neurologiquement bonnes à 30 jours semblable à la réanimation cardiorespiratoire conventionnelle pour les enfants de 8 ans et plus, pour les enfants âgés de 1 à 17 ans présentant une étiologie cardiaque ou un rythme choquable initial et pour les nourrissons présentant une étiologie cardiaque ou un arrêt cardiaque devant témoin.

Telephone cardiopulmonary resuscitation is independently associated with improved survival and improved functional outcome after out-of-hospital cardiac arrest.
Wu Z, Panczyk M, Spaite DW, Hu C, Fukushima H, Langlais B, Sutter J, Bobrow BJ. | Resuscitation. 2018 Jan;122:135-140
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Compression-only CPR; Functional outcome; Resuscitation; Survival; Telephone CPR

Original research article

Introduction : This study aims to quantify the relative impact of Dispatcher-Initiated Telephone cardiopulmonary resuscitation (TCPR) on survival and survival with favorable functional outcome after out-of-hospital cardiac arrest (OHCA) in a population of patients served by multiple emergency dispatch centers and more than 130 emergency medical services (EMS) agencies.

Méthode : We conducted a retrospective, observational study of EMS-treated adult (≥18 years) patients with OHCA of presumed cardiac origin in Arizona, between January 1, 2011, and December 31, 2014. We compared survival and functional outcome among three distinct groups of OHCA patients: those who received no CPR before EMS arrival (no CPR group); those who received BCPR before EMS arrival and prior to or without telephone CPR instructions (BCPR group); and those who received TCPR (TCPR group).

Résultats : In this study, 2310 of 4391 patients met the study criteria (median age, 62 years; IQR 50, 74; 1540 male). 32.8% received no CPR, 23.8% received Bystander-Initiated CPR and 43.4% received TCPR. Overall survival was 11.5%. Using no CPR as the reference group, the multivariate adjusted odds ratio for survival at hospital discharge was 1.51 (95% confidence interval [CI], 1.04, 2.18) for BCPR and 1.64 (95% CI, 1.16, 2.30) for TCPR. The multivariate adjusted odds ratio of favorable functional outcome at discharge was 1.58 (95% CI 1.05, 2.39) for BCPR and 1.56 (95% CI, 1.06, 2.31) for TCPR.

Conclusion : TCPR is independently associated with improved survival and improved functional outcome after OHCA.

Conclusion (proposition de traduction) : La réanimation cardiopulmonaire par téléphone est associée de façon indépendante à une amélioration de la survie et à un meilleur résultat fonctionnel après un arrêt cardiaque extra-hospitalier

Commentaire : Confirmation, s'il en était besoin…

Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study.
Clattenburg EJ, Wroe P, Brown S, Gardner K, Losonczy L, Singh A, Nagdev A. | Resuscitation. 2018 Jan;122:65-68
Keywords: Cardiopulmonary resuscitation; Point-of-care ultrasound

Short Papers

Introduction : We aim to evaluate if point-of-care ultrasound use in cardiac arrest is associated with CPR pause duration.

Méthode : This is a prospective cohort study of patients with cardiac arrest (CA) presenting to an urban emergency department from July 2016 to January 2017. We collected video recordings of patients with CA in designated code rooms with video recording equipment. The CAs recordings were reviewed and coded by two abstractors. The primary outcome was the difference CPR pause duration when POCUS was and was not performed.

Résultats : A total of 110 CPR pauses were evaluated during this study. The median CPR pause with POCUS performed lasted 17s (IQR 13 - 22.5) versus 11s (IQR 7 - 16) without POCUS. In addition, multiple regression analysis demonstrated that POCUS was associated with longer pauses (6.4s, 95%CI 2.1- 10.8); ultrasound fellowship trained faculty trended towards shorter CPR pauses (-4.1s, 95%CI -8.8-0.6) compared to non-ultrasound fellowship trained faculty; and when the same provider led the resuscitation and performed the POCUS, pause durations were 6.1s (95%CI 0.4 -11.8) longer than when another provider performed the POCUS.

Conclusion : In this prospective cohort trial of 24 patients with CA, POCUS during CPR pauses was associated with longer interruptions in CPR.

Conclusion (proposition de traduction) : Dans cet essai de cohorte prospective portant sur 24 patients en arrêt cardiaque, l'échographie au chevet du patient pendant les pauses de RCP était associé à des interruptions plus longues de la RCP.

Commentaire : Voir la réponse du Dr F. Lapostolle and al. : Point-of-care ultrasound during advanced cardiopulmonary resuscitation: Rule of art has to be respected!   et du Dr M. Allison and al. : Reply to: Point-of-care ultrasound during advanced cardiopulmonary resuscitation: Rule of art have to be respected! 
Un autre article à consulter : Point-of-care ultrasound in cardiopulmonary resuscitation: a concise review 


Improving Patient Selection for Refractory Out of Hospital Cardiac Arrest Treated with Extracorporeal Life Support.
Chouihed T, Kimmoun A, Lauvray A, Laithier FX, Jaeger D, Lemoine S, Maureira JP, Nace L, Duarte K, Albizzati S, Girerd N, Levy B. | Shock. 2018 Jan;49(1):24-28
Keywords: Aucun

Clinical Science Aspects

Introduction : Despite recent management improvement, including Extracorporeal Life Support (ECLS), refractory out of hospital cardiac arrest (ROHCA) survival remains dramatically low.

Méthode : We assessed an innovative strategy (Out of hoSpital Cardiac ARrest-ExtraCorporeal Life Support-"OSCAR-ECLS") to optimize access to ECLS of ROHCA patients and reduce the delay between recognition and ECLS implantation. This study, conducted in a tertiary teaching hospital, compared the survival and delay times of ROHCA patients treated by ECLS before and after OSCAR-ECLS implementation. This procedure included an early recognition of ROHCA 10 min after initiation of advanced cardiopulmonary resuscitation; the optimization of patient selection and reduction in time from collapse to ECLS initiation.

Résultats : Fourteen patients before and 32 patients after OSCAR-ECLS implementation were identified between 2013 and 2016. Time to ECLS initiation was 99 (90-107) min before OSCAR-ECLS vs. 80 (65-94) min during the OSCAR-ECLS period (P = 0.0007), mostly due to a reduction in time spent on site: 48 (40.0-54.0) min vs. 24 (20.0-28.0) min (P = 0.0001). Survival at hospital discharge was 7% (1/14) before OSCAR-ECLS and 25% (8/32) during the OSCAR-ECLS period (P = 0.20). Only one patient survived with a Glasgow Pittsburgh Cerebral Performance Category (CPC) score = 1 before the OSCAR-ECLS procedure while during the OSCAR-ECLS procedure, eight patients (25%) survived, six with a CPC score = 1, one with a CPC score = 2, and one with a CPC score = 3.

Conclusion : The use of a new paradigm of ROHCA dramatically shortened the time to ECLS initiation by reducing the time spent on site by more than 20 min. Survival improved from 7% to 25% after implementation of OSCAR-ECLS.

Conclusion (proposition de traduction) : L'utilisation d'un nouveau modèle de prise en charge des arrêts cardiaques réfractaires pré-hospitaliers a raccourci le temps nécessaire à l'initiation de l'Extracorporeal Life Support (ECLS) en réduisant le temps passé sur le site de plus de 20 minutes. La survie s'est améliorée de 7% à 25% après la mise en œuvre du programme OSCAR-ECLS (assistance vitale extracorporelle des arrêt cardiaques pré-hospitalier).

The American Journal of Emergency Medicine

Hemodynamic changes in patients with influenza A after propacetamol infusion in the emergency department.
Lee HJ, Suh YJ, Kim AJ, Han SB, Durey A. | Am J Emerg Med. 2018 Jan;36(1):1-4
Keywords: Aucun

Original Contribution

Introduction : Recently, there has been an emerging clinical data suggesting that intravenous propacetamol may cause iatrogenic hypotension. The primary objective of this study was to evaluate hemodynamic changes after propacetamol infusion in the emergency department (ED) with the patients of influenza A. Secondary objective was to assess the incidence of propacetamol-induced significant hypotension and to evaluate factors associated with this adverse effect by comparing two groups of patients with or without a significant reduction in blood pressure (BP).

Méthode : We retrospectively reviewed the medical records of the patients with laboratory-confirmed influenza A who received intravenous propacetamol for the control of fever in the ED during the 2015-16 influenza season.

Résultats : 101 patients of influenza A were included in this study. Overall, all the vital signs including BP, pulse rate and body temperature recorded after propacetamol administration were lower than the pre-infusion values. A significant reduction in BP was observed in 30 (29.7%) patients and 6 (20%) of them required crystalloid infusion. Interestingly, pre-infusion BPs were higher in the group of propacetamol-induced significant hypotension, yet there was no difference in post-infusion BPs between the groups.

Conclusion : To our knowledge this is the first study on the effect of intravenous propacetamol in the ED patients with influenza A infection. We hypothesized that the group with a significant reduction in BP could have higher sympathetic tone, consequently showing higher pre-infusion BPs and pulse rate. And there was no difference in post-infusion BPs because baroreflex homeostasis could compensate further decrease in BPs.

Conclusion (proposition de traduction) : À notre connaissance, il s'agit de la première étude sur l'effet du propacétamol administré par voie intraveineuse chez les patients présentant une grippe A aux urgences. Nous avons émis l'hypothèse que le groupe avec une réduction significative de la pression artérielle (20 % des patients en hypotension nécessitaient une perfusion de cristalloïdes) pourrait avoir un tonus sympathique plus élevé, montrant par conséquent une pression artérielle pré-perfusion et une fréquence du pouls plus élevées. Et il n'y avait pas de différence dans la tension artérielle post-perfusion parce que l'homéostasie baroréflexe pourrait compenser une diminution supplémentaire de la pression artérielle.

Commentaire : On n'utilise plus le propacétamol en France au profit du paracétamol injectable...

The influence of crowding on clinical practice in the emergency department.
Chiu IM, Lin YR, Syue YJ, Kung CT, Wu KH, Li CJ. | Am J Emerg Med. 2018 Jan;36(1):56-60
Keywords: Aucun

Original Contribution

Introduction : This study aimed to clarify the association between the crowding and clinical practice in the emergency department (ED).

Méthode : This 1-year retrospective cohort study conducted in two EDs in Taiwan included 70,222 adult non-trauma visits during the day shift between July 1, 2011, and June 30, 2012. The ED occupancy status, determined by the number of patients staying during their time of visit, was used to measure crowding, grouped into four quartiles, and analyzed in reference to the clinical practice. The clinical practices included decision-making time, patient length of stay, patient disposition, and use of laboratory examinations and computed tomography (CT).

Résultats : The four quartiles of occupancy statuses determined by the number of patients staying during their time of visit were <24, 24-39, 39-62, and >62. Comparing >62 and <24 ED occupancy statuses, the physicians' decision-making time and patients' length of stay increased by 0.3h and 1.1h, respectively. The percentage of patients discharged from the ED decreased by 15.5% as the ED observation, general ward, and intensive care unit admissions increased by 10.9%, 4%, and 0.7%, respectively. CT and laboratory examination slightly increased in the fourth quartile of ED occupancy.

Conclusion : Overcrowding in the ED might increase physicians' decision-making time and patients' length of stay, and more patients could be admitted to observation units or an inpatient department. The use of CT and laboratory examinations would also increase. All of these could lead more patients to stay in the ED.

Conclusion (proposition de traduction) : L’affluence excessive aux urgence pourrait augmenter le temps de prise de décision des médecins et la durée du séjour des patients, et un plus grand nombre de patients pourraient être admis dans des unités d'observation ou dans un service d'hospitalisation. L'utilisation de la tomodensitométrie et des examens de laboratoire augmenterait également. Tout cela pourrait amener plus de patients à rester aux urgences.

Commentaire : Sans commentaire !

Randomized controlled trial of internal and external targeted temperature management methods in post- cardiac arrest patients.
Look X, Li H, Ng M, Lim ETS, Pothiawala S, Tan KBK, Sewa DW, Shahidah N, Pek PP, Ong MEH. | Am J Emerg Med. 2018 Jan;36(1):66-72
Keywords: Aucun

Original Contribution

Introduction : Targeted temperature management post-cardiac arrest is currently implemented using various methods, broadly categorized as internal and external. This study aimed to evaluate survival-to-hospital discharge and neurological outcomes (Glasgow-Pittsburgh Score) of post-cardiac arrest patients undergoing internal cooling verses external cooling.

Méthode : A randomized controlled trial of post-resuscitation cardiac arrest patients was conducted from October 2008-September 2014. Patients were randomized to either internal or external cooling methods. Historical controls were selected matched by age and gender. Analysis using SPSS version 21.0 presented descriptive statistics and frequencies while univariate logistic regression was done using R 3.1.3.

Résultats : 23 patients were randomized to internal cooling and 22 patients to external cooling and 42 matched controls were selected. No significant difference was seen between internal and external cooling in terms of survival, neurological outcomes and complications. However in the internal cooling arm, there was lower risk of developing overcooling (p=0.01) and rebound hyperthermia (p=0.02). Compared to normothermia, internal cooling had higher survival (OR=3.36, 95% CI=(1.130, 10.412), and lower risk of developing cardiac arrhythmias (OR=0.18, 95% CI=(0.04, 0.63)). Subgroup analysis showed those with cardiac cause of arrest (OR=4.29, 95% CI=(1.26, 15.80)) and sustained ROSC (OR=5.50, 95% CI=(1.64, 20.39)) had better survival with internal cooling compared to normothermia. Cooling curves showed tighter temperature control for internal compared to external cooling.

Conclusion : Internal cooling showed tighter temperature control compared to external cooling. Internal cooling can potentially provide better survival-to-hospital discharge outcomes and reduce cardiac arrhythmia complications in carefully selected patients as compared to normothermia.

Conclusion (proposition de traduction) : Le refroidissement interne a montré un contrôle de température plus optimal comparé au refroidissement externe. Le refroidissement interne peut potentiellement fournir de meilleurs résultats de sortie de survie à l'hôpital et réduire les complications d'arythmie cardiaque chez les patients soigneusement sélectionnés par rapport à la normothermie.

Commentaire : Etude randomisée sur un petit effectif de patients.

Effects of advanced life support on patients who suffered cardiac arrest outside of hospital and were defibrillated.
Hagihara A, Onozuka D, Nagata T, Hasegawa M. | Am J Emerg Med. 2018 Jan;36(1):73-78
Keywords: Aucun

Original research article

Introduction : The effects and relative benefits of advanced airway management and epinephrine on patients with out-of-hospital cardiac arrest (OHCA) who were defibrillated are not well understood.

Méthode : This was a prospective observational study. Using data of all out-of-hospital cardiac arrest cases occurring between 2005 and 2013 in Japan, hierarchical logistic regression and conditional logistic regression along with time-dependent propensity matching were performed. Outcome measures were survival and minimal neurological impairment [cerebral performance category (CPC) 1 or 2] at 1month after the event.

Résultats : We analyzed 37,873 cases that met the inclusion criteria. Among propensity-matched patients, advanced airway management and/or prehospital epinephrine use was related to decreased rates of 1-month survival (adjusted odds ratio 0.88, 95% confidence interval 0.80 to 0.97) and CPC (1, 2) (adjusted odds ratio 0.56, 95% confidence interval 0.48 to 0.66). Advanced airway management was related to decreased rates of 1-month survival (adjusted odds ratio 0.89, 95% confidence interval 0.81to 0.98) and CPC (1, 2) (adjusted odds ratio 0.54, 95% confidence interval 0.46 to 0.64) in patients who did not receive epinephrine, whereas epinephrine use was not related to the outcome measures.

Conclusion : In defibrillated patients with OHCA, advanced airway management and/or epinephrine are related to reduced long-term survival, and advanced airway management is less beneficial than epinephrine. However, the proportion of patients with OHCA who responded to an initial shock was very low in the study subjects, and the external validity of our findings might be limited.

Conclusion (proposition de traduction) : Chez les arrêts cardiaques extra-hospitaliers, la prise en charge spécialisée des voies aériennes et/ou l'administration d’adrénaline sont liées à une survie à long terme réduite, et la prise en charge spécialisée des voies aériennes est moins bénéfique que l'épinéphrine. Cependant, la proportion des arrêts cardiaques extra-hospitaliers qui ont répondu à un choc initial était très faible chez les sujets de l'étude, et la validité externe de nos résultats pourrait être limitée.

Commentaire : Une étude supplémentaire sur l'effets négatifs de l'intubation et de l'utilisation de l'adrénaline... Pour ce qui est de l'intubation, le niveau de performance des intervenants est probablement en lien avec les moins bons résultats (essai CAAM : ventilation versus intubation , conduite par le Pr F. ADNET).

Impact of hypotension after return of spontaneous circulation on survival in patients of out-of-hospital cardiac arrest.
Chiu YK, Lui CT, Tsui KL. | Am J Emerg Med. 2018 Jan;36(1):79-83
Keywords: Aucun

Original research article

Introduction : To investigate the relationship between hypotension in the first 3h after return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest.

Méthode : This retrospective cohort study occurred at two regional hospitals and included adult OHCA patients who experienced ROSC from July 1, 2014 to December 31, 2015. Hemodynamic and inotrope administration data were retrieved for 3h after ROSC. We calculated the hypotensive exposure index (HEI) as the surrogate marker of the exposure of hypotension. The area under the ROC curve and multivariate logistic regression models were performed to analyze the effect of HEI on survival. Mean arterial pressure (MAP) was explored in the surviving and non-surviving patient groups using repeated measures MANCOVA, adjusted for the use of inotropes and down time.

Résultats : A total of 289 patients were included in the study, and 29 survived. The median 1-hour HEI and 3-hour HEI were significantly lower in the survival group (p<0.001). The area under the ROC curve for 3-hour HEI was 0.861. The repeated measures MANCOVA indicated that an interaction existed between post-ROSC time and downtime [F(5,197)=2.31, p=0.046]. No significant change in the MAP was observed in the 3h after ROSC, except in the group with a prolonged down time. According to the tests examining the effects of the use of inotropes on the survival outcomes of the different subjects, the MAP was significantly higher in the surviving group [F(1,201)=4.11; p=0.044; ηp2=0.020].

Conclusion : Among the patients who experienced ROSC after OHCA, post-ROSC hypotension was an independent predictor of survival.

Conclusion (proposition de traduction) : Parmi les patients ayant eu une RACS après un arrêt cardiaque extra-hospitalier, l'hypotension post-RACS était un facteur prédictif indépendant de la survie.

Commentaire : Effet bénéfique de l'hypotension artérielle après une RACS ? L'article ne détaille pas l'inotrope utilisé, hors l'utilisation d'adrénaline (versus noradrénaline) pourrait expliquer les effets délétères d'une augmentation de la pression artérielle au prix des effets néfastes de l'adrénaline sur le myocarde.

Predicting need for additional CT scan in children with a non-diagnostic ultrasound for appendicitis in the emergency department.
Nishizawa T, Maeda S, Goldman RD, Hayashi H. | Am J Emerg Med. 2018 Jan;36(1):49-55
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original Contribution

Introduction : This study aimed to determine which children with suspected appendicitis should be considered for a computerized tomography (CT) scan after a non-diagnostic ultrasound (US) in the Emergency Department (ED).

Méthode : We retrospectively reviewed patients 0-18year old, who presented to the ED with complaints of abdominal pain, during 2011-2015 and while in the hospital had both US and CT. We recorded demographic and clinical data and outcomes, and used univariate and multivariate methods for comparing patients who did and didn't have appendicitis on CT after non-diagnostic US. Multivariate analysis was performed using logistic regression to determine what variables were independently associated with appendicitis.

Résultats : A total of 328 patients were enrolled, 257 with non-diagnostic US (CT: 82 had appendicitis, 175 no-appendicitis). Younger children and those who reported vomiting or had right lower abdominal quadrant (RLQ) tenderness, peritoneal signs or White Blood Cell (WBC) count >10,000 in mm3 were more likely to have appendicitis on CT. RLQ tenderness (Odds Ratio: 2.84, 95%CI: 1.07-7.53), peritoneal signs (Odds Ratio: 11.37, 95%CI: 5.08-25.47) and WBC count >10,000 in mm3 (Odds Ratio: 21.88, 95%CI: 7.95-60.21) remained significant after multivariate analysis. Considering CT with 2 or 3 of these predictors would have resulted in sensitivity of 94%, specificity of 67%, positive predictive value of 57% and negative predictive value of 96% for appendicitis.

Conclusion : Ordering CT should be considered after non-diagnostic US for appendicitis only when children meet at least 2 predictors of RLQ tenderness, peritoneal signs and WBC>10,000 in mm3.

Conclusion (proposition de traduction) : Pour confirmer le diagnostic d’une appendicite aigüe chez l’enfant après une échographie abdominale non contributive, on peut proposer une tomographie abdominale uniquement lorsque l’on retrouve au moins 2 critères parmi les 3 signes suivants : sensibilité à la palpation de la fosse iliaque droite, signes d’irritation péritonéaux et globules blancs supérieurs à 10 000 mm3.

Commentaire : Etude rétrospective incluant 473 dossiers d'enfants ayant bénéficié d'une échographie et d'un scanner abdominal pour le diagnostic d'une appendicite en service d'urgence.

Achieving ventricular rate control in patients taking chronic beta-blocker therapy.
Feeney ME, Rowe SLB, Mah ND, Barton CA, Ran R. | Am J Emerg Med. 2018 Jan;36(1):110-113
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Brief Report

Introduction : The objective of this study is to evaluate the difference in response to ventricular rate control with intravenous (IV) metoprolol compared to IV diltiazem in patients taking chronic beta-blocker therapy who present to the emergency department (ED) in atrial fibrillation (AF) with rapid ventricular rate (RVR).

Méthode : This was a single-center, retrospective study of adult patients taking chronic oral metoprolol. Chronic metoprolol therapy was defined as patients prescribed and taking oral metoprolol within 5days of study inclusion. Rate control was defined as either a decrease in ventricular rate<100bpm or <120bpm if the decrease was at least 20% from the presenting heart rate.

Résultats : A total of 332 patients were included, with 16 patients in the IV diltiazem group and 316 patients in the IV metoprolol group. In the diltiazem arm, 68.8% of patients achieved successful rate control compared to 42.4% of patients in the metoprolol group (p=0.067). Treatment with IV metoprolol resulted in more hospital admissions (58% vs. 6.25% with diltiazem, p<0.001). Treatment with diltiazem was associated with a greater incidence of bradycardia compared to IV metoprolol (13% vs. 0%, p=0.002).

Conclusion : The use of IV diltiazem was associated with a higher rate of successful response to rate control compared to IV metoprolol in patients in AF with RVR on chronic beta-blocker therapy, however the difference between groups was not statistically significant.

Conclusion (proposition de traduction) : L'utilisation du diltiazem IV était associée à un taux plus élevé de contrôle de la fréquence cardiaque par rapport au métoprolol IV chez les patients présentant une fibrillation atriale à réponse ventriculaire rapide sous traitement chronique par bêtabloquant, mais la différence entre les groupes n'était pas statistiquement significative.

Definitive airway management after pre-hospital supraglottic airway insertion: Outcomes and a management algorithm for trauma patients.
Hernandez MC, Aho JM, Zielinski MD, Zietlow SP, Kim BD, Morris DS. | Am J Emerg Med. 2018 Jan;36(1):114-119
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Brief Report

Introduction : Prehospital airway management increasingly involves supraglottic airway insertion and a paucity of data evaluates outcomes in trauma populations. We aim to describe definitive airway management in traumatically injured patients who necessitated prehospital supraglottic airway insertion.

Méthode : We performed a single institution retrospective review of multisystem injured patients (≥15years) that received prehospital supraglottic airway insertion during 2009 to 2016. Baseline demographics, number and type of: supraglottic airway insertion attempts, definitive airway and complications were recorded. Primary outcome was need for tracheostomy. Univariate and multivariable statistics were performed.

Résultats : 56 patients met inclusion criteria and were reviewed, 78% were male. Median age [IQR] was 36 [24-56] years. Injuries comprised blunt (94%), penetrating (4%) and burns (2%). Median ISS was 26 [22-41]. Median number of prehospital endotracheal intubation (PETI) attempts was 2 [1-3]. Definitive airway management included: (n=20, 36%, tracheostomy), (n=10, 18%, direct laryngoscopy), (n=6, 11%, bougie), (n=9, 15%, Glidescope), (n=11, 20%, bronchoscopic assistance). 24-hour mortality was 41%. Increasing number of PETI was associated with increasing facial injury. On regression, increasing cervical and facial injury patterns as well as number of PETI were associated with definitive airway control via surgical tracheostomy.

Conclusion : After supraglottic airway insertion, operative or non-operative approaches can be utilized to obtain a definitive airway. Patients with increased craniofacial injuries have an increased risk for airway complications and need for tracheostomy. We used these factors to generate an evidence based algorithm that requires prospective validation.

Conclusion (proposition de traduction) : Après l'abord supraglottiques des voies aériennes, des approches opératoires ou non opératoires peuvent être utilisées pour obtenir une gestion respiratoire définitive. Les patients présentant des lésions craniofaciales accrues présentent un risque accru de complications des voies respiratoires et de besoin de trachéostomie. Nous avons utilisé ces facteurs pour générer un algorithme basé sur des preuves nécessitant une validation prospective.

Commentaire : Étude rétrospective monocentrique

Effect of the Macintosh curved blade size on direct laryngoscopic view in edentulous patients.
Kim H, Chang JE, Han SH, Lee JM, Yoon S, Hwang JY. | Am J Emerg Med. 2018 Jan;36(1):120-123
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Brief Report

Introduction : In the present study, we compared the laryngoscopic view depending on the size of the Macintosh curved blade in edentulous patients.

Méthode : Thirty-five edentulous adult patients scheduled for elective surgery were included in the study. After induction of anesthesia, two direct laryngoscopies were performed alternately using a standard-sized Macintosh curved blade (No. 4 for men and No. 3 for women) and smaller-sized Macintosh curved blade (No. 3 for men and No. 2 for women). During direct laryngoscopy with each blade, two digital photographs of the lateral view were taken when the blade tip was placed in the valleculae; the laryngoscope was lifted to achieve the best laryngeal view. Then, the best laryngeal views were assessed using the percentage of glottic opening (POGO) score. On the photographs of the lateral view of direct laryngoscopy, the angles between the line extending along the laryngoscopic handle and the horizontal line were measured.

Résultats : The POGO score was improved with the smaller-sized blade compared with the standard-sized blade (87.3% [11.8%] vs. 71.3% [20.0%], P<0.001, respectively). The angles between the laryngoscopic handle and the horizontal line were greater with the smaller-sized blade compared to the standard-sized blade when the blade tip was placed on the valleculae and when the laryngoscope was lifted to achieve the best laryngeal view (both P<0.001).

Conclusion : Compared to a standard-sized Macintosh blade, a smaller-sized Macintosh curved blade improved the laryngeal exposure in edentulous patients.

Conclusion (proposition de traduction) : Comparée à une lame de Macintosh de taille standard, une lame de Macintosh incurvée de plus petite taille améliorait l'exposition laryngée chez les patients édentés.

Comparison of the loop technique with incision and drainage for soft tissue abscesses: A systematic review and meta-analysis..
Gottlieb M, Peksa GD. | Am J Emerg Med. 2018 Jan;36(1):128-133
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : Skin and soft tissue infections are a common presentation to the emergency department. Traditional management of abscesses involves a linear incision through the center of the abscess with packing placed. The loop drainage technique (LDT) is an alternate approach that may reduce pain and scarring, as well as decrease the number of follow up visits needed. This systematic review and meta-analysis aimed to compare the efficacy of the LDT with conventional incision and drainage (CID) in the treatment of soft tissue abscesses.

Méthode : PubMed, CINAHL, Scopus, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and bibliographies of selected articles were assessed for all retrospective, prospective, or randomized controlled trials comparing the LDT to CID with an outcome of treatment failure, as defined by the individual study. Data were double extracted into a predefined worksheet and quality analysis was performed using the Cochrane Risk of Bias tool. Data were summarized and a meta-analysis was performed with subgroup analyses by adult versus pediatric age groups.

Résultats : This systematic review identified four studies comprising 470 total patients. Overall, the CID technique failed in 25 of 265 cases (9.43%). The LDT failed in 8 of 195 cases (4.10%). There was an odds ratio of 2.63 (95% CI 1.04 to 6.63) in favor of higher failures in the CID group. Funnel plot analysis demonstrated no evidence of publication bias. Subgroups analysis by age group demonstrated improved efficacy of the LDT in pediatric patients, but the adult subgroup did not reach statistical significance.

Conclusion : The existing literature suggests that LDT is associated with a lower failure rate than CID. However, the data is limited by small sample sizes and predominantly retrospective study designs. Given the potential for less pain, decreased scarring, and lower associated healthcare costs, this technique should be considered for the treatment of skin and soft tissue abscesses in the ED setting, but further studies are needed.

Conclusion (proposition de traduction) : La littérature existante suggère que la technique de drainage avec la technique de la boucle est associée à un taux d'échec plus faible que l'incision et le drainage conventionnels. Cependant, les données sont limitées par la petite taille des échantillons et des modèles d'étude principalement rétrospectifs. Étant donné le potentiel de diminution de la douleur, de réduction des cicatrices et des coûts de soins de santé inférieurs, cette technique devrait être envisagée pour le traitement des abcès de la peau et des tissus mous dans les services d'urgence, mais d'autres études sont nécessaires.

Commentaire : La technique semble séduisante, à confirmer... Video à visionner sur YouTube  .

The Journal of Emergency Medicine

Physical Examination is the Best Predictor of the Need for Abdominal Surgery in Children Following Motor Vehicle Collision.
Drucker NA, McDuffie L, Groh E, Hackworth J, Bell TM, Markel TA. | J Emerg Med. 2018 Jan;54(1):1-7
DOI:  | Télécharger l'article au format  
Keywords: children; injury; motor vehicle crash; seat belt sign

Original Contributions

Introduction : Exploratory laparotomy in children after motor vehicle collision (MVC) is rare. In the absence of definitive hemorrhage or free abdominal air on radiographic imaging, predictors for operative exploration are conflicting.
OBJECTIVE: The purpose of this study was to explore objective findings that may aid in determining which children require operative abdominal exploration after MVC.

Méthode : Data from 2010-2014 at an American College of Surgeons-certified level 1 pediatric trauma center were retrospectively reviewed. Demographics, vital signs, laboratory data, radiologic studies, operative records, associated injuries, and outcomes were analyzed and p < 0.05 was considered statistically significant.

Résultats : Eight hundred sixty-two patients 0-18 years of age presented to the hospital after an MVC during the study period. Seventeen patients (2.0%) required abdominal exploration and all were found to have intraabdominal injuries. Respiratory rate was the only vital sign that was significantly altered (p = 0.04) in those who required abdominal surgery compared with those who did not. Physical examination findings, such as the seat belt sign, abdominal bruising, abdominal wound, and abdominal tenderness, were present significantly more frequently in those requiring abdominal surgery (p < 0.0001). Each finding had a negative predictive value for the need for operative exploration of at least 0.98. There were no significant differences in trauma laboratory values or radiographic findings between the 2 groups.

Conclusion : Data from this study solidify the relationship between specific physical examination findings and the need for abdominal exploration after MVC in children. In addition, these data suggest that a lack of the seat belt sign, abdominal bruising, abdominal wounds, or abdominal tenderness are individually predictive of patients who will not require surgical intervention.

Conclusion (proposition de traduction) : Les données de cette étude confirment la relation entre les résultats de l'examen clinique spécifique et le besoin d'exploration chirurgicale abdominale après une collision avec un véhicule à moteur chez l'enfant.
De plus, ces données suggèrent que l'absence de signe cutané en regard de la ceinture de sécurité, d'ecchymose abdominale, de plaies abdominales ou de sensibilité abdominale sont des facteurs prédictifs individuels des patients qui n'auront pas besoin d'une intervention chirurgicale.

Palliative Care Symptom Management in The Emergency Department: The ABC's of Symptom Management for The Emergency Physician.
Siegel M, Bigelow S. | J Emerg Med. 2018 Jan;54(1):25-32
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Keywords: emergency medicine; end of life; palliative care; symptom management

Original research article

Introduction : Palliative care is a rapidly evolving area of emergency medicine. With an estimated 5,000 to 10,000 baby boomers per day reaching retirement age, emergency departments (EDs) are treating more patients with chronic and serious disease. Palliative care offers comprehensive care for patients with advanced medical illness, aims to alleviate suffering and improve quality of life, and plays an important role in caring for these patients in the ED.

Méthode : We sought to increase the emergency physician's knowledge of and comfort with symptom control in palliative and hospice patients.

Discussion : Having the skills to deliver efficient and appropriate palliative and hospice care is imperative for emergency physicians. Palliative care should be considered in any patient suffering from symptoms of a life-limiting illness, whereas hospice care should be considered in the patient with likely <6 months left to live. Palliative care is appropriate earlier in the course of disease, and is appropriate when the practitioner would not be surprised if the patient died in the next 2 years ("The Surprise Question"). This article discusses management in the ED of pain, nausea, dyspnea, agitation, and oral secretions in patients appropriate for hospice and palliative care.

Conclusion : The need for palliative and hospice care in the ED is increasing, requiring that emergency physicians be familiar with palliative and hospice care and competent in the delivery of rapid symptom management in patients with severe and life-limiting disease.

Conclusion (proposition de traduction) : Les besoins en soins palliatifs aux urgences augmentent, nécessitant des médecins d'urgence qu'ils connaissent la gestion des soins palliatifs et qu'ils soient compétents dans la prise en charge rapide des symptômes chez les patients atteints d'une maladie grave et limitant l'espérance de vie.

Complications from Administration of Vasopressors Through Peripheral Venous Catheters: An Observational Study.
Medlej K, Kazzi AA, El Hajj Chehade A, Saad Eldine M, Chami A, Bachir R, Zebian D, Abou Dagher G. | J Emerg Med. 2018 Jan;54(1):47-53
DOI:  | Télécharger l'article au format  
Keywords: complications; critical care; peripheral venous catheters; sepsis; septic shock; vasopressors

Original research article

Introduction : The placement of a central venous catheter for the administration of vasopressors is still recommended and required by many institutions because of concern about complications associated with peripheral administration of vasopressors.
OBJECTIVE: Our aim was to determine the incidence of complications from the administration of vasopressors through peripheral venous catheters (PVC) in patients with circulatory shock, and to identify the factors associated with these complications.

Méthode : This was a prospective, observational study conducted in the emergency department (ED) of a tertiary care medical center. Patients presenting to the ED with circulatory shock and in whom a vasopressor was started through a PVC were included. Research fellows examined the i.v. access site for complications twice daily during the period of peripheral vasopressor administration, then daily up to 48 h after treatment discontinuation or until the patient expired.

Résultats : Of the 55 patients that were recruited, 3 (5.45% overall, 6% of patients receiving norepinephrine) developed complications; none were major. Two developed local extravasation and one developed local thrombophlebitis. All three complications occurred during the vasopressor infusion, none in the 48 h after discontinuation, and none required any medical or surgical intervention. Two of the three complications occurred in the hand, and all occurred in patients receiving norepinephrine and with 20-gauge catheters.

Conclusion : The incidence of complications from the administration of vasopressors through a PVC is small and did not result in significant morbidity in this study. Larger prospective studies are needed to better determine the factors that are associated with these complications, and identify patients in whom this practice is safe.

Conclusion (proposition de traduction) : L'incidence des complications de l'administration de vasopresseurs par voie veineuse périphérique est faible et n'a pas entraîné de morbidité significative dans cette étude. De plus amples études prospectives sont nécessaires pour mieux déterminer les facteurs associés à ces complications et identifier les patients chez qui cette pratique est sécuritaire.

Commentaire : Les résultats rapportent tout de même un cas de thrombophlébite… événement indésirable jugé mineur !?

Advances in Diabetes Pharmacotherapy: An Update for the Emergency Provider.
Mazer-Amirshahi M, Pourmand A. | J Emerg Med. 2018 Jan;54(1):73-80
DOI:  | Télécharger l'article au format  
Keywords: emergency department; new diabetes therapies

Original research article

Introduction : Diabetes mellitus is a disease that affects millions of Americans, and its prevalence is only anticipated to increase in coming years. It is estimated that diabetes-related visits account for 1% of all emergency department (ED) encounters. In recent years, there have been several new categories of medications approved for the treatment of diabetes, including new insulins, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, an amylin analogue, and sodium-glucose cotransporter-2 inhibitors.

Méthode : This review presents recently approved agents to treat diabetes, with a focus on basic mechanism, place in therapy, and toxicities the ED provider may encounter.

Discussion : Many of these new therapies have been incorporated as first- and second-line agents for the management of diabetes. Recently approved diabetes medications often have different mechanisms of action and adverse effect and overdose profiles compared to traditional agents, such as sulfonylureas and metformin.

Conclusion : Emergency providers will encounter patients taking these newly approved medications, as well as treat those presenting with adverse effects and overdoses from them. As such, emergency providers must have a basic understanding of these new therapies so that they can optimally care for diabetic patients.

Conclusion (proposition de traduction) : Les urgentistes rencontreront des patients prenant des médicaments nouvellement indiqués, ainsi que ceux qui présentent des effets indésirables et des surdosages. En tant que tels, les urgentistes doivent avoir une compréhension de base de ces nouvelles thérapies afin qu'ils puissent prendre soin de manière optimale des patients diabétiques.

The Journal of Trauma and Acute Care Surgery

The temporal response and mechanism of action of tranexamic acid in endothelial glycocalyx degradation.
Diebel ME, Martin JV, Liberati DM, Diebel LN. | J Trauma Acute Care Surg. 2018 Jan;84(1):75-80
Keywords: Aucun

Plenary Paper

Introduction : The endothelial glycocalyx (GCX) plays an important role in vascular barrier function. Damage to the GCX occurs due to a variety of causes including hypoxia, ischemia-reperfusion, stress-related sympathoadrenal activation, and inflammation. Tranexamic acid (TXA) may prevent GCX degradation. The therapeutic window for TXA administration and the mechanism of action has been under review. Membrane-anchored proteases (sheddases) are key components in endothelial cell biology including the regulation of vascular permeability. The effect of TXA administration on stress-related GCX damage, and the role of sheddases in this process was studied in a cell-based model.

Méthode : Confluent human umbilical vein endothelial cells (HUVEC) were exposed to hydrogen peroxide and/or epinephrine (EPI) to stimulate postshock reperfusion. TXA was added at various times after hydrogen peroxide (H2O2) and/or EPI exposure. GCX degradation was indexed by syndecan-1 and hyaluronic acid release. Activation of endothelial sheddases was indexed by A Disintegrin and Metalloproteinase-17 and matrix metalloproteinase-9 activity in culture supernatants.

Résultats : Exposure of HUVEC to either/both EPI and H2O2 resulted in a cellular stress and GCX disruption demonstrated by increased levels of syndecan-1 shedding, hyaluronic acid release, tumor necrosis factor-α release. Shedding of these GCX components was associated with increased activity of both A Disintegrin and Metalloproteinase-17 and matrix metalloproteinase. Disruption of the GCX was further demonstrated via fluorescent imaging, which demonstrated disruption after exposure to either/both H2O2 and EPI. Early administration of either TXA or doxycycline resulted in preservation of the GCX. Late administration of TXA had no effect, whereas doxycycline had some residual protective effect.

Conclusion : Tranexamic acid as a serine protease inhibitor prevented GCX degradation via inhibition of endothelial sheddase activation. This effect was not apparent when TXA was administered greater than 60 minutes after "simulated" reperfusion. Our study supports the clinical practice of early TXA administration in the severely injured patient.

Conclusion (proposition de traduction) : L'acide tranexamique en tant qu'inhibiteur de la sérine protéase empêche la dégradation du glycocalyx via l'inhibition de l'activation endothéliale de la sheddase. Cet effet n'était pas visible lorsque l'acide tranexamique était administré plus de 60 minutes après la reperfusion « simulée ». Notre étude confirme la pratique clinique de l'administration précoce de l'acide tranexamique chez le patient gravement blessé.

Negative computed tomography can safely rule out clinically significant intra-abdominal injury in the asymptomatic patient after blunt trauma: Prospective evaluation of 1193 patients.
Benjamin E, Cho J, Recinos G, Dilektasli E, Lam L, Brunner J, Inaba K, Demetriades D. | J Trauma Acute Care Surg. 2018 Jan;84(1):128-132
Keywords: Aucun

Original Articles

Introduction : Computed tomography of the abdomen and pelvis (CTAP) is highly specific for injury identification and commonly used in the evaluation of blunt trauma patients. Despite this, there is no consensus on the required clinical observation period after negative imaging, often impacting patient flow and hospital cost. The purpose of this study was to evaluate the use of CTAP after blunt trauma and the need for observation after negative imaging.

Méthode : A prospective analysis at a large Level I trauma center was conducted from November 2014 to May 2015. All blunt trauma patients, older than 14 years with CTAP on admission were included. Symptomatic patients were defined as having abdominal pain or external signs of trauma on admission. The main outcome was missed injury.

Résultats : Over the study period, there were 1,468 blunt trauma admissions, of which 1,193 patients underwent CTAP. Eight hundred six (67.6%) patients were evaluable on admission (Glasgow Coma Scale score, 15), and of these, 327 (40.6%) were symptomatic, 479 (59.4%) asymptomatic. Among the evaluable asymptomatic patients, there were 65 (13.6%) positive computed tomography scans including 11 patients with grade III, IV, or V solid organ injury and three that required operation. In the 414 evaluable asymptomatic patients with negative imaging, median length of stay was 3 days, and there were zero missed injuries. All images were reviewed by an attending radiologist.

Conclusion : Abdominal imaging after trauma is justified in the appropriate clinical setting to evaluate for significant abdominal injury regardless of symptomatology. In asymptomatic, evaluable patients with a negative CTAP, clinically significant abdominal injury is unlikely, and these patients may be considered for early discharge or disposition to another treatment service.

Conclusion (proposition de traduction) : L'imagerie abdominale après un traumatisme est justifiée dans l'approche clinique pour évaluer une lésion abdominale significative indépendamment de la symptomatologie. Chez les patients asymptomatiques avec une imagerie abdominale négative, une lésion abdominale cliniquement significative est peu probable, et ces patients peuvent bénéficier d'une sortie précoce ou d'un transfert dans un service médical.

The Lancet

Tranexamic acid: is it about time?.
Dries DJ | Lancet. 2018 Jan 13;391(10116):97-98
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Keywords: Aucun


Editorial : For decades, the antifibrinolytic drug tranexamic acid has been used for indications such as dental extractions in patients with haemophilia. Additionally, tranexamic acid has been widely used, although not routinely across the world, to reduce blood loss in surgery. More recently, the potential of tranexamic acid in trauma and post-partum haemorrhage has been of interest. In two large, randomised controlled trials, CRASH-2 and WOMAN, tranexamic acid reduced mortality from bleeding in patients with these conditions. One caution identified from these large trials is that mortality due to bleeding can be increased if tranexamic acid is given more than 3 h after injury.
The extensive data review of the Antifibrinolytic Trials Collaboration, reported in The Lancet, appears to confirm this temporal relationship.

Conclusion : A multitude of trials can be identified in registries, such as from the US National Library of Medicine, reflecting ongoing work with tranexamic acid. At present, the careful study of Gayet-Ageron and coworkers suggests applicability of early administration of this agent in patients with substantial bleeding from multiple causes.4 As data from additional trials with tranexamic acid become available, the spectrum of applications for this agent should become apparent.

Conclusion (proposition de traduction) : Une multitude d'essais peuvent être identifiés dans les registres, tels que de la National Library of Medicine des États-Unis, illustrant le travail en cours sur l'acide tranexamique. À l'heure actuelle, l'étude approfondie de Gayet-Ageron et de ses collègues suggère l'applicabilité de l'administration précoce de cet agent chez les patients présentant des hémorragies importantes dues à des causes multiples. Au fur et à mesure que les données d'essais supplémentaires avec l'acide tranexamique sont disponibles, le champ des applications pour ce médicament devrait devenir évident.

Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients.
Gayet-Ageron A, Prieto-Merino D, Ker K, Shakur H, Ageron FX, Roberts I; Antifibrinolytic Trials Collaboration. | Lancet. 2018 Jan 13;391(10116):125-132
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Keywords: Aucun

Original research article

Introduction : Antifibrinolytics reduce death from bleeding in trauma and post-partum haemorrhage. We examined the effect of treatment delay on the effectiveness of antifibrinolytics.

Méthode : We did an individual patient-level data meta-analysis of randomised trials done with more than 1000 patients that assessed antifibrinolytics in acute severe bleeding. We identified trials done between Jan 1, 1946, and April 7, 2017, from MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, PubMed, Popline, and the WHO International Clinical Trials Registry Platform. The primary measure of treatment benefit was absence of death from bleeding. We examined the effect of treatment delay on treatment effectiveness using logistic regression models. We investigated the effect of measurement error (misclassification) in sensitivity analyses. This study is registered with PROSPERO, number 42016052155.

Résultats : We obtained data for 40 138 patients from two randomised trials of tranexamic acid in acute severe bleeding (traumatic and post-partum haemorrhage). Overall, there were 3558 deaths, of which 1408 (40%) were from bleeding. Most (884 [63%] of 1408) bleeding deaths occurred within 12 h of onset. Deaths from post-partum haemorrhage peaked 2-3 h after childbirth. Tranexamic acid significantly increased overall survival from bleeding (odds ratio [OR] 1·20, 95% CI 1·08-1·33; p=0·001), with no heterogeneity by site of bleeding (interaction p=0·7243). Treatment delay reduced the treatment benefit (p<0·0001). Immediate treatment improved survival by more than 70% (OR 1·72, 95% CI 1·42-2·10; p<0·0001). Thereafter, the survival benefit decreased by 10% for every 15 min of treatment delay until 3 h, after which there was no benefit. There was no increase in vascular occlusive events with tranexamic acid, with no heterogeneity by site of bleeding (p=0·5956). Treatment delay did not modify the effect of tranexamic acid on vascular occlusive events.

Conclusion : Death from bleeding occurs soon after onset and even a short delay in treatment reduces the benefit of tranexamic acid administration. Patients must be treated immediately. Further research is needed to deepen our understanding of the mechanism of action of tranexamic acid.

Conclusion (proposition de traduction) : La mort par saignement survient peu après le début du traitement et même un court délai de traitement réduit le bénéfice de l'administration d'acide tranexamique. Les patients doivent être traités immédiatement.
Des recherches supplémentaires sont nécessaires pour approfondir notre compréhension du mécanisme d'action de l'acide tranexamique.

The Lancet Respiratory Medicine

Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial.
Alam N, Oskam E, Stassen PM, Exter PV, van de Ven PM, Haak HR, Holleman F, Zanten AV, Leeuwen-Nguyen HV, Bon V, Duineveld BAM, Nannan Panday RS, Kramer MHH, Nanayakkara PWB; PHANTASi Trial Investigators and the ORCA (Onderzoeks Consortium Acute Geneeskunde) Research Consortium the Netherlands. | Lancet Respir Med. 2018 Jan;6(1):40-50
Keywords: Aucun


Introduction : Emergency medical services (EMS) personnel have already made substantial contributions to improving care for patients with time-dependent illnesses, such as trauma and myocardial infarction. Patients with sepsis could also benefit from timely prehospital care.

Méthode : After training EMS personnel in recognising sepsis, we did a randomised controlled open-label trial in ten large regional ambulance services serving 34 secondary and tertiary care hospitals in the Netherlands. We compared the effects of early administration of antibiotics in the ambulance with usual care. Eligible patients were randomly assigned (1:1) using block-randomisation with blocks of size 4 to the intervention (open-label intravenous ceftriaxone 2000 mg in addition to usual care) or usual care (fluid resuscitation and supplementary oxygen). Randomisation was stratified per region. The primary outcome was all-cause mortality at 28 days and analysis was by intention to treat. To assess the effect of training, we determined the average time to antibiotics (TTA) in the emergency department and recognition of sepsis by EMS personnel before and after training.

Résultats : 2698 patients were enrolled between June 30, 2014, and June 26, 2016. 2672 patients were included in the intention-to-treat analysis: 1535 in the intervention group and 1137 in the usual care group. The intervention group received antibiotics a median of 26 min (IQR 19-34) before arriving at the emergency department. In the usual care group, median TTA after arriving at the emergency department was 70 min (IQR 36-128), compared with 93 min (IQR 39-140) before EMS personnel training (p=0·142). At day 28, 120 (8%) patients had died in the intervention group and 93 (8%) had died in the usual care group (relative risk 0·95, 95% CI 0·74-1·24). 102 (7%) patients in the intervention group and 119 (10%) in the usual care group were re-admitted to hospital within 28 days (p=0·0004). Seven mild allergic reactions occurred, none of which could be attributed to ceftriaxone.

Conclusion : In patients with varying severity of sepsis, EMS personnel training improved early recognition and care in the whole acute care chain. However, giving antibiotics in the ambulance did not lead to improved survival, regardless of illness severity.

Conclusion (proposition de traduction) : Chez les patients présentant une septicémie plus ou moins grave, la formation du personnel du personnel des services médicaux d'urgence a amélioré le dépistage et les soins précoces dans l'ensemble de la chaîne des soins actifs. Cependant, l'administration d'antibiotiques dans l'ambulance n'a pas permis d'améliorer la survie, quelle que soit la gravité de la maladie.

Commentaire : Voir l'analyse de l'article sur le site de la Société de Réanimation de Langue Française (SRLF) : L’antibiothérapie en préhospitalier n’améliore pas la survie dans le sepsis  . Rédigé par le Dr Emmanuel Montassier, URGENCES-SAMU-SMUR, CHU de Nantes, le 28/03/2019.

The New England Journal of Medicine

Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection.
Kwong JC, Schwartz KL, Campitelli MA, Chung H, Crowcroft NS, Karnauchow T, Katz K, Ko DT, McGeer AJ, McNally D, Richardson DC, Rosella LC, Simor A, Smieja M, Zahariadis G, Gubbay JB. | N Engl J Med. 2018 Jan 25;378(4):345-353
Keywords: Aucun

Original articles

Introduction : Acute myocardial infarction can be triggered by acute respiratory infections. Previous studies have suggested an association between influenza and acute myocardial infarction, but those studies used nonspecific measures of influenza infection or study designs that were susceptible to bias. We evaluated the association between laboratory-confirmed influenza infection and acute myocardial infarction.

Méthode : We used the self-controlled case-series design to evaluate the association between laboratory-confirmed influenza infection and hospitalization for acute myocardial infarction. We used various high-specificity laboratory methods to confirm influenza infection in respiratory specimens, and we ascertained hospitalization for acute myocardial infarction from administrative data. We defined the "risk interval" as the first 7 days after respiratory specimen collection and the "control interval" as 1 year before and 1 year after the risk interval.

Résultats : We identified 364 hospitalizations for acute myocardial infarction that occurred within 1 year before and 1 year after a positive test result for influenza. Of these, 20 (20.0 admissions per week) occurred during the risk interval and 344 (3.3 admissions per week) occurred during the control interval. The incidence ratio of an admission for acute myocardial infarction during the risk interval as compared with the control interval was 6.05 (95% confidence interval [CI], 3.86 to 9.50). No increased incidence was observed after day 7. Incidence ratios for acute myocardial infarction within 7 days after detection of influenza B, influenza A, respiratory syncytial virus, and other viruses were 10.11 (95% CI, 4.37 to 23.38), 5.17 (95% CI, 3.02 to 8.84), 3.51 (95% CI, 1.11 to 11.12), and 2.77 (95% CI, 1.23 to 6.24), respectively.

Conclusion : We found a significant association between respiratory infections, especially influenza, and acute myocardial infarction.

Conclusion (proposition de traduction) : L'infarctus du myocarde aigu après une étude de laboratoire a révélé une association significative entre les infections respiratoires, en particulier la grippe, et l'infarctus aigu du myocarde.

Hemorrhagic Shock.
Cannon JW | N Engl J Med. 2018 Jan;378:370-379
Keywords: Aucun

Review article

Editorial : Understanding the pathophysiology of the body’s response to hemorrhage has led to improvements in prehospital care, more rapid hemostasis, avoidance of massive crystalloid resuscitation, and improved survival.

Conclusion : Hemorrhagic shock is a major cause of death and disability both in the United States and globally. Through an improved understanding of the pathobiology of hemorrhage and an emphasis on rapid achievement of definitive hemostasis, starting with prehospital care, survival of pa- tients with massive bleeding and recovery from hemorrhagic shock are now possible. However, much work remains to be done in the areas of primary prevention, early recognition, resuscitation options, and rapid hemostasis to increase the likelihood of recovery and reduce the burden of hemorrhagic shock to zero.

Conclusion (proposition de traduction) : Le choc hémorragique est une cause majeure de décès et d'invalidité aux États-Unis et dans le monde. Grâce à une meilleure compréhension de la pathobiologie de l'hémorragie et à la mise en évidence rapide de l'hémostase définitive, en commençant par les soins préhospitaliers, la survie des patients présentant des hémorragies massives et la guérison du choc hémorragique sont désormais possibles.
Cependant, il reste beaucoup à faire dans les domaines de la prévention primaire, de la reconnaissance précoce, des options de réanimation et de l'hémostase rapide pour augmenter la probabilité de guérison et réduire à zéro le fardeau du choc hémorragique.

Toxic Alcohols.
Kraut JA, Mullins ME. | N Engl J Med. 2018 Jan 18;378(3):270-280
Keywords: Aucun

Review article

Editorial : Poisonings by the toxic alcohols (methanol, ethylene glycol, iso- propanol, diethylene glycol, and propylene glycol) can cause cellular dysfunction and death, but symptoms may be nonspecific. Delays in diagnosis increase the risk of irreversible organ damage and death. In this review, we discuss the mechanisms of toxicity, methods available for diagnosis, and current recom- mendations for therapy.

Conclusion : Methanol, ethylene glycol, and diethylene glycol poisoning can cause severe cellular dysfunction and high mortality if not recognized and treated quickly. Isopropanol frequently causes medical complications but has a lower risk of death. A high anion-gap metabolic acidosis, an increased serum osmolal gap, or both can suggest that one of the toxic alcohols is present in the blood, but these abnormal laboratory results are not always present. One of the poisonings should be strongly suspected in persons with the clinical findings described previously, in all obtunded patients, or in those with an unexplained high osmolal gap, high anion-gap metabolic acidosis, or both. Definitive tests such as high-pressure liquid chromatography are not always available, even in developed countries but especially in undeveloped countries. Therefore, there is an unmet need for tests that are accurate and can be completed rapidly. Treatment with alcohol dehydrogenase inhibitors and the use of dialysis are effective, but both methods are not always available. Also, there is no consensus on when one or both methods should be used. Despite much progress in our understanding of the pathogenesis of reactions to these toxic alcohols and despite the development of effective treatments, much remains to be done to eliminate the severe clinical disturbances that result from exposure to these substances.

Conclusion (proposition de traduction) : L'empoisonnement au méthanol, à l'éthylène glycol et au diéthylène glycol peut entraîner un dysfonctionnement cellulaire grave et une mortalité élevée s'il n'est pas reconnu et traité rapidement. L'isopropanol provoque fréquemment des complications médicales mais présente un risque de décès plus faible. Une acidose métabolique à anion gap élevé, une augmentation du gap osmolal sérique, ou les deux, peuvent suggérer que l'un des alcools toxiques est présent dans le sang, mais ces résultats de laboratoire anormaux ne sont pas toujours présents. L'un des empoisonnements doit être fortement suspecté chez les personnes présentant les résultats cliniques décrits précédemment, chez tous les patients obtundus, ou chez ceux présentant une forte lacune osmolale inexpliquée, une acidose métabolique à forte lacune anionique, ou les deux. Les tests définitifs tels que la chromatographie liquide à haute pression ne sont pas toujours disponibles, même dans les pays développés, mais surtout dans les pays en développement. Par conséquent, il existe un besoin non satisfait de tests précis et pouvant être réalisés rapidement. Le traitement avec des inhibiteurs de l'alcool déshydrogénase et l'utilisation de la dialyse sont efficaces, mais les deux méthodes ne sont pas toujours disponibles. De plus, il n'y a pas de consensus sur le moment où l'une ou les deux méthodes doivent être utilisées. Malgré les progrès considérables réalisés dans la compréhension de la pathogénie des réactions à ces alcools toxiques et malgré le développement de traitements efficaces, il reste beaucoup à faire pour éliminer les graves troubles cliniques qui résultent de l'exposition à ces substances.

Oxygen Therapy in Suspected Acute Myocardial Infarction.
Lellouche F, Simon M, L’Her E. | N Engl J Med. 2018 Jan 11;378(2):201
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Keywords: Aucun


Editorial : Hofmann et al. (Sept. 28 issue) found that oxygen supplementation in patients with suspected myocardial infarction who did not have hypoxemia at baseline did not affect 1-year mortality or the incidence of rehospitaliza- tion after 30 days. The trial outcome measures did not include any related to neurologic func- tion or quality of life, despite the fact that cogni- tive deficits and functional disability often occur after myocardial infarction.

Conclusion : It is unknown whether myocardial infarction, particularly in patients who have chronic hypertension or who are elderly, compromises cerebral perfusion at values that would be considered normotensive in most patients, because monitoring of brain-tissue oxygenation has not been performed in patients with normal oxygen levels during myocardial infarction. Cerebral hypoxia can occur in the absence of peripheral hypoxemia in particular clinical scenarios. The DETO2X-AMI (Determination of the Role of Oxygen in Suspected Acute Myocardial Infarction) trial was conducted predominantly in Swedes, whose vulnerability to cerebral hypoperfusion may differ from that of other ethnic groups, potentially limiting generalizability. Post hoc analysis of neurologic function in DETO2X-AMI participants, or a sufficiently powered subgroup of them, could be performed to determine whether oxygen supplementation decreases the risk of neurologic compromise in myocardial infarction.

Conclusion (proposition de traduction) : On ignore si l'infarctus du myocarde, en particulier chez les patients souffrant d'hypertension chronique ou les personnes âgées, compromet la perfusion cérébrale à des valeurs qui seraient considérées comme normotendues chez la plupart des patients, car la surveillance de l'oxygénation des tissus cérébraux n'a pas été effectuée chez les patients dont le taux d'oxygène était normal pendant l'infarctus du myocarde. L'hypoxie cérébrale peut survenir en l'absence d'hypoxémie périphérique dans certains scénarios cliniques. L'essai DETO2X-AMI (Determination of the Role of Oxygen in Suspected Acute Myocardial Infarction) a été mené principalement en Suède, dont la vulnérabilité à l'hypoperfusion cérébrale peut être différente de celle des autres groupes ethniques, ce qui limite potentiellement la généralisabilité. Une analyse post hoc de la fonction neurologique chez les participants au DETO2X-AMI, ou un sous-groupe suffisamment puissant de ceux-ci, pourrait être effectuée pour déterminer si la supplémentation en oxygène diminue le risque de compromission neurologique en cas d'infarctus du myocarde.

Commentaire : Comment in: Oxygen Therapy in Suspected Acute Myocardial Infarction. [N Engl J Med 2018; 378:200-202] 
  . Comment on: Oxygen Therapy in Suspected Acute Myocardial Infarction. [N Engl J Med 2017; 377:1240-1249] 
Se reporter aux dernières recommandations de ESC Clinical Practice Guidelines : Acute Myocardial Infarction in patients presenting with ST-segment elevation (Management of) 

Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.
Nogueira RG, and al.; DAWN Trial Investigators.. | N Engl J Med. 2018 Jan 4;378(1):11-21
Keywords: Aucun

Original articles

Introduction : The effect of endovascular thrombectomy that is performed more than 6 hours after the onset of ischemic stroke is uncertain. Patients with a clinical deficit that is disproportionately severe relative to the infarct volume may benefit from late thrombectomy.

Méthode : We enrolled patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, with mismatch criteria defined according to age (<80 years or ≥80 years). Patients were randomly assigned to thrombectomy plus standard care (the thrombectomy group) or to standard care alone (the control group). The coprimary end points were the mean score for disability on the utility-weighted modified Rankin scale (which ranges from 0 [death] to 10 [no symptoms or disability]) and the rate of functional independence (a score of 0, 1, or 2 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating more severe disability) at 90 days.

Résultats : A total of 206 patients were enrolled; 107 were assigned to the thrombectomy group and 99 to the control group. At 31 months, enrollment in the trial was stopped because of the results of a prespecified interim analysis. The mean score on the utility-weighted modified Rankin scale at 90 days was 5.5 in the thrombectomy group as compared with 3.4 in the control group (adjusted difference [Bayesian analysis], 2.0 points; 95% credible interval, 1.1 to 3.0; posterior probability of superiority, >0.999), and the rate of functional independence at 90 days was 49% in the thrombectomy group as compared with 13% in the control group (adjusted difference, 33 percentage points; 95% credible interval, 24 to 44; posterior probability of superiority, >0.999). The rate of symptomatic intracranial hemorrhage did not differ significantly between the two groups (6% in the thrombectomy group and 3% in the control group, P=0.50), nor did 90-day mortality (19% and 18%, respectively; P=1.00).

Conclusion : Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone.

Conclusion (proposition de traduction) : Parmi les patients se présentant avec un AVC à la phase aigu dont le début des signes remontait entre 6 et 24 heures et qui présentaient un décalage entre le déficit clinique et la taille de l'infarctus, les résultats sur la persistance d'une séquelle à 90 jours étaient meilleurs avec une thrombectomie qu'avec un traitement standard.

Acute Pyelonephritis in Adults.
Johnson JR, Russo TA. | N Engl J Med. 2018 Jan 4;378(1):48-59
Keywords: Aucun

Clinical practice

Editorial : An otherwise healthy 35-year-old woman presents with urinary urgency, dysuria, fever, malaise, nausea, and flank pain. During a recent trip to India, she took a fluoroquinolone for diarrhea. On examination, the temperature is 38.6°C, the pulse 110 beats per minute, and the blood pressure 105/50 mm Hg; she has supra- pubic and flank tenderness, without abdominal tenderness. The white-cell count is 16,500 per cubic millimeter, and the serum creatinine concentration 1.4 mg per deciliter (124 μmol per liter) (most recent measurement before presentation, 0.8 mg per deciliter [71 μmol per liter]). Urinalysis is positive for leukocyte esterase and nitrites. How would you evaluate and manage this case?

Conclusion : This patient has acute pyelonephritis. She would probably benefit from fluid resuscitation in the emergency department. Rapid improvement might allow her to be discharged home with instructions to take an empirical oral therapy (e.g., a f luoroquinolone or an extended-spectrum cephalosporin). (...) Once susceptibility results are known, therapy should be narrowed appropriately. When the patient’s condition is clinically stable, she can be treated orally if a suitable agent is available. Regardless of the presence or absence of bacteremia, a 7-day course of a fluoroquinolone should suffice for a susceptible organism, whereas a 10-to-14-day course is preferable with trimethoprim–sulfa-methoxazole or a betalactam. If the clinical course is uneventful, no follow-up testing is needed, whereas worsening or a lack of improvement after 1 to 2 days should prompt repeat cultures plus imaging.

Conclusion (proposition de traduction) : Ce patient souffre d'une pyélonéphrite aiguë. Elle bénéficierait probablement d'une réanimation liquidienne aux urgences. Une amélioration rapide pourrait lui permettre d'être renvoyée chez elle avec l'instruction de suivre une thérapie orale empirique (par exemple, une f luoroquinolone ou une céphalosporine à spectre étendu) (. . . ) Une fois que les résultats de la susceptibilité sont connus, le traitement doit être limité de manière appropriée. Lorsque l'état de la patiente est cliniquement stable, elle peut être traitée par voie orale si un agent approprié est disponible. Indépendamment de la présence ou de l'absence de bactériémie, une cure de 7 jours d'une fluoroquinolone devrait suffire pour un organisme sensible, tandis qu'une cure de 10 à 14 jours est préférable avec du triméthoprime-sulfa-méthoxazole ou un bétalactam. Si l'évolution clinique est sans incident, aucun test de suivi n'est nécessaire, alors qu'une aggravation ou une absence d'amélioration après 1 à 2 jours devrait inciter à répéter les cultures et l'imagerie.

Commentaire : Une étude de cas qui donne l'occasion de faire le point sur la pyélonéphrite aigüe…


Prevalence of asthma-like symptoms with ageing.
Jarvis D, Newson R, Janson C, Corsico A, Heinrich J, Anto JM, Abramson MJ, Kirsten AM, Zock JP, Bono R, Demoly P, Leynaert B, Raherison C, Pin I, Gislason T, Jogi R, Schlunssen V, Svanes C, Watkins J, Weyler J, Pereira-Vega A, Urrutia I, Gullón JA, Forsberg B, Probst-Hensch N, Boezen HM, Martinez-Moratalla Rovira J, Accordini S, de Marco R, Burney P. | Thorax. 2018 Jan;73(1):37-48
DOI:  | Télécharger l'article au format  
Keywords: Asthma Epidemiology

Original Article

Introduction : Change in the prevalence of asthma-like symptoms in populations of ageing adults is likely to be influenced by smoking, asthma treatment and atopy

Méthode : The European Community Respiratory Health Survey collected information on prevalent asthma-like symptoms from representative samples of adults aged 20-44 years (29 centres in 13 European countries and Australia) at baseline and 10 and 20 years later (n=7844). Net changes in symptom prevalence were determined using generalised estimating equations (accounting for non-response through inverse probability weighting), followed by meta-analysis of centre level estimates.

Résultats : Over 20 years the prevalence of 'wheeze' and 'wheeze in the absence of a cold' decreased (-2.4%, 95% CI -3.5 to -1.3%; -1.5%, 95% CI -2.4 to -0.6%, respectively) but the prevalence of asthma attacks, use of asthma medication and hay fever/nasal allergies increased (0.6%, 95% CI 0.1 to 1.11; 3.6%, 95% CI 3.0 to 4.2; 2.7%, 95% CI 1.7 to 3.7). Changes were similar in the first 10 years compared with the second 10 years, except for hay fever/nasal allergies (increase seen in the first 10 years only). Decreases in these wheeze-related symptoms were largely seen in the group who gave up smoking, and were seen in those who reported hay fever/nasal allergies at baseline.

Conclusion : European adults born between 1946 and 1970 have, over the last 20 years, experienced less wheeze, although they were more likely to report asthma attacks, use of asthma medication and hay fever. Decrease in wheeze is largely attributable to smoking cessation, rather than improved treatment of asthma. It may also be influenced by reductions in atopy with ageing.

Conclusion (proposition de traduction) : Les adultes européens nés entre 1946 et 1970 ont connu, au cours des 20 dernières années, moins de dyspnée sifflante, bien qu'ils soient plus susceptibles de présenter des crises d'asthme, l'utilisation de médicaments contre l'asthme et le rhume des foins.
La diminution de la dyspnée sifflante est en grande partie attribuable au sevrage tabagique, plutôt qu'à un meilleur traitement de l'asthme. Il peut également être influencé par des réductions de l'atopie avec le vieillissement.

World Journal of Emergency Medicine

Video versus direct laryngoscopy on successful first-pass endotracheal intubation in ICU patients.
Gao YX, Song YB, Gu ZJ, Zhang JS, Chen XF, Sun H, Lu Z. | World J Emerg Med. 2018 Jan;9(2):99-104
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Keywords: Direct laryngoscopy; Intensive care unit; Intubation; Video laryngoscopy

Original Articles

Introduction : Airway management in intensive care unit (ICU) patients is challenging. The aim of this study was to compare the rate of successful first-pass intubation in the ICU by using the direct laryngoscopy (DL) and that by using the video laryngoscopy (VL).

Méthode : A randomized, non-blinded trial comparing first-pass success rate of intubation between VL and DL was performed. Patients were recruited in the period from August 2014 to August 2016. All physicians working at ICU received hands-on training in the use of the video and direct laryngoscope. The primary outcome measure was the first-pass intubation success.

Résultats : A total of 163 ICU patients underwent intubation during the study period (81 patients in VL group and 82 in DL group). The rate of successful first-pass intubation was not significantly different between the VL and the DL group (67.9% vs. 69.5%, P=0.824). Moreover, the overall intubation success and total number of attempts to achieve intubation success did not differ between the two groups. In patients with successful first-pass intubation, the median duration of the intubation procedure did not differ between the two groups. The Cormack-Lehane grades and the percentage of glottic opening score were similar, and no significant differences were found between the two groups. There were no statistical differences between the VL and the DL group in intubation complications (all P>0.05).

Conclusion : Among ICU patients requiring intubation, there was no significant difference in the rate of successful first-pass intubation between VL and DL.

Conclusion (proposition de traduction) : Parmi les patients en USI nécessitant une intubation, il n'y avait pas de différence significative dans le taux d'intubation de premier passage réussie entre laryngoscopie directe et celle en utilisant la vidéo laryngoscopie.

Outcomes of severe sepsis and septic shock patients after stratification by initial lactate value.
Chambers KA, Park AY, Banuelos RC, Darger BF, Akkanti BH, Macaluso A, Thangam M, Doshi PB. | World J Emerg Med. 2018 Jan;9(2):113-117
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Keywords: Emergency medicine; Lactic acid; Sepsis

Original article

Introduction : In the setting of severe sepsis and septic shock, mortality increases when lactate levels are ≥ 4 mmol/L. However, the consequences of lower lactate levels in this population are not well understood. The study aimed to determine the in-hospital mortality associated with severe sepsis and septic shock when initial lactate levels are < 4 mmol/L.

Méthode : This is a retrospective cohort study of septic patients admitted over a 40-month period. Totally 338 patients were divided into three groups based on initial lactate values. Group 1 had lactate levels < 2 mmol/L; group 2: 2-4 mmol/L; and group 3: ≥ 4 mmol/L. The primary outcome was in-hospital mortality.

Résultats : There were 111 patients in group 1, 96 patients in group 2, and 131 in group 3. The mortality rates were 21.6%, 35.4%, and 51.9% respectively. Univariate analysis revealed the mortality differences to be statistically significant. Multivariate logistic regression demonstrated higher odds of death with higher lactate tier group, however the findings did not reach statistical significance.

Conclusion : This study found that only assignment to group 3, initial lactic acid level of ≥ 4 mmol/L, was independently associated with increased mortality after correcting for underlying severity of illness and organ dysfunction. However, rising lactate levels in the other two groups were associated with increased severity of illness and were inversely proportional to prognosis.

Conclusion (proposition de traduction) : Cette étude a révélé que seule l'affectation au groupe 3, soit le niveau initial d'acide lactique ≥ 4 mmol/L, était associée indépendamment à une augmentation de la mortalité après correction de la gravité sous-jacente de la maladie et du dysfonctionnement des organes. Toutefois, l'élévation du taux de lactate dans les deux autres groupes était associée à une gravité accrue de la maladie et était inversement proportionnelle au pronostic.

Intravenous fluid selection rationales in acute clinical management.
Cheung WYS, Cheung WK, Lam CH, Chan YW, Chow HC, Cheng KL, Wong YH, Kam CW. | World J Emerg Med. 2018 Jan;9(1):13-19
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Keywords: Aucun

Original Article

Introduction : Intravenous fluid (IVF) is commonly used in acute clinical management. This study aimed to review the choice and primary considerations in IVF prescriptions and to evaluate the adequacy of guidelines and trainings on it in the New Territories West Cluster (NTWC) of Hong Kong.

Méthode : This is a descriptive study based on data collected from an online survey. Data were processed by SPSS for statistical analysis. This study focused on a general description and doctor-nurse between group comparison. Participants were asked the choice of IVF for nine acute clinical scenarios and provide reason. A 1-10 scale was used to assess the sufficiency of guideline, training and information, and time for revision on IVF prescription.

Résultats : 0.9% sodium chloride was the most familiar IVF (36%), followed by 5% Dextrose solution (26%). In the nine scenarios, the most chosen IVF was 0.9% sodium chloride (37%-61%). There was significant difference in the choice of IVF between doctors and nurses in 7 cases. The second most chosen IVF for doctors was Plasma-Lyte A while that for nurses was Gelofusine. Departmental practice was the most chosen reason to account for the prescription. The adequacy of guideline, information and training, and time for revision was rated 5. Doctors had significantly more time at work than nurses to update knowledge in IVF prescription (5.41 versus 4.57).

Conclusion : 0.9% sodium chloride was mostly chosen. The choice of IVF was mainly based on departmental practice. Adequacy of guideline, information and training, and time for revision on IVF prescription were average, indicating significant training deficit.

Conclusion (proposition de traduction) : Le chlorure de sodium à 0,9% était le plus utilisé. Le choix du soluté était principalement basé sur la pratique locale. L'adéquation des recommandations, de l'information et de la formation, et le temps nécessaire à la révision de la prescription des solutés intraveineux étaient moyens, ce qui indique un important déficit de pratique.

Commentaire : L'occasion d'une revue des recommandations sur l'utilisation des solutés intraveineux.

Drug calculation ability of qualified paramedics: A pilot study.
Boyle MJ1, Eastwood K. | World J Emerg Med. 2018 Jan;9(1):41-45
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Keywords: Education; Emergency medical technician; Medication errors; Safety management

Original Article

Introduction : he inability of paramedics to perform accurate calculations may result in a compromise of patient safety which may result from under or over dosing of drugs, incorrect joules for defibrillation, or a major adverse event such as death. The objective of this study was to identify the drug calculation and mathematical ability of qualified operational paramedics.

Méthode : The study used a cross-sectional design with a paper-based calculation questionnaire. Twenty paramedics enrolled in an intensive care paramedic course were eligible to participate in the study. The questionnaire consisted of demographic, drug calculation (seven questions), and mathematical (five) questions. Students were given no notice of the impending study and use of a calculator was not permitted.

Résultats : All eligible students participated in the study. The average time employed as a paramedic was 7.25 years, SD 2.5 years, range four years to twelve years. Four (20%) students got all 12 questions correct, and five (41.6%) got 50% or less. The average score was 8.6 (71.7%) correct, SD 2.8 correct, range 3 to 12 correct questions. There were eight (40%) conceptual errors, 12 (60%) arithmetical errors, and five (25%) computational errors.

Conclusion : The results from this study supports similar international studies where paramedic's ability to undertake mathematical and drug calculations without a calculator varies, with some results highlighting the paramedics mathematical skills as a potential risk to patient safety. These results highlight the need for regular continuing mathematical and drug calculation practice and education to ensure a lower error rate.

Conclusion (proposition de traduction) : Les résultats de cette étude soutiennent les études internationales similaires où la capacité du paramédic à entreprendre des calculs mathématiques et pharmaceutiques sans calculatrice varie, avec certains résultats mettant en évidence les compétences mathématiques paramédicales comme un risque potentiel pour la sécurité des patients. Ces résultats soulignent la nécessité d'une pratique régulière de calcul et de formation continue en mathématiques et sur les médicaments pour assurer un taux d'erreur plus faible.

Falls from height: A retrospective analysis.
Turgut K, Sarihan ME, Colak C, Güven T, Gür A, Gürbüz S. | World J Emerg Med. 2018 Jan;9(1):46-50
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Keywords: Trauma; Falls; Mortality; Emergency medicine

Original article

Introduction : Emergency services manage trauma patients frequently and falls from height comprise the main cause of emergency service admissions. In this study, we aimed to analyse the demographic characteristics of falls from height and their relationship to the mortality.

Méthode : A total of 460 patients, who admitted to the Emergency Department of Inonu University between November 2011 and November 2014 with a history of fall from height, were examined retrospectively. Demographic parameters, fall characteristics and their effect to mortality were evaluated statistically.

Résultats : The study comprised of 292 (63.5%) men and 168 (36.5%) women patients. The mean age of all patients was 27±24.99 years. Twenty-six (5.6%) patients died and the majority of them were in ≥62 years old group. The highest percentage of falls was at 0–5 years age group (28.3%). People fell mainly from 1.1–4 metres(m) level (46.1%). The causes of falls were ordered as unintentional (92.2%), workplace (8.1%) and suicidal (1.7%). Skin and soft tissue injuries (37.4%) were the main traumatic lesions.

Conclusion : Age, fall height, fall place, lineer skull fracture, subarachnoidal hemorrhage, cervical fracture, thoracic vertebra fracture and trauma scores had statistically significant effect on mortality. The casualties died because of subarachnoid hemorrhage mostly.

Conclusion (proposition de traduction) : L'âge, la hauteur de chute, le lieu de chute, une fracture du crâne, une hémorragie sous-arachnoïdienne, une fracture cervicale, une fracture de vertèbre thoracique et les scores de traumatisme ont eu un effet statistiquement significatif sur la mortalité.
Les victimes sont mortes à cause d'une hémorragie sous-arachnoïdienne principalement.

Comparison of sedative effectiveness of thiopental versus midazolam in reduction of shoulder dislocation.
Vahidi E, Hemati R, Momeni M, Jahanshir A, Saeedi M. | World J Emerg Med. 2018;9(2):125-129
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Keywords: Emergency medicine; Midazolam; Shoulder dislocation; Thiopental

Original Articles

Introduction : Various sedative drugs have been proposed to control anxiety and agitation in shoulder dislocation, but none of them has been diagnosed as the best sedative and relaxant agent. The study aimed to compare the sedative effectiveness of thiopental versus midazolam in reduction of shoulder dislocation.

Méthode : A randomized double-blind controlled trail was performed in 80 patients with shoulder dislocation recruited from the emergency department. Ten patients were excluded and 70 patients were enrolled in the study. Case group received intravenous thiopental 2 mg/kg+2 µg/kg fentanyl while control group received intravenous midazolam 0.1 mg/kg+2 µg/kg fentanyl. Number of times, patients and physician's satisfaction, difficulty of procedure, degree of muscle relaxation, time of sedation and complete recovery, number of patients with apnea episode, O2 saturation, patient's pain score and adverse events were all recorded.

Résultats : Muscular tone had significant difference between the two groups (P-value=0.014) and thiopental was more muscle relaxant than midazolam. Replacement of shoulder dislocation in thiopental group was easier than midazolam group (P-value=0.043). There was no need to use multiple methods of reduction in either group. Before drug infusion the mean±SD VAS scores were 8.37±2.21 in the midazolam group (A) and 8.94±1.78 in the thiopental group (B); mean difference 0.57, 95% CI= -0.38 to 1.52. After completion of the procedure, the mean±SD VAS scores in group (A) and (B) were 3.20±1.30 vs. 3.65±1.30; mean difference -0.45, 95% CI= -1.07 to 0.16.

Conclusion : Thiopental might be more effective and relaxant than midazolam for reduction of shoulder dislocation.

Conclusion (proposition de traduction) : Le thiopental semble être plus efficace et plus myorelaxant que le midazolam pour réduction d'une luxation de l'épaule.

Mois de janvier 2018