The 2017 Academic Emergency Medicine Consensus Conference: Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcomes.
Bond WF, Hui J, Fernandez R. | Acad Emerg Med. 2018 Feb;25(2):109-115
DOI: https://doi.org/10.1111/acem.13302  | Télécharger l'article au format  
Keywords: Aucun

Consensus conference

Editorial : Over the past decade, emergency medicine (EM) took a lead role in healthcare simulation in part due to its demands for successful interprofessional and multidisciplinary collaboration, along with educational needs in a diverse array of cognitive and procedural skills. Simulation-based methodologies have the capacity to support training and research platforms that model micro-, meso-, and macrosystems of healthcare. To fully capitalize on the potential of simulation-based research to improve emergency healthcare delivery will require the application of rigorous methods from engineering, social science, and basic science disciplines. The Academic Emergency Medicine (AEM) Consensus Conference "Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcome" was conceived to foster discussion among experts in EM, engineering, and social sciences, focusing on key barriers and opportunities in simulation-based research. This executive summary describes the overall rationale for the conference, conference planning, and consensus-building approaches and outlines the focus of the eight breakout sessions. The consensus outcomes from each breakout session are summarized in proceedings papers published in this issue of Academic Emergency Medicine. Each paper provides an overview of methodologic and knowledge gaps in simulation research and identifies future research targets aimed at improving the safety and quality of healthcare.

Conclusion : The proceedings from this conference willprovide a roadmap for future work in simulation-basedresearch within emergency medicine.

Conclusion (proposition de traduction) : Les actes de cette conférence fourniront une feuille de route pour les travaux futurs sur la recherche basée sur la simulation en médecine d'urgence.

Commentaire : Cet article est le sommaire pour les articles suivant dans la revue que vous trouverez à l'adresse suivante : Academic Emergency Medicine   Volume 25, Issue 2, Pages 103–254. Tous les documents sont en accès libre.

The Impact of Prehospital Tranexamic Acid on Blood Coagulation in Trauma Patients.
Stein P, Studt JD, Albrecht R, Müller S, von Ow D, Fischer S, Seifert B, Mariotti S, Spahn DR, Theusinger OM. | Anesth Analg. 2018 Feb;126(2):522-529
DOI: https://doi.org/10.1213/ANE.0000000000002708
Keywords: Aucun

Original Clinical Research Report

Introduction : There is limited data on prehospital administration of tranexamic acid (TXA) in civilian trauma. The aim of this study was to evaluate changes in coagulation after severe trauma from on-scene to the hospital after TXA application in comparison to a previous study without TXA.

Méthode : The study protocol was registered at ClinicalTrials.gov (NCT02354885  ). A prospective, multicenter, observational study investigating coagulation status in 70 trauma patients receiving TXA (1 g intravenously) on-scene versus a control group of 38 patients previously published without TXA. To account for potential differences in patient and trauma epidemiology, crystalloid and colloidal resuscitation fluid, 2 propensity score matched groups (n = 24 per group) were created. Measurements included ROTEM, standard coagulation tests and blood gas analyses on-scene and emergency department admission. Presented values are mean and [standard deviation], and difference in means and 95% confidence intervals.

Résultats : Patient epidemiology was not different between groups. Coagulation assays on-scene were comparable between the TXA and C. Prehospital hyperfibrinolysis was blunted in all 4 patients in the TXA group. Viscoelastic FIBTEM maximum clot firmness (MCF), representing functional fibrinogen levels, did not change from on-scene to the emergency department in the TXA group, whereas MCF decreased -3.7 [1.8] mm in the control group. Decrease of MCF was significantly reduced in the TXA group in EXTEM by 9.2 (7.2-11.2) mm (P < .001) and INTEM by 6.8 (4.7-9.0) mm (P < .001) in favor of the TXA group. Production of fibrinogen fragments (represented by D-dimers) was significantly lower in the TXA group compared to group C.

Conclusion : Early prehospital administration of TXA leads to clot stabilization and a reduction of fibrinolytic activity, causing a decrease in fibrin degradation products buildup (D-dimer).

Conclusion (proposition de traduction) : L'administration pré-hospitalière précoce d'acide tranexamique entraîne une stabilisation du caillot et une réduction de l'activité fibrinolytique, entraînant une diminution de l'accumulation de produits de dégradation de la fibrine (D-dimères).

The Impact of Prehospital Tranexamic Acid on Blood Coagulation in Trauma Patients.
Stein P, Stein P, von Ow D, Fischer S, Seifert B, Mariotti S, Spahn DR, Theusinger OM. | Anesth Analg. 2018 Feb;126(2):522-529
DOI: https://doi.org/10.1213/ANE.0000000000002708
Keywords: Aucun

Original Clinical Research Report

Introduction : There is limited data on prehospital administration of tranexamic acid (TXA) in civilian trauma. The aim of this study was to evaluate changes in coagulation after severe trauma from on-scene to the hospital after TXA application in comparison to a previous study without TXA.

Méthode : The study protocol was registered at ClinicalTrials.gov (NCT02354885). A prospective, multicenter, observational study investigating coagulation status in 70 trauma patients receiving TXA (1 g intravenously) on-scene versus a control group of 38 patients previously published without TXA. To account for potential differences in patient and trauma epidemiology, crystalloid and colloidal resuscitation fluid, 2 propensity score matched groups (n = 24 per group) were created. Measurements included ROTEM, standard coagulation tests and blood gas analyses on-scene and emergency department admission. Presented values are mean and [standard deviation], and difference in means and 95% confidence intervals.

Résultats : Patient epidemiology was not different between groups. Coagulation assays on-scene were comparable between the TXA and C. Prehospital hyperfibrinolysis was blunted in all 4 patients in the TXA group. Viscoelastic FIBTEM maximum clot firmness (MCF), representing functional fibrinogen levels, did not change from on-scene to the emergency department in the TXA group, whereas MCF decreased -3.7 [1.8] mm in the control group. Decrease of MCF was significantly reduced in the TXA group in EXTEM by 9.2 (7.2-11.2) mm (P < .001) and INTEM by 6.8 (4.7-9.0) mm (P < .001) in favor of the TXA group. Production of fibrinogen fragments (represented by D-dimers) was significantly lower in the TXA group compared to group C.

Conclusion : Early prehospital administration of TXA leads to clot stabilization and a reduction of fibrinolytic activity, causing a decrease in fibrin degradation products buildup (D-dimer).

Conclusion (proposition de traduction) : L'administration pré-hospitalière précoce d'acide tranéxamique entraîne une stabilisation du caillot et une réduction de l'activité fibrinolytique, entraînant une diminution de l'accumulation de produits de dégradation de la fibrine (D-dimères).

Comparison of Transcranial Doppler and Ultrasound-Tagged Near Infrared Spectroscopy for Measuring Relative Changes in Cerebral Blood Flow in Human Subjects.
Lipnick MS, Cahill EA, Feiner JR, Bickler PE. | Anesth Analg. 2018 Feb;126(2):579-587
DOI: https://doi.org/10.1213/ANE.0000000000002590
Keywords: Aucun

Original Laboratory Research Report

Introduction : Currently, no reliable method exists for continuous, noninvasive measurements of absolute cerebral blood flow (CBF). We sought to determine how changes measured by ultrasound-tagged near-infrared spectroscopy (UT-NIRS) compare with changes in CBF as measured by transcranial Doppler (TCD) in healthy volunteers during profound hypocapnia and hypercapnia.

Méthode : Ten healthy volunteers were monitored with a combination of TCD, UT-NIRS (c-FLOW, Ornim Medical), as well as heart rate, blood pressure, end-tidal PCO2 (PEtCO2), end-tidal O2, and inspired O2. Inspired CO2 and minute ventilation were controlled to achieve 5 stable plateau goals of EtCO2 at 15-20, 25-30, 35-40, 45-50, and 55-60 mm Hg, for a total of 7 measurements per subject. CBF was assessed at a steady state, with the TCD designated as the reference standard. The primary analysis was a linear mixed-effect model of TCD and UT-NIRS flow with PEtCO2, which accounts for repeated measures. Receiver operating characteristic curves were determined for detection of changes in CBF.

Résultats : Hyperventilation (nadir PEtCO2 17.1 ± 2.4) resulted in significantly decreased mean flow velocity of the middle cerebral artery from baseline (to 79% ± 22%), but not a consistent decrease in UT-NIRS cerebral flow velocity index (n = 10; 101% ± 6% of baseline). Hypercapnia (peak PEtCO2 59.3 ± 3.3) resulted in a significant increase from baseline in both mean flow velocity of the middle cerebral artery (153% ± 25%) and UT-NIRS (119% ± 11%). Comparing slopes versus PEtCO2 as a percent of baseline for the TCD (1.7% [1.5%-2%]) and UT-NIRS (0.4% [0.3%-0.5%]) shows that the UT-NIRS slope is significantly flatter, P < .0001. Area under the receiver operating characteristic curve was significantly higher for the TCD than for UT-NIRS, 0.97 (95% confidence interval, 0.92-0.99) versus 0.75 (95% confidence interval, 0.66-0.82).

Conclusion : Our data indicate that UT-NIRS cerebral flow velocity index detects changes in CBF only during hypercarbia but not hypocarbia in healthy subjects and with much less sensitivity than TCD. Additional refinement and validation are needed before widespread clinical utilization of UT-NIRS.

Conclusion (proposition de traduction) : Nos données indiquent que l'indice de vitesse du flux cérébral par spectroscopie proche infrarouge marquée par ultrasons détecte les changements du flux sanguin cérébral uniquement pendant l'hypercarbie, mais pas chez les sujets sains et avec une sensibilité bien moindre que le Doppler transcrânien. Des perfectionnements et une validation supplémentaires sont nécessaires avant l'utilisation clinique généralisée de la spectroscopie proche infrarouge marquée par ultrasons.

Commentaire : Spectroscopie dans l'infrarouge proche (ou dans le proche infrarouge, SPIR)

Variability in Interpretation of Cardiac Standstill Among Physician Sonographers.
Hu K, Gupta N, Teran F, Saul T, Nelson BP, Andrus P. | Ann Emerg Med. 2018 Feb;71(2):193-198
DOI: https://doi.org/10.1016/j.annemergmed.2017.07.476
Keywords: Aucun

Original research article

Introduction : Cardiac standstill on point-of-care ultrasonography has been widely studied as a marker of prognosis in cardiac arrest. Return of spontaneous circulation has been reported in as few as 0% and as many as 45% of patients with cardiac standstill. When explicitly documented, the definition of cardiac activity in these studies varied from any slight change in echogenicity of the myocardium to any kinetic cardiac activity. We hypothesize that the variability in research definitions of cardiac activity may affect interpretation of video clips of patients in cardiac arrest. The goal of this study is to assess the variability in interpretation of standstill among physician sonographers.

Méthode : We surveyed physician sonographers at 6 conferences held at 3 academic medical centers in the Greater New York area. Survey respondents were allotted 20 seconds per slide to determine whether each of 15 video clips of patients in cardiac arrest were standstill or not. Data were collected anonymously with radio frequency remotes.

Résultats : There were 127 total participants, including faculty, fellows, and resident physicians specializing in emergency medicine, critical care, and cardiology. There was only moderate interrater agreement among all participants (α=0.47). This lack of agreement persisted across specialties, self-reported training levels, and self-reported ultrasonographic expertise.

Conclusion : According to the results of our study, there appears to be considerable variability in interpretation of cardiac standstill among physician sonographers. Consensus definitions of cardiac activity and standstill would improve the quality of cardiac arrest ultrasonographic research and standardize the use of this technology at the bedside.

Conclusion (proposition de traduction) : Selon les résultats de notre étude, il semble y avoir une variabilité importante dans l'interprétation de l'arrêt cardiaque chez les médecins échographistes. Des définitions consensuelles de l'activité cardiaque et de l'arrêt cardiaque amélioreraient la qualité de la recherche échographique sur arrêt cardiaque et normaliseraient l'utilisation de cette technologie au chevet du patient.

Transesophageal Echocardiography: Guidelines for Point-of-Care Applications in Cardiac Arrest Resuscitation.
Fair J, Mallin M, Mallemat H, Zimmerman J, Arntfield R, Kessler R, Bailitz J, Blaivas M. | Ann Emerg Med. 2018 Feb;71(2):201-207
DOI: https://doi.org/10.1016/j.annemergmed.2017.09.003
Keywords: Aucun

Imaging/concepts

Editorial : Cardiac arrest is one of the most challenging patient presentations managed by emergency care providers, and echocardiography can be instrumental in the diagnosis, prognosis, and treatment guidance in these critically ill patients. Transesophageal echocardiography has many advantages over transthoracic echocardiography in a cardiac arrest resuscitation. As transesophageal echocardiography is implemented more widely at the point of care during cardiac arrest resuscitations, guidelines are needed to assist emergency providers in acquiring the equipment and skills necessary to successfully incorporate it into the management of cardiac arrest victims.

Conclusion (proposition de traduction) : L'arrêt cardiaque est l'une des situations cliniques les plus difficiles à gérer par les urgentistes, et l'échocardiographie peut jouer un rôle dans le diagnostic, le pronostic et les conseils thérapeutiques chez ces patients en situation critique.
L'échocardiographie transoesophagienne présente de nombreux avantages par rapport à l'échocardiographie transthoracique lors d'une réanimation d'un arrêt cardiaque. Comme l'échocardiographie transœsophagienne est mise en œuvre plus largement au lit du malade pendant les réanimations cardiaques, des recommandations sont nécessaires pour aider les urgentistes à acquérir l'équipement et les compétences nécessaires pour l'intégrer dans la prise en charge des victimes d'arrêt cardiaque.

Does Spontaneous Cardiac Motion, Identified With Point-of-Care Echocardiography During Cardiac Arrest, Predict Survival?.
April MD, Long B. | Ann Emerg Med. 2018 Feb;71(2):208-210
DOI: https://doi.org/10.1016/j.annemergmed.2017.04.042
Keywords: Aucun

Imaging/systematic review snapshot

Méthode : The authors included 15 studies evaluating the accuracy of outcome prediction by detection of spontaneous cardiac motion among 1,695 patients in cardiac arrest. Ten of these studies took place in the ED, 3 in the out-of-hospital setting, and 2 in a combination of out-of-hospital and ED settings. Two studies recruited trauma patients, 7 studies recruited nontrauma patients, and the remaining studies either recruited mixed populations or did not specify their patient recruitmentmethods. Seven studies used ultrasonography performed by advanced performers (defined as attending physicians, senior residents, or residents with formal advanced ultrasonographic training), with 6 studies conducted by intermediateexperience performers (defined as all other providers) and 2 studies using providers with both intermediate and advanced experience.

Résultats : The absence of spontaneous cardiac motion on ultrasonography demonstrates ability to rule out return of spontaneous circulation (LR– 0.06) and survival to hospital admission (LR– 0.13). The authors reported a more modest value for a positive result (spontaneous cardiac motion) to rule in return of spontaneous circulation (LRfl 4.8) or survival to hospital admission (LRfl 4.1). The lack of reported training level prevented investigators from pooling results evaluating accuracy based on training level. Heterogeneity, as evaluated by I2, was 98% for return of spontaneous circulation and 82% for hospital admission.

Conclusion : Point-of-care echocardiography demonstrating no spontaneous cardiac motion is associated with lower likelihood of return of spontaneous circulation and survival to hospital admission. This may be used to assist with decisionmaking about resuscitation termination.

Conclusion (proposition de traduction) : L'échocardiographie au lit du malade retrouvant l'absence de mouvement cardiaque spontané est associée à une probabilité moindre de retour de une circulation spontanée et une survie à l'admission à l'hôpital.
Cela peut être utilisé pour aider à la prise de décision concernant l'arrêt de la réanimation.

Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial.
April MD, Oliver JJ, Davis WT, Ong D, Simon EM, Ng PC, Hunter CJ. | Ann Emerg Med. 2018 Feb 17. pii: S0196-0644(18)30029-5
DOI: https://doi.org/10.1016/j.annemergmed.2018.01.016
Keywords: Aucun

Article in Press

Introduction : We compare aromatherapy with inhaled isopropyl alcohol versus oral ondansetron for treating nausea among emergency department (ED) patients not requiring immediate intravenous access.

Méthode : In a randomized, blinded, placebo-controlled trial, we enrolled a convenience sample of adults presenting to an urban tertiary care ED with chief complaints including nausea or vomiting. We randomized subjects to 1 of 3 arms: inhaled isopropyl alcohol and 4 mg oral ondansetron, inhaled isopropyl alcohol and oral placebo, and inhaled saline solution placebo and 4 mg oral ondansetron. The primary outcome was mean nausea reduction measured by a 0- to 100-mm visual analog scale from enrollment to 30 minutes postintervention. Secondary outcomes included receipt of rescue antiemetic medications and adverse events.

Résultats : We enrolled 122 subjects, of whom 120 (98.3%) completed the study. Of randomized subjects, 40 received inhaled isopropyl alcohol and oral ondansetron, 41 received inhaled isopropyl alcohol and oral placebo, and 41 received inhaled saline solution placebo and oral ondansetron. The mean decrease in nausea visual analog scale score in each arm was 30 mm (95% confidence interval [CI] 22 to 37 mm), 32 mm (95% CI 25 to 39 mm), and 9 mm (95% CI 5 to 14 mm), respectively. The proportions of subjects who received rescue antiemetic therapy in each arm were 27.5% (95% CI 14.6% to 43.9%), 25.0% (95% CI 12.7% to 41.2%), and 45.0% (95% CI 29.3% to 61.5%), respectively. There were no adverse events.

Conclusion : Among ED patients with acute nausea and not requiring immediate intravenous access, aromatherapy with or without oral ondansetron provides greater nausea relief than oral ondansetron alone.

Conclusion (proposition de traduction) : Chez les patients des urgences présentant des nausées aiguës et ne nécessitant pas de voie intraveineuse immédiate, l'aromathérapie avec ou sans ondansétron per os procure un plus grand soulagement des nausées que l'ondansétron seul par voie orale.

The Newest Threat to Emergency Department Procedural Sedation.
Green SM, Roback MG, Krauss BS. | Ann Emerg Med. 2018 Feb 2. pii: S0196-0644(17)31970-4
DOI: https://doi.org/10.1016/j.annemergmed.2017.12.008  | Télécharger l'article au format  
Keywords: Aucun

Article in Press

Editorial : Guidelines for procedural sedation first appeared in 1985—a National Institutes of Health guideline for dentists and an American Academy of Pediatrics guideline for children. Because procedural sedation is a multidisciplinary field, a wide array of specialty societies, including the American College of Emergency Physicians (ACEP), subsequently crafted and periodically update their own sedation guidelines. These documents are not mandated by regulatory bodies such as The Joint Commission or the Centers for Medicare & Medicaid Services (CMS), but are instead initiated by the specialty societies on behalf of their members. These guidelines begin with accepted core sedation principles and include customized elements to address specialty-specific needs, challenges, and patient populations.

Conclusion : In summary, the ASA guideline update contains numerous confusing statements on critical issues relating to ED sedation practice and misleading characterizations in regard to deep sedation, ketamine, and propofol that are contrary to the existing scientific evidence. Key issues such as deep sedation, guideline relationships, skill sets, and specific drugs lack sufficient clarity for meaningful understanding or consistent interpretation. Given the critical need for emergency physicians to advocate on behalf of their patients, and given that each of the vague or omitted areas favors previously asserted adverse ASA positions, we believe that emergency physicians must assume the document to be politically motivated until proven otherwise. Emergency physicians are fully qualified by their training to administer all levels of sedation, and emergency medicine has long been at the forefront of sedation research and safe sedation practice. Non–evidence-based efforts by another specialty to dictate our scope of practice must be vigorously opposed.

Conclusion (proposition de traduction) : Les médecins urgentistes sont pleinement qualifiés par leur formation pour administrer tous les niveaux de sédation, et la médecine d'urgence est depuis longtemps à l'avant-garde de la recherche en sédation et des pratiques de sédation sécuritaires. Nous devons vigoureusement nous opposer aux efforts non fondés sur des données probantes d'autre spécialité pour nous dicter notre champ d'exercice.

Prognostic Accuracy of the Quick Sequential Organ Failure Assessment for Mortality in Patients With Suspected Infection: A Systematic Review and Meta-analysis.
Fernando SM, Tran A, Taljaard M, Cheng W, Rochwerg B, Seely AJE, Perry JJ. | Ann Intern Med. 2018 Feb 20;168(4):266-275
DOI: https://doi.org/10.7326/M17-2820
Keywords: Aucun

Review

Introduction : The quick Sequential Organ Failure Assessment (qSOFA) has been proposed for prediction of mortality in patients with suspected infection.
PURPOSE: To summarize and compare the prognostic accuracy of qSOFA and the systemic inflammatory response syndrome (SIRS) criteria for prediction of mortality in adult patients with suspected infection.

Méthode : Four databases from inception through November 2017.
STUDY SELECTION: English-language studies using qSOFA for prediction of mortality (in-hospital, 28-day, or 30-day) in adult patients with suspected infection in the intensive care unit (ICU), emergency department (ED), or hospital wards.
DATA EXTRACTION: Two investigators independently extracted data and assessed study quality using standard criteria.

Résultats : Thirty-eight studies were included (n = 385 333). qSOFA was associated with a pooled sensitivity of 60.8% (95% CI, 51.4% to 69.4%) and a pooled specificity of 72.0% (CI, 63.4% to 79.2%) for mortality. The SIRS criteria were associated with a pooled sensitivity of 88.1% (CI, 82.3% to 92.1%) and a pooled specificity of 25.8% (CI, 17.1% to 36.9%). The pooled sensitivity of qSOFA was higher in the ICU population (87.2% [CI, 75.8% to 93.7%]) than the non-ICU population (51.2% [CI, 43.6% to 58.7%]). The pooled specificity of qSOFA was higher in the non-ICU population (79.6% [CI, 73.3% to 84.7%]) than the ICU population (33.3% [CI, 23.8% to 44.4%]).
LIMITATION: Potential risk of bias in included studies due to qSOFA interpretation and patient selection.

Conclusion : qSOFA had poor sensitivity and moderate specificity for short-term mortality. The SIRS criteria had sensitivity superior to that of qSOFA, supporting their use for screening of patients and as a prompt for treatment initiation.

Conclusion (proposition de traduction) : Le qSOFA avait une sensibilité médiocre et une spécificité modérée pour la mortalité à court terme. Les critères du SIRS avaient une sensibilité supérieure à celle du qSOFA, justifiant leur utilisation pour le dépistage des patients et comme incitation à l'initiation du traitement.

Age trends in 30 day hospital readmissions: US national retrospective analysis.
Berry JG, Gay JC, Joynt Maddox K, Coleman EA, Bucholz EM, O'Neill MR, Blaine K, Hall M. | BMJ. 2018 Feb 27;360:k497
DOI: https://doi.org/10.1136/bmj.k497
Keywords: Aucun

Research

Introduction : To assess trends in and risk factors for readmission to hospital across the age continuum.
DESIGN: Retrospective analysis.
SETTING AND PARTICIPANTS: 31 729 762 index hospital admissions for all conditions in 2013 from the US Agency for Healthcare Research and Quality Nationwide Readmissions Database.

Méthode : 30 day, all cause, unplanned hospital readmissions. Odds of readmission were compared by patients' age in one year epochs with logistic regression, accounting for sex, payer, length of stay, discharge disposition, number of chronic conditions, reason for and severity of admission, and data clustering by hospital. The middle (45 years) of the age range (0-90+ years) was selected as the age reference group.

Résultats : The 30 day unplanned readmission rate following all US index admissions was 11.6% (n=3 678 018). Referenced by patients aged 45 years, the adjusted odds ratio for readmission increased between ages 16 and 20 years (from 0.70 (95% confidence interval 0.68 to 0.71) to 1.04 (1.02 to 1.06)), remained elevated between ages 21 and 44 years (range 1.02 (1.00 to 1.03) to 1.12 (1.10 to 1.14)), steadily decreased between ages 46 and 64 years (range 1.02 (1.00 to 1.04) to 0.91 (0.90 to 0.93)), and decreased abruptly at age 65 years (0.78 (0.77 to 0.79)), after which the odds remained relatively constant with advancing age. Across all ages, multiple chronic conditions were associated with the highest adjusted odds of readmission (for example, 3.67 (3.64 to 3.69) for six or more versus no chronic conditions). Among children, young adults, and middle aged adults, mental health was one of the most common reasons for index admissions that had high adjusted readmission rates (≥75th centile).

Conclusion : The likelihood of readmission was elevated for children transitioning to adulthood, children and younger adults with mental health disorders, and patients of all ages with multiple chronic conditions. Further attention to the measurement and causes of readmission and opportunities for its reduction in these groups is warranted.

Conclusion (proposition de traduction) : La probabilité de réadmission était plus élevée chez les adolescents, chez les enfants et les jeunes adultes ayant des troubles de santé mentale et chez les patients de tous âges atteints de maladies chroniques multiples. Une plus grande attention à la mesure et aux causes de réadmission ainsi que les possibilités de réduction de ces groupes sont justifiées.

Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: network meta-analysis of diagnostic randomised controlled trials.
Siontis GC, Mavridis D, Greenwood JP, Coles B, Nikolakopoulou A, Jüni P, Salanti G, Windecker S. | BMJ. 2018 Feb 21;360:k504
DOI: https://doi.org/10.1136/bmj.k504
Keywords: Aucun

Research

Introduction : To evaluate differences in downstream testing, coronary revascularisation, and clinical outcomes following non-invasive diagnostic modalities used to detect coronary artery disease.
DESIGN: Systematic review and network meta-analysis.
DATA SOURCES: Medline, Medline in process, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, SCOPUS, WHO International Clinical Trials Registry Platform, and Clinicaltrials.gov.

Méthode : Diagnostic randomised controlled trials comparing non-invasive diagnostic modalities in patients presenting with symptoms suggestive of low risk acute coronary syndrome or stable coronary artery disease.
DATA SYNTHESIS: A random effects network meta-analysis synthesised available evidence from trials evaluating the effect of non-invasive diagnostic modalities on downstream testing and patient oriented outcomes in patients with suspected coronary artery disease. Modalities included exercise electrocardiograms, stress echocardiography, single photon emission computed tomography-myocardial perfusion imaging, real time myocardial contrast echocardiography, coronary computed tomographic angiography, and cardiovascular magnetic resonance. Unpublished outcome data were obtained from 11 trials.

Résultats : 18 trials of patients with low risk acute coronary syndrome (n=11 329) and 12 trials of those with suspected stable coronary artery disease (n=22 062) were included. Among patients with low risk acute coronary syndrome, stress echocardiography, cardiovascular magnetic resonance, and exercise electrocardiograms resulted in fewer invasive referrals for coronary angiography than coronary computed tomographic angiography (odds ratio 0.28 (95% confidence interval 0.14 to 0.57), 0.32 (0.15 to 0.71), and 0.53 (0.28 to 1.00), respectively). There was no effect on the subsequent risk of myocardial infarction, but estimates were imprecise. Heterogeneity and inconsistency were low. In patients with suspected stable coronary artery disease, an initial diagnostic strategy of stress echocardiography or single photon emission computed tomography-myocardial perfusion imaging resulted in fewer downstream tests than coronary computed tomographic angiography (0.24 (0.08 to 0.74) and 0.57 (0.37 to 0.87), respectively). However, exercise electrocardiograms yielded the highest downstream testing rate. Estimates for death and myocardial infarction were imprecise without clear discrimination between strategies.

Conclusion : For patients with low risk acute coronary syndrome, an initial diagnostic strategy of stress echocardiography or cardiovascular magnetic resonance is associated with fewer referrals for invasive coronary angiography and revascularisation procedures than non-invasive anatomical testing, without apparent impact on the future risk of myocardial infarction. For suspected stable coronary artery disease, there was no clear discrimination between diagnostic strategies regarding the subsequent need for invasive coronary angiography, and differences in the risk of myocardial infarction cannot be ruled out.

Conclusion (proposition de traduction) : Pour les patients présentant un syndrome coronarien aigu à faible risque, une stratégie diagnostique initiale d'échocardiographie de stress ou de résonance magnétique cardiovasculaire est associée à un nombre moins important de procédures d'angiographie coronarienne invasive et de revascularisation que les tests anatomiques non invasifs sans impact apparent sur le risque futur d'infarctus du myocarde. En cas de suspicion de coronaropathie stable, il n'y avait pas de discrimination nette entre les stratégies de diagnostic concernant le besoin ultérieur d'angiographie coronarienne invasive, et des différences dans le risque d'infarctus du myocarde ne peuvent être exclues.

Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study.
Crellin E, Mansfield KE, Leyrat C, Nitsch D, Douglas IJ, Root A, Williamson E, Smeeth L, Tomlinson LA. | BMJ. 2018 Feb 9;360:k341
DOI: https://doi.org/10.1136/bmj.k341
Keywords: Aucun

Research

Introduction : To determine if trimethoprim use for urinary tract infection (UTI) is associated with an increased risk of acute kidney injury, hyperkalaemia, or sudden death in the general population.
DESIGN: Cohort study.
SETTING: UK electronic primary care records from practices contributing to the Clinical Practice Research Datalink linked to the Hospital Episode Statistics database.

Méthode : Adults aged 65 and over with a prescription for trimethoprim, amoxicillin, cefalexin, ciprofloxacin, or nitrofurantoin prescribed up to three days after a primary care diagnosis of UTI between April 1997 and September 2015.
MAIN OUTCOME MEASURES: The outcomes were acute kidney injury, hyperkalaemia, and death within 14 days of a UTI treated with antibiotics.

Résultats : Among a cohort of 1 191 905 patients aged 65 and over, 178 238 individuals were identified with at least one UTI treated with antibiotics, comprising a total of 422 514 episodes of UTIs treated with antibiotics. The odds of acute kidney injury in the 14 days following antibiotic initiation were higher following trimethoprim (adjusted odds ratio 1.72, 95% confidence interval 1.31 to 2.24) and ciprofloxacin (1.48, 1.03 to 2.13) compared with amoxicillin. The odds of hyperkalaemia in the 14 days following antibiotic initiation were only higher following trimethoprim (2.27, 1.49 to 3.45) compared with amoxicillin. However, the odds of death within the 14 days following antibiotic initiation were not higher with trimethoprim than with amoxicillin: in the whole population the adjusted odds ratio was 0.90 (95% confidence interval 0.76 to 1.07) while among users of renin-angiotensin system blockers the odds of death within 14 days of antibiotic initiation was 1.12 (0.80 to 1.57). The results suggest that, for 1000 UTIs treated with antibiotics among people 65 and over, treatment with trimethoprim instead of amoxicillin would result in one to two additional cases of hyperkalaemia and two admissions with acute kidney injury, regardless of renin-angiotensin system blockade. However, for people taking renin-angiotensin system blockers and spironolactone treatment with trimethoprim instead of amoxicillin there were 18 additional cases of hyperkalaemia and 11 admissions with acute kidney injury.

Conclusion : Trimethoprim is associated with a greater risk of acute kidney injury and hyperkalaemia compared with other antibiotics used to treat UTIs, but not a greater risk of death. The relative risk increase is similar across population groups, but the higher baseline risk among those taking renin-angiotensin system blockers and potassium-sparing diuretics translates into higher absolute risks of acute kidney injury and hyperkalaemia in these groups.

Conclusion (proposition de traduction) : Le Triméthoprime est associé à un risque accru d'atteintes rénales aiguës et d'hyperkaliémie par rapport aux autres antibiotiques utilisés pour traiter les infections urinaires, mais pas à un risque plus élevé de décès. L'augmentation du risque relatif est similaire dans tous les groupes de population, mais le risque de base est plus élevé parmi ceux qui prennent des inhibiteurs du système rénine-angiotensine et des diurétiques épargneurs de potassium qui se traduit par des risques absolus plus élevés de lésions rénales aiguës et d'hyperkaliémie.

Commentaire : L'association Triméthoprime-sulfaméthoxazole (dosage « forte ») pendant 5 jours est indiquée chez l'adulte pour le traitement de la cystite à risque de complication   - SPILF 2014.

Ischaemic stroke, haemorrhage, and mortality in older patients with chronic kidney disease newly started on anticoagulation for atrial fibrillation: a population based study from UK primary care.
Kumar S, de Lusignan S, McGovern A, Correa A, Hriskova M, Gatenby P, Jones S, Goldsmith D, Camm AJ. | BMJ. 2018 Feb 14;360:k342
DOI: https://doi.org/10.1136/bmj.k342
Keywords: Aucun

Research

Introduction : To assess the association between anticoagulation, ischaemic stroke, gastrointestinal and cerebral haemorrhage, and all cause mortality in older people with atrial fibrillation and chronic kidney disease.
DESIGN: Propensity matched, population based, retrospective cohort analysis from January 2006 through December 2016.
SETTING: The Royal College of General Practitioners Research and Surveillance Centre database population of almost 2.73 million patients from 110 general practices across England and Wales.

Méthode : Patients aged 65 years and over with a new diagnosis of atrial fibrillation and estimated glomerular filtration rate (eGFR) of <50 mL/min/1.73m2, calculated using the chronic kidney disease epidemiology collaboration creatinine equation. Patients with a previous diagnosis of atrial fibrillation or receiving anticoagulation in the preceding 120 days were excluded, as were patients requiring dialysis and recipients of renal transplants.
INTERVENTION: Receipt of an anticoagulant prescription within 60 days of atrial fibrillation diagnosis.
MAIN OUTCOME MEASURES: Ischaemic stroke, cerebral or gastrointestinal haemorrhage, and all cause mortality.

Résultats : 6977 patients with chronic kidney disease and newly diagnosed atrial fibrillation were identified, of whom 2434 were on anticoagulants within 60 days of diagnosis and 4543 were not. 2434 pairs were matched using propensity scores by exposure to anticoagulant or none and followed for a median of 506 days. The crude rates for ischaemic stroke and haemorrhage were 4.6 and 1.2 after taking anticoagulants and 1.5 and 0.4 in patients who were not taking anticoagulant per 100 person years, respectively. The hazard ratios for ischaemic stroke, haemorrhage, and all cause mortality for those on anticoagulants were 2.60 (95% confidence interval 2.00 to 3.38), 2.42 (1.44 to 4.05), and 0.82 (0.74 to 0.91) compared with those who received no anticoagulation.

Conclusion : Giving anticoagulants to older people with concomitant atrial fibrillation and chronic kidney disease was associated with an increased rate of ischaemic stroke and haemorrhage but a paradoxical lowered rate of all cause mortality. Careful consideration should be given before starting anticoagulants in older people with chronic kidney disease who develop atrial fibrillation. There remains an urgent need for adequately powered randomised trials in this population to explore these findings and to provide clarity on correct clinical management.

Conclusion (proposition de traduction) : L'administration d'anticoagulants aux personnes âgées présentant une fibrillation auriculaire et une insuffisance rénale chronique concomitante était associée à une augmentation du taux d'AVC ischémiques et d'hémorragiques, mais à un taux de mortalité toutes causes confondues paradoxalement bas. Une attention particulière doit être accordée avant de débuter un traitement anticoagulant pour fibrillation auriculaire chez les personnes âgées se présentant avec une insuffisance rénale chronique. Il y a un besoin urgent d'essais randomisés de bonne qualité dans cette population pour confirmer ces résultats et clarifier la prise en charge clinique adéquate.

Five and 10 minute Apgar scores and risks of cerebral palsy and epilepsy: population based cohort study in Sweden.
Persson M, Razaz N, Tedroff K, Joseph KS, Cnattingius S. | BMJ. 2018 Feb 7;360:k207
DOI: https://doi.org/10.1136/bmj.k207
Keywords: Aucun

Research Update

Introduction : To investigate associations between Apgar score at five and 10 minutes across the entire range of score values (from 0 to 10) and risks of childhood cerebral palsy or epilepsy, and to analyse the effect of changes in Apgar scores from five to 10 minutes after birth in infants born ≥37 completed weeks.
DESIGN, SETTING, AND PARTICIPANTS: Population based cohort study in Sweden, including 1 213 470 non-malformed live singleton infants, born at term between 1999 and 2012. Data on maternal and pregnancy characteristics and diagnoses of cerebral palsy and epilepsy were obtained by individual record linkages of nationwide Swedish registries.
EXPOSURES: Apgar scores at five and 10 minutes.

Méthode : Cerebral palsy and epilepsy diagnosed up to 16 years of age. Adjusted hazard ratios were calculated, along with 95% confidence intervals.

Résultats : 1221 (0.1%) children were diagnosed as having cerebral palsy and 3975 (0.3%) as having epilepsy. Compared with children with an Apgar score of 10 at five minutes, the adjusted hazard ratio for cerebral palsy increased steadily with decreasing Apgar score: from 1.9 (95% confidence interval 1.6 to 2.2) for an Apgar score of 9 to 277.7 (154.4 to 499.5) for an Apgar score of 0. Similar and even stronger associations were obtained between Apgar scores at 10 minutes and cerebral palsy. Associations between Apgar scores and epilepsy were less pronounced, but increased hazard ratios were noted in infants with a five minute Apgar score of 7 or less and a 10 minute Apgar score of 8 or less. Compared with infants with an Apgar of 9-10 at both five and 10 minutes, hazard ratios of cerebral palsy and epilepsy were higher among infants with a five minute Apgar score of 7-8 and a 10 minute Apgar score of 9-10.

Conclusion : Risks of cerebral palsy and epilepsy are inversely associated with five minute and 10 minute Apgar scores across the entire range of Apgar scores.

Conclusion (proposition de traduction) : Les risques d'atteintes cérébrales et d'épilepsie sont inversement associés aux scores Apgar de cinq minutes et 10 minutes sur toute la gamme des scores d'Apgar.

No Clinical Benefit of Empirical Antimicrobial Therapy for Pediatric Diarrhea in a High-Usage, High-Resistance Setting.
Duong VT, Tuyen HT, Van Minh P, Campbell JI, Phuc HL, Nhu TDH, Tu LTP, Chau TTH, Nhi LTQ, Hung NT, Ngoc NM, Huong NTT, Vi LL, Thompson CN, Thwaites GE, de Alwis R, Baker S. | Clin Infect Dis. 2018 Feb 1;66(4):504-511
DOI: https://doi.org/10.1093/cid/cix844
Keywords: Campylobacter; Shigella; antimicrobial resistance; disease outcome; fluoroquinolones; multidrug resistance; nontyphoidal Salmonella; pediatric diarrhea

Articles and commentaries

Introduction : Pediatric diarrheal disease presents a major public health burden in low- to middle-income countries. The clinical benefits of empirical antimicrobial treatment for diarrhea are unclear in settings that lack reliable diagnostics and have high antimicrobial resistance (AMR).

Méthode : We conducted a prospective multicenter cross-sectional study of pediatric patients hospitalized with diarrhea containing blood and/or mucus in Ho Chi Minh City, Vietnam. Clinical parameters, including disease outcome and treatment, were measured. Shigella, nontyphoidal Salmonella (NTS), and Campylobacter were isolated from fecal samples, and their antimicrobial susceptibility profiles were determined. Statistical analyses, comprising log-rank tests and accelerated failure time models, were performed to assess the effect of antimicrobials on disease outcome.

Résultats : Among 3166 recruited participants (median age 10 months; interquartile range, 6.5-16.7 months), one-third (1096 of 3166) had bloody diarrhea, and 25% (793 of 3166) were culture positive for Shigella, NTS, or Campylobacter. More than 85% of patients (2697 of 3166) were treated with antimicrobials; fluoroquinolones were the most commonly administered antimicrobials. AMR was highly prevalent among the isolated bacteria, including resistance against fluoroquinolones and third-generation cephalosporins. Antimicrobial treatment and multidrug resistance status of the infecting pathogens were found to have no significant effect on outcome. Antimicrobial treatment was significantly associated with an increase in the duration of hospitalization with particular groups of diarrheal diseases.

Conclusion : In a setting with high antimicrobial usage and high AMR, our results imply a lack of clinical benefit for treating diarrhea with antimicrobials; adequately powered randomized controlled trials are required to assess the role of antimicrobials for diarrhea.

Conclusion (proposition de traduction) : Dans un contexte de consommation élevée d'antibiotiques et de résistance élevée, nos résultats montrent l'absence de bénéfice clinique pour le traitement de la diarrhée par les antibiotiques ; des essais contrôlés randomisés suffisamment puissants sont nécessaires pour évaluer le rôle des antibiotiques dans la diarrhée.

Commentaire : Chez les enfants, la prescription d’antibiotiques pour la diarrhée aiguë est une pratique courante notamment recommandée par l’OMS en cas de selles hémorragiques, quel que soit l’âge de l’enfant. Le bénéfice clinique de cette pratique n’est cependant pas démontré y compris dans les pays ayant des conditions socio-économiques défavorables.
Le principal résultat de cette étude, l’absence de bénéfice clinique des antibiotiques pour le traitement de la diarrhée infantile, rejoint ceux déjà observés dans les études comparant antibiotiques et placebo pour les diarrhées à Salmonelles mineures ou à Campylobacter. Même si ce travail présente des biais, le fait que l’antibiothérapie soit un facteur de risque d’hospitalisation prolongée, notamment pour les formes cliniques les moins graves, suggère un effet délétère de l’exposition aux antibiotiques dont il serait intéressant d’en connaître la raison.

Prevalence and outcome of patients with non-ST segment elevation myocardial infarction with occluded "culprit" artery - a systemic review and meta-analysis.
Hung CS, Chen YH, Huang CC, Lin MS, Yeh CF, Li HY, Kao HL. | Crit Care. 2018 Feb 9;22(1):34
DOI: https://doi.org/10.1186/s13054-018-1944-x  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : The aim was to determine the prevalence and impact of an occluded "culprit" artery (OCA) in patients with non-ST segment elevation myocardial infarction (NSTEMI).

Méthode : We searched PubMed, EMBASE, and Web of Science, with no language restrictions, up to 1 Jul. 2016. Observational cohorts or clinical trials of adult NSTEMI were eligible for inclusion to determine the prevalence if the proportion of OCA on coronary angiography was reported. Studies were further eligible for inclusion to determine the outcome if the association between OCA and clinical endpoints was reported.

Résultats : Among the 60,898 patients with NSTEMI enrolled in 25 studies, 17,212 were found to have OCA. The average proportion of OCA in NSTEMI was 34% (95% CI 30-37%). Patients with OCA were more likely to have left circumflex artery as their culprit artery (odds ratio (OR) 1.65, 95% CI 1.15-2.37, p = 0.007), and this was associated with lower left ventricular ejection fraction (standard mean difference -0.29, 95% CI -0.34 to -0.34, p < 0.001), higher peak enzyme level (standard mean difference 0.43, 95% CI 0.27-0.58, p < 0.001), and higher risk for cardiogenic shock (OR 1.66, 95% CI 1.35-2.04, p < 0.001), compared with patients with a non-occlusive culprit artery. Death rate (OR 1.72, 95% CI 1.49-1.98, p < 0.001) and recurrent myocardial infarction (OR 1.7, 95% CI 1.06-2.75, p = 0.029) were also higher in patients with OCA, compared with patients with a non-occlusive culprit artery.

Conclusion : Patients with OCA comprised a substantial portion of the NSTEMI population. These patients present with more severe symptoms and worse clinical outcome. Whether these patients should be treated with more aggressive strategy warrants further study.

Conclusion (proposition de traduction) : Les patients présentant une artère « coupable » occluse représentaient une partie substantielle de la population des NSTEMI. Ces patients présentent des symptômes plus sévères et des résultats cliniques plus mauvais. Si ces patients devaient être traités avec une stratégie plus agressive, cela nécessiterait une étude plus approfondie.

Pre-hospital transthoracic echocardiography for early identification of non-ST-elevation myocardial infarction in patients with acute coronary syndrome.
Bergmann I, Büttner B, Teut E, Jacobshagen C, Hinz J, Quintel M, Mansur A, Roessler M. | Crit Care. 2018 Feb 7;22(1):29
DOI: https://doi.org/10.1186/s13054-017-1929-1  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : Non-ST elevation myocardial infarction (NSTEMI) is a common manifestation of acute coronary syndrome (ACS), but delayed diagnosis can increase mortality. In this proof of principle study, the emergency physician performed transthoracic echocardiography (TTE) on scene to determine whether NSTEMI could be correctly diagnosed pre-hospitalization. This could expedite admission to the appropriate facility and reduce the delay until initiation of correct therapy.

Méthode : Pre-hospital TTE was performed on scene by the emergency physician in patients presenting with ACS but without ST-elevation in the initial 12-lead electrocardiography (ECG) (NSTE-ACS). A presumptive NSTEMI diagnosis was made if regional wall motion abnormalities (RWMA) were detected. These patients were admitted directly to a specialist cardiac facility. Patient characteristics and pre-admission and post-admission clinical, pre-hospital TTE data, and therapeutic measures were recorded.

Résultats : Patients with NSTE-ACS (n = 53; 72.5 ± 13.4 years of age; 23 female) were studied. The 20 patients with pre-hospital RWMA and presumptive NSTEMI, and two without RWMA were conclusively diagnosed with NSTEMI in hospital. Percutaneous coronary intervention was performed in 50% of the patients presumed to have NSTEMI immediately after admission. The RWMA seen before hospital TTE corresponded with the in-hospital ECG findings and/or the supply regions of the occluded coronary vessels seen during PCI in 85% of the cases. The diagnostic sensitivity of pre-hospital TTE for NSTEMI was 90.9% with 100% specificity.

Conclusion : Pre-hospital transthoracic echocardiography by the emergency physician can correctly diagnose NSTEMI in more than 90% of cases. This can expedite the initiation of appropriate therapy and could thereby conceivably reduce morbidity and mortality.

Conclusion (proposition de traduction) : L'échocardiographie trans-thoracique extra-hospitalière réalisée par un médecin urgentiste permet de diagnostiquer correctement le NSTEMI dans plus de 90 % des cas. Cela pourrait accélérer l'initiation d'une thérapie appropriée et pourrait ainsi réduire la morbidité et la mortalité.

Performance of the quick Sequential (sepsis-related) Organ Failure Assessment score as a prognostic tool in infected patients outside the intensive care unit: a systematic review and meta-analysis.
Song JU, Sin CK, Park HK, Shim SR, Lee J. | Crit Care. 2018 Feb 6;22(1):28
DOI: https://doi.org/10.1186/s13054-018-1952-x  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : The usefulness of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score in providing bedside criteria for early prediction of poor outcomes in patients with suspected infection remains controversial. We investigated the prognostic performance of a positive qSOFA score outside the intensive care unit (ICU) compared with positive systemic inflammatory response syndrome (SIRS) criteria.

Méthode : A systematic literature search was performed using MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Data were pooled on the basis of sensitivity, specificity, and diagnostic OR. Overall test performance was summarized using a hierarchical summary ROC and the AUC. Meta-regression analysis was used to identify potential sources of bias.

Résultats : We identified 23 studies with a total of 146,551 patients. When predicting in-hospital mortality in our meta-analysis, we identified pooled sensitivities of 0.51 for a positive qSOFA score and 0.86 for positive SIRS criteria, as well as pooled specificities of 0.83 for a positive qSOFA score and 0.29 for positive SIRS criteria. Discrimination for in-hospital mortality had similar AUCs between the two tools (0.74 vs. 0.71; P = 0.816). Using meta-regression analysis, an overall mortality rate ≥ 10% and timing of qSOFA score measurement could be significant sources of heterogeneity. For predicting acute organ dysfunction, although the AUC for a positive qSOFA score was higher than that for positive SIRS criteria (0.87 vs. 0.76; P < 0.001), the pooled sensitivity of positive qSOFA score was very low (0.47). In addition, a positive qSOFA score tended to be inferior to positive SIRS criteria in predicting ICU admission (0.63 vs. 0.78; P = 0.121).

Conclusion : A positive qSOFA score had high specificity outside the ICU in early detection of in-hospital mortality, acute organ dysfunction, and ICU admission, but low sensitivity may have limitations as a predictive tool for adverse outcomes. Because between-study heterogeneity was highly represented among the studies, our results should be interpreted with caution.

Conclusion (proposition de traduction) : Un score qSOFA positif présentait une spécificité élevée en dehors de l'USI pour la détection précoce de la mortalité hospitalière, du syndrome de défaillance multiviscérale et de l'admission en réanimation, mais une faible sensibilité peut avoir des limites en tant qu'outil prédictif de résultats indésirables.
Étant donné que l'hétérogénéité entre les études est forte, nos résultats doivent être interprétés avec prudence.

Commentaire : Une nouvelle étude qui tente d'utiliser le qSOFA en dehors du service de réanimation.

Vasoplegia treatments: the past, the present, and the future.
Levy B, Fritz C, Tahon E, Jacquot A, Auchet T, Kimmoun A. | Crit Care. 2018 Feb 27;22(1):52
DOI: https://doi.org/10.1186/s13054-018-1967-3  | Télécharger l'article au format  
Keywords: Catecholamines; Circulatory failure; Septic shock; Vasoconstrictor agents; Vasoplegic syndrome

Review

Editorial : Vasoplegia is a ubiquitous phenomenon in all advanced shock states, including septic, cardiogenic, hemorrhagic, and anaphylactic shock. Its pathophysiology is complex, involving various mechanisms in vascular smooth muscle cells such as G protein-coupled receptor desensitization (adrenoceptors, vasopressin 1 receptors, angiotensin type 1 receptors), alteration of second messenger pathways, critical illness-related corticosteroid insufficiency, and increased production of nitric oxide. This review, based on a critical appraisal of the literature, discusses the main current treatments and future approaches. Our improved understanding of these mechanisms is progressively changing our therapeutic approach to vasoplegia from a standardized to a personalized multimodal treatment with the prescription of several vasopressors. While norepinephrine is confirmed as first line therapy for the treatment of vasoplegia, the latest Surviving Sepsis Campaign guidelines also consider that the best therapeutic management of vascular hyporesponsiveness to vasopressors could be a combination of multiple vasopressors, including norepinephrine and early prescription of vasopressin. This new approach is seemingly justified by the need to limit adrenoceptor desensitization as well as sympathetic overactivation given its subsequent deleterious impacts on hemodynamics and inflammation. Finally, based on new pathophysiological data, two potential drugs, selepressin and angiotensin II, are currently being evaluated.

Conclusion : Vasoplegia is a common feature of all advanced shock states, with norepinephrine remaining the cornerstone of vasoplegia-induced hypotension. However, given our improved understanding of vasoplegia, management is likely to evolve from a standardized therapy with nor- epinephrine alone to a multimodal strategy with two or more vasopressors. Based on new pathophysiological data, numerous potential drugs are currently being in- vestigated. Nevertheless, these new potential treatments or therapeutic strategies should be evaluated not only for their ability to increase arterial pressure but also for their capacity to improve survival or decrease major morbidity as well as for their effectiveness/cost ratio.

Conclusion (proposition de traduction) : La vasoplégie est une caractéristique commune à tous les états de choc confirmés, la noradrénaline restant la pierre angulaire de l'hypotension induite par la vasoplégie. Cependant, étant donné notre meilleure compréhension de la vasoplégie, la prise en charge est susceptible d'évoluer d'une thérapie standardisée avec la norépinéphrine seule à une stratégie multimodale avec deux vasopresseurs ou plus. Sur la base de nouvelles données physiopathologiques, de nombreux médicaments potentiels sont actuellement étudiés. Néanmoins, ces nouveaux traitements potentiels ou stratégies thérapeutiques doivent être évalués non seulement pour leur capacité à augmenter la pression artérielle mais aussi pour leur capacité à améliorer la survie ou à diminuer la morbidité majeure ainsi que pour leur rapport efficacité / coût.

Hemodynamic effects of acute hyperoxia: systematic review and meta-analysis.
Smit B, Smulders YM, van der Wouden JC, Oudemans-van Straaten HM, Spoelstra-de Man AME. | Crit Care. 2018 Feb 25;22(1):45
DOI: https://doi.org/10.1186/s13054-018-1968-2  | Télécharger l'article au format  
Keywords: Hemodynamics; Hyperoxia; Meta-analysis; Oxygen; Systematic review

Review

Introduction : In clinical practice, oxygen is generally administered to patients with the intention of increasing oxygen delivery. Supplemental oxygen may, however, cause arterial hyperoxia, which is associated with hemodynamic alterations. We performed a systematic review and meta-analysis of the literature to determine the effect of hyperoxia on central hemodynamics and oxygen delivery in healthy volunteers and cardiovascular-compromised patients.

Méthode : PubMed and EMBASE were searched up to March 2017. Studies with adult humans investigating changes in central hemodynamics or oxygen delivery induced by acute normobaric hyperoxia were included. Studies focusing on lung, retinal, or brain parameters were not included. We extracted subject and oxygen exposure characteristics, indexed and unindexed values for heart rate, stroke volume, cardiac output, mean arterial pressure (MAP), systemic vascular resistance, and oxygen delivery during normoxia and hyperoxia. For quantitative synthesis of the data, a random-effects ratio of means (RoM) model was used.

Résultats : We identified 33 studies with 42 datasets. Study categories included healthy volunteers (n = 22 datasets), patients with coronary artery disease (CAD; n = 6), heart failure (HF; n = 6), coronary artery bypass graft (CABG; n = 3) and sepsis (n = 5). Hyperoxia (arterial oxygen tension of 234-617 mmHg) reduced cardiac output (CO) by 10-15% in both healthy volunteers (-10.2%, 95% confidence interval (CI) -12.9% to -7.3%) and CAD (-9.6%, 95% CI -12.3% to -6.9%) or HF patients (-15.2%, 95% CI -21.7% to -8.2%). No significant changes in cardiac output were seen in CABG or septic patients (-3%). Systemic vascular resistance increased remarkably in patients with heart failure (24.6%, 95% CI 19.3% to 30.1%). In healthy volunteers, and those with CAD and CABG, the effect was smaller (11-16%) and was virtually absent in patients with sepsis (4.3%, 95% CI -3.2% to 12.3%). No notable effect on MAP was found in any group (2-3%). Oxygen delivery was not altered by hyperoxia. Considerable heterogeneity existed between study results, likely due to methodological differences.

Conclusion : Hyperoxia may considerably decrease cardiac output and increase systemic vascular resistance, but effects differ between patient categories. Heart failure patients were the most sensitive while no hemodynamic effects were seen in septic patients. There is currently no evidence supporting the notion that oxygen supplementation increases oxygen delivery.

Conclusion (proposition de traduction) : L'hyperoxie peut réduire considérablement le débit cardiaque et augmenter les résistances vasculaires systémiques, mais les effets diffèrent d'une catégorie de patients à l'autre. Les patients atteints d'insuffisance cardiaque étaient les plus sensibles, tandis qu'aucun effet hémodynamique n'a pas été observé chez les patients septiques.
Il n'y a actuellement aucune preuve permettant de suggérer que la supplémentation en oxygène augmente l'apport d'oxygène (aux tissus et organes).

Pre-hospital transthoracic echocardiography for early identification of non-ST-elevation myocardial infarction in patients with acute coronary syndrome.
Bergmann I, Büttner B, Teut E, Jacobshagen C, Hinz J, Quintel M, Mansur A, Roessler M. | Crit Care. 2018 Feb 7;22(1):29
DOI: https://doi.org/10.1186/s13054-017-1929-1  | Télécharger l'article au format  
Keywords: Acute coronary syndrome; Emergency physician; NSTEMI; Non-ST-elevation myocardial infarction; Pre-hospital; Regional wall motion abnormalities; Transthoracic echocardiography

Research

Introduction : Non-ST elevation myocardial infarction (NSTEMI) is a common manifestation of acute coronary syndrome (ACS), but delayed diagnosis can increase mortality. In this proof of principle study, the emergency physician performed transthoracic echocardiography (TTE) on scene to determine whether NSTEMI could be correctly diagnosed pre-hospitalization. This could expedite admission to the appropriate facility and reduce the delay until initiation of correct therapy.

Méthode : Pre-hospital TTE was performed on scene by the emergency physician in patients presenting with ACS but without ST-elevation in the initial 12-lead electrocardiography (ECG) (NSTE-ACS). A presumptive NSTEMI diagnosis was made if regional wall motion abnormalities (RWMA) were detected. These patients were admitted directly to a specialist cardiac facility. Patient characteristics and pre-admission and post-admission clinical, pre-hospital TTE data, and therapeutic measures were recorded.

Résultats : Patients with NSTE-ACS (n = 53; 72.5 ± 13.4 years of age; 23 female) were studied. The 20 patients with pre-hospital RWMA and presumptive NSTEMI, and two without RWMA were conclusively diagnosed with NSTEMI in hospital. Percutaneous coronary intervention was performed in 50% of the patients presumed to have NSTEMI immediately after admission. The RWMA seen before hospital TTE corresponded with the in-hospital ECG findings and/or the supply regions of the occluded coronary vessels seen during PCI in 85% of the cases. The diagnostic sensitivity of pre-hospital TTE for NSTEMI was 90.9% with 100% specificity.

Conclusion : Pre-hospital transthoracic echocardiography by the emergency physician can correctly diagnose NSTEMI in more than 90% of cases. This can expedite the initiation of appropriate therapy and could thereby conceivably reduce morbidity and mortality.

Conclusion (proposition de traduction) : L'échocardiographie transthoracique pré-hospitalière par le médecin urgentiste permet de diagnostiquer correctement le NSTEMI dans plus de 90% des cas. Cela peut accélérer l'initiation d'une thérapie appropriée et pourrait ainsi réduire la morbidité et la mortalité.

Performance of the quick Sequential (sepsis-related) Organ Failure Assessment score as a prognostic tool in infected patients outside the intensive care unit: a systematic review and meta-analysis.
Song JU, Sin CK, Park HK, Shim SR, Lee J. | Crit Care. 2018 Feb 6;22(1):28
DOI: https://doi.org/10.1186/s13054-018-1952-x  | Télécharger l'article au format  
Keywords: Emergency department; Intensive care unit; Mortality; Sepsis; qSOFA

Research

Introduction : The usefulness of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score in providing bedside criteria for early prediction of poor outcomes in patients with suspected infection remains controversial. We investigated the prognostic performance of a positive qSOFA score outside the intensive care unit (ICU) compared with positive systemic inflammatory response syndrome (SIRS) criteria.

Méthode : A systematic literature search was performed using MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Data were pooled on the basis of sensitivity, specificity, and diagnostic OR. Overall test performance was summarized using a hierarchical summary ROC and the AUC. Meta-regression analysis was used to identify potential sources of bias.

Résultats : We identified 23 studies with a total of 146,551 patients. When predicting in-hospital mortality in our meta-analysis, we identified pooled sensitivities of 0.51 for a positive qSOFA score and 0.86 for positive SIRS criteria, as well as pooled specificities of 0.83 for a positive qSOFA score and 0.29 for positive SIRS criteria. Discrimination for in-hospital mortality had similar AUCs between the two tools (0.74 vs. 0.71; P = 0.816). Using meta-regression analysis, an overall mortality rate ≥ 10% and timing of qSOFA score measurement could be significant sources of heterogeneity. For predicting acute organ dysfunction, although the AUC for a positive qSOFA score was higher than that for positive SIRS criteria (0.87 vs. 0.76; P < 0.001), the pooled sensitivity of positive qSOFA score was very low (0.47). In addition, a positive qSOFA score tended to be inferior to positive SIRS criteria in predicting ICU admission (0.63 vs. 0.78; P = 0.121).

Conclusion : A positive qSOFA score had high specificity outside the ICU in early detection of in-hospital mortality, acute organ dysfunction, and ICU admission, but low sensitivity may have limitations as a predictive tool for adverse outcomes. Because between-study heterogeneity was highly represented among the studies, our results should be interpreted with caution.

Conclusion (proposition de traduction) : Un score de qSOFA positif présentait une spécificité élevée en dehors de l'USI pour la détection précoce de la mortalité à l'hôpital, du dysfonctionnement aigu d'organes et de l'admission en réanimation, mais avec une sensibilité faible ce qui en fait une limite en tant qu'outil prédictif d'évolution indésirable.
Comme l'hétérogénéité entre les études était fortement présente dans les études retenues, nos résultats doivent être interprétés avec prudence.

Predictors, Prevalence, and Outcomes of Early Crystalloid Responsiveness Among Initially Hypotensive Patients With Sepsis and Septic Shock.
Leisman DE, Doerfler ME, Schneider SM, Masick KD, D'Amore JA, D'Angelo JK. | Crit Care Med. 2018 Feb;46(2):189-198
DOI: https://doi.org/10.1097/CCM.0000000000002834  | Télécharger l'article au format  
Keywords: intravenous fluids; sepsis; septic shock

Feature Articles

Introduction : The prevalence of responsiveness to initial fluid challenge among hypotensive sepsis patients is unclear. To avoid fluid overload, and unnecessary treatment, it is important to differentiate these phenotypes. We aimed to 1) determine the proportion of hypotensive sepsis patients sustaining favorable hemodynamic response after initial fluid challenge, 2) determine demographic and clinical risk factors that predicted refractory hypotension, and 3) assess the association between timeliness of fluid resuscitation and refractoriness.

Méthode : Design: Secondary analysis of a prospective, multisite, observational, consecutive-sample cohort.
Setting: Nine tertiary and community hospitals over 1.5 years.
Patients: Inclusion criteria 1) suspected or confirmed infection, 2) greater than or equal to two systemic inflammatory response syndrome criteria, 3) systolic blood pressure less than 90 mm Hg, greater than 40% decrease from baseline, or mean arterial pressure less than 65 mm Hg.

Résultats : Sex, age, heart failure, renal failure, immunocompromise, source of infection, initial lactate, coagulopathy, temperature, altered mentation, altered gas exchange, and acute kidney injury were used to generate a risk score. The primary outcome was sustained normotension after fluid challenge without vasopressor titration. Among 3,686 patients, 2,350 (64%) were fluid responsive. Six candidate risk factors significantly predicted refractoriness in multivariable analysis: heart failure (odds ratio, 1.43; CI, 1.20–1.72), hypothermia (odds ratio, 1.37; 1.10–1.69), altered gas exchange (odds ratio, 1.33; 1.12–1.57), initial lactate greater than or equal to 4.0 mmol/L (odds ratio, 1.28; 1.08–1.52), immunocompromise (odds ratio, 1.23; 1.03–1.47), and coagulopathy (odds ratio, 1.23; 1.03–1.48). High-risk patients (≥ three risk factors) had 70% higher (CI, 48–96%) refractory risk (19% higher absolute risk; CI, 14–25%) versus low-risk (zero risk factors) patients. Initiating fluids in greater than 2 hours also predicted refractoriness (odds ratio, 1.96; CI, 1.49–2.58). Mortality was 15% higher (CI, 10-18%) for refractory patients.

Conclusion : Two in three hypotensive sepsis patients were responsive to initial fluid resuscitation. Heart failure, hypothermia, immunocompromise, hyperlactemia, and coagulopathy were associated with the refractory phenotype. Fluid resuscitation initiated after the initial 2 hours more strongly predicted refractoriness than any patient factor tested.

Conclusion (proposition de traduction) : Deux patients présentant une septicémie avec hypotension sur trois ont réagi à la réanimation liquidienne initiale. L'insuffisance cardiaque, l'hypothermie, l'immunocompromis, l'hyperlactémie et la coagulopathie étaient associés au phénotype réfractaire. La réanimation liquidienne commencée après les 2 heures initiales est plus fortement prédite comme réfractaire que n'importe quel facteur associé au patient.

Predictors of Intubation in Patients With Acute Hypoxemic Respiratory Failure Treated With a Noninvasive Oxygenation Strategy.
Frat JP, Ragot S, Coudroy R, Constantin JM, Girault C, Prat G, Boulain T, Demoule A, Ricard JD, Razazi K, Lascarrou JB, Devaquet J, Mira JP, Argaud L, Chakarian JC, Fartoukh M, Nseir S, Mercat A, Brochard L, Robert R, Thille AW; REVA network. | Crit Care Med. 2018 Feb;46(2):208-215
DOI: https://doi.org/10.1097/CCM.0000000000002818  | Télécharger l'article au format  
Keywords: acute respiratory failure; high-flow nasal cannula; high-flow oxygen therapy; intubation; noninvasive ventilation

Clinical Investigations

Introduction : In patients with acute hypoxemic respiratory failure, noninvasive ventilation and high-flow nasal cannula oxygen are alternative strategies to conventional oxygen therapy. Endotracheal intubation is frequently needed in these patients with a risk of delay, and early predictors of failure may help clinicians to decide early. We aimed to identify factors associated with intubation in patients with acute hypoxemic respiratory failure treated with different noninvasive oxygenation techniques.

Méthode : Design: Post hoc analysis of a randomized clinical trial.
Setting: Twenty-three ICUs.
Patients: Patients with a respiratory rate greater than 25 breaths/min and a PaO2/FIO2 ratio less than or equal to 300 mm Hg.
Intervention: Patients were treated with standard oxygen, high-flow nasal cannula oxygen, or noninvasive ventilation.

Résultats : Respiratory variables one hour after treatment initiation. Under standard oxygen, patients with a respiratory rate greater than or equal to 30 breaths/min were more likely to need intubation (odds ratio, 2.76; 95% CI, 1.13-6.75; p = 0.03). One hour after high-flow nasal cannula oxygen initiation, increased heart rate was the only factor associated with intubation. One hour after noninvasive ventilation initiation, a PaO2/FIO2 ratio less than or equal to 200 mm Hg and a tidal volume greater than 9 mL/kg of predicted body weight were independent predictors of intubation (adjusted odds ratio, 4.26; 95% CI, 1.62-11.16; p = 0.003 and adjusted odds ratio, 3.14; 95% CI, 1.22-8.06; p = 0.02, respectively). A tidal volume above 9 mL/kg during noninvasive ventilation remained independently associated with 90-day mortality.

Conclusion : In patients with acute hypoxemic respiratory failure breathing spontaneously, the respiratory rate was a predictor of intubation under standard oxygen, but not under high-flow nasal cannula oxygen or noninvasive ventilation. A PaO2/FIO2 below 200 mm Hg and a high tidal volume greater than 9 mL/kg were the two strong predictors of intubation under noninvasive ventilation.

Conclusion (proposition de traduction) : Chez les patients présentant une insuffisance respiratoire hypoxémique aiguë en ventilation spontanée, la fréquence respiratoire était un critère prédictif d'intubation chez ceux sous oxygène standard mais pas chez ceux sous oxygènothérapie à haut débit nasal (HFNC) Optiflow ou sous ventilation non invasive.
Une PaO2/FIO2 inférieure à 200 mmHg et un volume courant élevé supérieur à 9 mL/kg étaient les deux principaux prédicteurs de l'intubation sous ventilation non invasive.

Moisset X, Mawet J, Guegan-Massardier E, Bozzolo E, Gilard V, Tollard E, Feraud T, Noëlle B, Rondet C, Donnet A . | Douleurs Évaluation - Diagnostic - Traitement. 2018 February;19(1):4-16
DOI: https://doi.org/10.1016/j.douler.2018.01.001  | Télécharger l'article au format  
Keywords: Aucun

Recommandations

Editorial : Les recommandations concernent la prise en charge des céphalées en urgence : distinction des quatre tableaux cliniques, éléments clés de l’interrogatoire et de l’examen physique, stratégie diagnostique et thérapeutique. La prise en charge des céphalées autres que les urgences ne seront pas approfondies. Des recommandations spécifiques existent pour les migraines, les céphalées chroniques quotidiennes ou l’algie vasculaire de la face.

Introduction : Environ 15 % de la population a présenté au moins une céphalée intense au cours des 3 derniers mois. Cela explique que les céphalées constituent près de 1 % de l’ensemble des consultations ambulatoires et environ 2 % des motifs de consultation aux urgences. Bien qu’environ 95 % de ces patients rentrent à leur domicile avec un diagnostic de céphalée primaire, bénigne, le médecin de premier recours doit pouvoir détecter et référer une céphalée secondaire et potentiellement grave.

Conclusion (proposition de traduction) : Nous rappelons en préambule que l’intensité d’une céphalée n’est pas corrélée à sa gravité. La majorité des céphalées, même vues dans un contexte d’urgence, est constituée par les céphalées primaires. Une céphalée pri- maire peut être extrêmement invalidante, mais ne présente pas de risque fonctionnel ou vital en elle-même. L’important est donc de repérer une céphalée secondaire afin de mettre en place un traitement adapté, parfois urgent.
Les céphalées de début brutal et/ou inhabituelles doivent être considérées comme des céphalées secondaires jusqu’à preuve du contraire et justifient la réalisation d’examens complémentaires en urgence.

Utility of prehospital electrocardiogram characteristics as prognostic markers in out-of-hospital pulseless electrical activity arrests.
Ho ML, Gatien M, Vaillancourt C, Whitham V, Stiell IG. | Emerg Med J. 2018 Feb;35(2):89-95
DOI: https://doi.org/10.1136/emermed-2017-206878
Keywords: cardiac arrest; emergency departments

Original articles

Introduction : It is unclear if there are predictors of survival, including ECG characteristics, that can guide resuscitative efforts in pulseless electrical activity (PEA) cardiac arrests. We studied the predictive potential of presenting prehospital ECGs on survival for patients with out-of-hospital cardiac arrest (OHCA) with PEA.

Méthode : We studied prehospital ECGs of patients with OHCA prospectively enrolled between June 2007 and November 2009 at the Ottawa/OPALS (Ontario Prehospital Advanced Life Support Study) site of the Resuscitation Outcomes Consortium PRIMED study (Prehospital Resuscitation using an IMpedance valve and Early versus Delayed analysis). We included adult non-traumatic OHCA with PEA rhythm where resuscitation was attempted. We measured HR, QRS interval and presence of P waves, and determined their impact on return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) using multivariate regression analysis.

Résultats : The demographic characteristics of the 332 included cases were the following: mean age 71.8, male 58.4%, SHD 5.4% and ROSC at ED arrival 26.5%. Survivors had similar HR (56.8 vs 52.0 beats per minute (bpm), p=0.53) and QRS intervals (128.7 vs 129.6 ms, p=0.95) compared with non-survivors. Prehospital ECG characteristics did not predict SHD or ROSC on multivariate analyses. Patients with initial HR <30 bpm had a 3.8% survival rate; those with both HR <30 bpm and QRS≥120 ms had a 3.7% survival rate. Location of arrest predicted SHD (adjusted OR (AdjOR)=1.49, 1.11 to 1.99; p=0.007). Atropine use negatively predicted SHD (AdjOR=0.06, 0.02 to 0.22; p<0.001). Predictors of ROSC ALS paramedic on scene (AdjOR=8.90, 1.11 to 71.41; p=0.04) and successful intubation (AdjOR=3.35, 1.75 to 6.39; p<0.001). Atropine use negatively predicted ROSC (AdjOR=0.27, 0.14 to 0.50; p<0.001).

Conclusion : Presenting prehospital ECG characteristics did not predict SHD or ROSC in OHCA PEA victims and should not be used to guide termination of resuscitation. Location of arrest was a positive predictor for SHD; atropine use was a negative predictor. ALS paramedic on scene and successful intubation were positive predictors of ROSC; atropine use was a negative predictor.

Conclusion (proposition de traduction) : Les caractéristiques de l'ECG préhospitalier ne permettait pas de prédire la survie à la sortie de l'hôpital ou la reprise d'activité cardiaque spontanée chez les victimes d'arrêt cardiaque avec activité électrique sans pouls et ne devrait pas être utilisée pour guider la réanimation.
La localisation de l’arrêt cardiaque était un facteur prédicteur positif de la survie à la sortie de l'hôpital; l'utilisation d'atropine était un facteur prédicteur négatif. La réanimation avancée par un paramédic sur place et l'intubation réussie étaient des facteur prédicteurs positifs d’un retour à une circulation spontanée; l'utilisation d'atropine était un facteur prédicteur négatif.

Use of the low-frequency/high-frequency ratio of heart rate variability to predict short-term deterioration in emergency department patients with sepsis.
Barnaby DP, Fernando SM, Ferrick KJ, Herry CL, Seely AJE, Bijur PE, Gallagher EJ. | Emerg Med J. 2018 Feb;35(2):96-102
DOI: https://doi.org/10.1136/emermed-2017-206625
Keywords: ECG; clinical care; infectious diseases; intensive care; methods; resuscitation

Original article

Introduction : To examine the ability of the low-frequency/high-frequency (LF/HF) ratio of heart rate variability (HRV) analysis to identify patients with sepsis at risk of early deterioration.

Méthode : This is a prospective observational cohort study of patients with sepsis presenting to the Montefiore Medical Center ED from December 2014 through September 2015. On presentation, a single ECG Holter recording was obtained and analysed to obtain the LF/HF ratio of HRV. Initial Sequential Organ Failure Assessment (SOFA) scores were computed. Patients were followed for 72 hours to identify those with early deterioration.

Résultats : 466 patients presenting to the ED with sepsis were analysed. Thirty-two (7%) reached at least one endpoint within 72 hours. An LF/HF ratio <1 had a sensitivity and specificity of 34% (95% CI (19% to 53%)) and 82% (95% CI (78% to 85%)), respectively, with positive and negative likelihood ratios of 1.9 (95% CI (1.1 to 3.2)) and 0.8 (95% CI (0.6 to 1.0)). An initial SOFA score ≥3 had a sensitivity and specificity of 38% (95% CI (22% to 56%)) and 92% (95% CI (89% to 95%)), with positive and negative likelihood ratios of 4.9 (95% CI (2.8 to 8.6)) and 0.7 (95% CI (0.5 to 0.9)). The composite measure of HRV+SOFA had improved sensitivity (56%, 95% CI (38% to 73%)) but at the expense of specificity (77%, 95% CI (72% to 80%)), with positive and negative likelihood ratios of 2.4 (95% CI (1.7 to 3.4)) and 0.6 (95% CI (0.4 to 0.9)). Receiver operating characteristic analysis did not identify a superior alternate threshold for the LF/HF ratio. Kaplan-Meier survival functions differed significantly (p=0.02) between low (<1) and high (≥1) LF/HF groups.

Conclusion : While we found a statistically significant relationship between HRV, SOFA and HRV+SOFA, and early deterioration, none reliably functioned as a clinical predictive tool. More complex multivariable models will likely be required to construct models with clinical utility.

Conclusion (proposition de traduction) : Alors que nous avons trouvé une relation statistiquement significative entre HRV, SOFA et HRV + SOFA, et une aggravation précoce, aucun ne fonctionnait de manière fiable comme un outil de prédiction clinique.
Des modèles multivariés plus complexes seront probablement nécessaires pour construire des modèles ayant une utilisation en clinique.

Pre-emptive ice cube cryotherapy for reducing pain from local anaesthetic injections for simple lacerations: a randomised controlled trial.
Song J, Kim H, Park E, Ahn JH, Yoon E, Lampotang S, Gravenstein N, Choi S. | Emerg Med J. 2018 Feb;35(2):103-107
DOI: https://doi.org/10.1136/emermed-2017-206585
Keywords: emergency department; pain management; wounds, treatment

Original article

Introduction : Subcutaneous local anaesthetic injection can be painful to patients in the ED. We evaluated the effect of cryotherapy by application of an ice cube to the injection site prior to injection in patients with simple lacerations.

Méthode : We conducted a prospective, randomised, controlled trial in consented patients with simple lacerations needing primary repair at a single emergency centre from April to July 2016. We randomly assigned patients undergoing repair for simple lacerations to either the cryotherapy group or the control group (standard care; no cryotherapy or other pretreatment of the injection site). In cryotherapy group subjects, we applied an ice cube (size: 1.5×1.5×1.5 cm) placed inside a sterile glove on the wound at the anticipated subcutaneous lidocaine injection site for 2 min prior to injection. The primary outcome was a subjective numeric rating (0-10 scale) of the perceived pain from the subcutaneous local anaesthetic injections. Secondary outcomes were (a) perceived pain on a numeric scale for cryotherapy itself, that is, pain from contact of the ice cube/glove with the skin and (b) the rate of complications after primary laceration repair.

Résultats : Fifty patients were enrolled, consented and randomised, with 25 in the cryotherapy group and 25 in the control group. The numeric rating scale for subcutaneous anaesthetic injections was median, IQR, 95% CI 2.0 (1 to 3.5), 1.81 to 3.47, respectively, in the cryotherapy group and 5.0 (3 to 7), 3.91 to 6.05 in the control group (Mann-Whitney U=147.50, p=0.001). No wound complications occurred in either group. The numeric rating scale for cryotherapy itself was median, IQR, 95% CI: 2.0 (1 to 3.5), 1.90 to 3.70.

Conclusion : Pre-emptive topical injection site cryotherapy lasting 2 min before subcutaneous local anaesthetic injections can significantly reduce perceived pain from subcutaneous local anaesthetic injections in patients presenting for simple laceration repair.

Conclusion (proposition de traduction) : La cryothérapie préventive du site d'injection durant 2 minutes avant les injections d'anesthésiques locales sous-cutanées peut réduire de façon significative la douleur chez les patients se présentant pour une suture d'une plaie simple.

Radiation overexposure from repeated CT scans in young adults with acute abdominal pain.
Tonolini M, Valconi E, Vanzulli A, Bianco R. | Emerg Radiol. 2018 Feb;25(1):21-27
DOI: https://doi.org/10.1007/s10140-017-1554-y
Keywords: Acute abdomen; Computed tomography (CT); Effective dose; Ionizing radiation; Young adults

Original Article

Introduction : The purpose of this study is to assess the dose of ionizing radiation caused by repeated CT scans performed to investigate non-traumatic acute abdominal conditions in young adults.

Méthode : Over 26 months, we collected a cohort of patients aged 18 to 45 years who were subject to at least one urgent contrast-enhanced abdomen/pelvis CT. Patients affected with urolithiasis, HIV infection, tumors, and vascular and chronic inflammatory bowel diseases were excluded. All abdomen/pelvis CT scans carried out at our institution for over 6 years were retrospectively tallied, and the effective doses (EDs) were computed by multiplying the total dose-length product by the appropriate anatomic conversion factor. Examples of age- and gender-adjusted lifetime attributable cancer risks were estimated using the online calculator Radiation Risk Assessment Tool.

Résultats : Sixty-one patients (average age 34.2 years) received multiple CT scans (average 2.7 scans per patient). ED largely varied among single- and multi-phase acquisitions. Cumulative ED ranged from 14.1 mSv to a maximum of 436.6 mSv (average 70.1 mSv per person). Twenty-five patients (40.9%) received more than 50 mSv, 84% of them within year; 12 (19.7%) and 4 (6.6%) patients received more than 100 and 200 mSv, respectively.

Conclusion : Young adults are subject to repetitive CT imaging to monitor urogenital, intestinal, hepatobiliary, and pancreatic disorders during non-operative management to detect and follow up abdominal emergencies requiring surgical intervention and to assess post-surgical complications. In this population, the risk of accruing high cumulative radiation exposure should be considered.

Conclusion (proposition de traduction) : Les jeunes adultes peuvent être soumis à une imagerie TDM itérative pour surveiller des troubles urogénitaux, intestinaux, hépatobiliaires et pancréatiques au cours de la prise en charge non chirurgicale pour détecter et suivre des urgences abdominales pouvant nécessitant une intervention chirurgicale et pour éliminer des complications post-chirurgicales. Dans cette population, le risque d'accumuler une exposition élevée aux rayonnements cumulatifs devrait être pris en compte.

Awareness of radiation risks from CT scans among patients and providers and obstacles for informed decision-making.
Schuster AL, Forman HP, Strassle PD, Meyer LT, Connelly SV, Lee CI. | Emerg Radiol. 2018 Feb;25(1):41-49
DOI: https://doi.org/10.1007/s10140-017-1557-8
Keywords: Computed tomography; Informed consent; Radiation dose; Radiation risks

Original Article

Introduction : Using the study design from a prominent 2004 study, we aimed to reassess patient, provider, and radiologist awareness of CT radiation more than a decade later.

Méthode : Adults presenting to the emergency department of a tertiary care center over a 2-week period with mild to moderate pain requiring an abdominopelvic CT scan were surveyed. Patients were asked if anyone had discussed the risks/benefits of the CT scan including radiation dose and were asked to estimate their dose compared to a chest X-ray. Emergency providers and radiologists were given similar surveys and were asked about potential obstacles to discussing CT radiation with patients.

Résultats : A total of 101 patients, 570 emergency providers, and 161 radiologists were surveyed. Twenty-three percent (14/61) of patients, 39% (219/568) of emergency providers, and 48% (77/161) of radiologists correctly selected the radiation dose range of an abdominopelvic CT. Seventy-eight percent (441/567) of emergency providers reported routinely discussing radiation dose with patients, while 20% (20/98) of patients reported that their emergency provider discussed radiation dose with them. Time limitation and concern of dissuading the patient from CT were the most commonly reported obstacles for discussing risks.

Conclusion : Patients and providers in 2015 appear to be more aware of radiation dose from CT than they were in 2004. Discussion of CT scan radiation exposure and associated risks only occurs sometimes and may actually occur less frequently than perceived by emergency providers.

Conclusion (proposition de traduction) : Les patients et les prestataires en 2015 semblent être plus conscients de la dose de rayonnement reçue à l'occasion de la réalisation d'un scanner qu'en 2004. La discussion sur l'exposition aux radiations occasionnée par les examens scannographiques et sur les risques associés ne se réalisent que rarement et en fait, moins souvent, que ce perçoivent les urgentistes.

Signs and symptoms in adult patients with acute dyspnea: a systematic review and meta-analysis.
Renier W, Winckelmann KH, Verbakel JY, Aertgeerts B, Buntinx F. | Eur J Emerg Med. 2018 Feb;25(1):3-11
DOI: https://doi.org/10.1097/MEJ.0000000000000429
Keywords: Aucun

Original Articles

Introduction : Rapid and accurate diagnosis of patients with a new episode of acute dyspnea is a common challenge for Primary Care or Emergency Physicians.
OBJECTIVE: To determine the diagnostic accuracy of signs and symptoms in adult patients with a new episode of acute dyspnea presenting to a GP or an Emergency Physician (EP).

Méthode : This was a diagnostic systematic review. Using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, EMBASE, tracing references, and by contacting experts, studies were identified on the diagnostic accuracy of additional signs and symptoms in adult patients with acute or suddenly worsening dyspnea, presenting to a GP or an EP. Study quality was assessed using QUADAS and results were pooled using a random-effects model. Sensitivity, specificity, positive and negative likelihood ratio (NLR), and positive and negative predictive values for a diagnosis of heart failure (HF) were calculated for the combination of acute dyspnea and each additional sign or symptom in the selected studies.

Résultats : Eight of the 24 identified studies were carried out in the ED and provided us with all the required data, including 4737 patients. All publications reported HF; two studies additionally investigated pulmonary embolism, acute exacerbations of chronic obstructive pulmonary disease or asthma, acute pulmonary infectious diseases, or acute coronary syndrome. The prevalence of HF in patients with acute dyspnea ranged from 25 to 59%. Heterogeneity was present in all analyses.Comparing signs and symptoms, sensitivity was very poor for the presence of fever (0.05) and sputum production (0.06), and poor for fatigue (0.36-0.76), orthopnea (0.2-0.76), paroxysmal nocturnal dyspnea (0.23-0.70), elevated jugular venous pressure (0.19-0.70), rales (0.32-0.88), and peripheral edema (0.29-0.77). Specificity was poor for fatigue (0.28-0.69), moderate for the presence of fever (0.76-0.88), sputum production (0.73-0.89), orthopnea (0.49-0.92), paroxysmal nocturnal dyspnea (0.52-0.93), and rales (0.31-0.98), and good for elevated jugular venous pressure (0.75-0.97) and peripheral edema (0.67-0.89).For all other signs and symptoms, sensitivities varied between 0.20 and 0.43; specificities for symptoms varied widely between 0.37 and 0.91 and those of signs between 0.20 and 1.0.The pooled sensitivities, however, remained poor: below 0.55. Pooled specificity of most signs ranged between 0.69 and 0.88. The positive likelihood ratio was between 0.64 and 4.11 and the NLR was between 0.59 and 1.29 with one outlier: rales (pooled NLR=0.35).

Conclusion : This systematic review, which only included patients from ED settings, did not identify any single sign or symptom that had acceptable sensitivity to be useful in ruling out a diagnosis of HF, chronic obstructive pulmonary disease, asthma, or pulmonary embolism. Elevated jugular venous pressure (0.88, pooled odds ratio: 7), added third heart sound (0.97), and lung crepitations (0.77, pooled odds ratio: 11) are useful in ruling in HF.

Conclusion (proposition de traduction) : Cette revue systématique, qui ne concernait que les patients des services d'urgence, n'a identifié aucun signe ou symptôme ayant une sensibilité suffisante pour exclure un diagnostic d'insuffisance cardiaque, de maladie pulmonaire obstructive chronique, d'asthme ou d'embolie pulmonaire. La pression veineuse jugulaire élevée (0,88, odds ratio groupé: 7), un rythme de galop (0,97), et des crépitants à l’auscultation pulmonaire (0,77, odds ratio groupé: 11) sont utiles pour identifier une insuffisance cardiaque.

A criteria-directed protocol for in-hospital triage of trauma patients.
Granström A, Strömmer L, Schandl A, Östlund A. | Eur J Emerg Med. 2018 Feb;25(1):25-31
DOI: https://doi.org/10.1097/MEJ.0000000000000397  | Télécharger l'article au format  
Keywords: Aucun

Original Articles

Introduction : To better match hospital resources to patients' needs of trauma care, a protocol for facilitating in-hospital triage decisions was implemented at a Swedish level I trauma centre. In the protocol, physiological parameters, anatomical injuries and mechanism of injury were documented, and used to activate full or limited trauma team response. The aim of this study was to evaluate the efficacy of the criteria-directed protocol to determine in-hospital trauma triage in an emergency department.

Méthode : Level of triage and triage rates were compared before and after implementation of the protocol. Overtriage and undertriage were assessed with injury severity score higher than 15 as the cutoff for defining major trauma. Medical records for undertriaged patients were retrospectively reviewed.

Résultats : In 2011, 78% of 1408 trauma team activations required full trauma response, with an overtriage rate of 74% and an undertriage rate of 7%. In 2013, after protocol implementation, 58% of 1466 trauma team activations required full trauma response. Overtriage was reduced to 52% and undertriage was increased to 10%. However, there were no preventable deaths in the undertriaged patients.

Conclusion : A criteria-directed protocol for use in the emergency department was efficient in reducing overtriage rates without risking undertriaged patients' safety.

Conclusion (proposition de traduction) : Un protocole axé sur les critères à l'intention du service des urgences a permis de réduire efficacement les taux de surtriage sans mettre en péril la sécurité des patients sous-triés.

Prospective evaluation of clinical lung ultrasonography in the diagnosis of community-acquired pneumonia in a pediatric emergency department.
Samson F, Gorostiza I, González A, Landa M, Ruiz L, Grau M. | Eur J Emerg Med. 2018 Feb;25(1):65-70
DOI: https://doi.org/10.1097/MEJ.0000000000000418
Keywords: Aucun

Original Articles

Introduction : To evaluate the applicability and utility of point-of-care lung ultrasonography (POCLUS) for the diagnosis of community-acquired pneumonia (CAP) in a pediatric emergency department.

Méthode : A prospective observational study on children with suspected CAP was carried out in a pediatric emergency department from August to December 2014. The evaluation of the chest radiography (CR) by two independent radiologists was considered as a reference standard. POCLUS was performed by pediatricians who were blinded to CR results. Following the WHO criteria, typical CAP was defined as an alveolar consolidation or infiltrate in CR and a visualization of lung consolidation with sonographic air bronchograms in POCLUS. The diagnostic accuracy of POCLUS (sensitivity, specificity, positive, and negative predictive values) was established using CR as a gold standard.

Résultats : We enrolled 200 children with a median age of 29.5 months (interquartile range, 18.5-52.5); 58.1% were males and 42.0% had focal decreased breath sounds and/or crackles. The prevalence of typical CAP according to the radiologist's evaluation was 42.5% (end-point consolidation and/or pleural effusion 56.5%, alveolar infiltrate 43.5%). The sensitivity and specificity of POCLUS were 87.1% [95% confidence interval (CI) 78.0-93.4] and 94.8% (95% CI 89.0-98.1), respectively. The positive and negative predictive values were 92.5% (95% CI 84.4-97.2) and 90.8% (95% CI 84.2-95.3), respectively.

Conclusion : POCLUS performed by an emergency pediatrician with a limited experience in ultrasonography enables the diagnosis of pneumonia with high accuracy. POCLUS could become a feasible and promising alternative to CR in the diagnosis of suspected CAP, leading to a relevant decrease in children's exposure to ionizing radiations. Further studies specifically carried out in the pediatric outpatient setting are needed.

Conclusion (proposition de traduction) : L'échographie pulmonaire au lit du patient réalisée par un pédiatre urgentiste avec une expérience limitée en échographie permet le diagnostic de pneumonie avec une grande précision. L'échographie pulmonaire au lit du patient pourrait devenir une alternative réalisable et prometteuse à la radiographie thoracique dans le diagnostic d'une pneumonie ommunautaire, entraînant une diminution significative de l'exposition des enfants aux rayonnements ionisants. D'autres études spécifiquement réalisées dans le cadre du service de pédiatrie sont nécessaires.

Prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit.
Schlapbach LJ, Straney L, Bellomo R, MacLaren G, Pilcher D. | Intensive Care Med. 2018 Feb;44(2):179-188
DOI: https://doi.org/10.1007/s00134-017-5021-8  | Télécharger l'article au format  
Keywords: Childhood; Critical care; Infection; Mortality; PELOD; SIRS; SOFA; Scores; Sepsis

Original

Introduction : The Sepsis-3 consensus task force defined sepsis as life-threatening organ dysfunction caused by dysregulated host response to infection. However, the clinical criteria for this definition were neither designed for nor validated in children. We validated the performance of SIRS, age-adapted SOFA, quick SOFA and PELOD-2 scores as predictors of outcome in children.

Méthode : We performed a multicentre binational cohort study of patients < 18 years admitted with infection to ICUs in Australia and New Zealand. The primary outcome was ICU mortality. SIRS, age-adapted SOFA, quick SOFA and PELOD-2 scores were compared using crude and adjusted area under the receiver operating characteristic curve (AUROC) analysis.

Résultats : Of 2594 paediatric ICU admissions due to infection, 151 (5.8%) children died, and 949/2594 (36.6%) patients died or experienced an ICU length of stay ≥ 3 days. A ≥ 2-point increase in the individual score was associated with a crude mortality increase from 3.1 to 6.8% for SIRS, from 1.9 to 7.6% for age-adapted SOFA, from 1.7 to 7.3% for PELOD-2, and from 3.9 to 8.1% for qSOFA (p < 0.001). The discrimination of outcomes was significantly higher for SOFA (adjusted AUROC 0.829; 0.791-0.868) and PELOD-2 (0.816; 0.777-0.854) than for qSOFA (0.739; 0.695-0.784) and SIRS (0.710; 0.664-0.756).

Conclusion : SIRS criteria lack specificity to identify children with infection at substantially higher risk of mortality. We demonstrate that adapting Sepsis-3 to age-specific criteria performs better than Sepsis-2-based criteria. Our findings support the translation of Sepsis-3 into paediatric-specific sepsis definitions and highlight the importance of robust paediatric organ dysfunction characterization.

Conclusion (proposition de traduction) : Les critères SIRS manquent de spécificité pour identifier les enfants présentant une infection avec un risque de mortalité nettement plus élevé. Nous démontrons que l'adaptation de Sepsis-3 aux critères spécifiques à l'âge donne de meilleurs résultats que les critères basés sur Sepsis-2. Nos résultats vont dans le sens de la traduction du sepsis spécifique à la pédiatrique de Sepsis-3 et soulignent l'importance de la caractérisation robuste de dysfonctionnement des organes en pédiatrie.

Germans learn how to save lives: a nationwide CPR education initiative.
Malsy M, Leberle R, Graf B. | Int J Emerg Med. 2018 Feb 17;11(1):9
DOI: https://doi.org/10.1186/s12245-018-0171-1  | Télécharger l'article au format  
Keywords: Kids Save Lives; Lay resuscitation; Resuscitation; Resuscitation Week; Sudden cardiac arrest

Original Research

Introduction : Sudden cardiac death is one of the most frequent causes of death in Germany and the third leading cause of death in the industrialized world. Yet, the percentage of people providing first aid in the case of sudden cardiac arrest in Germany is alarmingly low by international comparison. Training Germans or reminding them of the simple but effective steps of resuscitation, so that everybody can save a live in an emergency.

Méthode : For the campaign 'Resuscitation Week', physicians and paramedics trained passers-by in cardiovascular resuscitation free of charge. Skills were evaluated before and after the instruction by means of a questionnaire.

Résultats : Three hundred three people aged between 9 and 89 years were trained and evaluated. Forty-nine passers-by had never participated in a resuscitation course, and 46.8% had participated in a course more than 20 years ago. Before the instruction, 41.6% of the passers-by were confident to be capable of resuscitating a person; after the instruction, however, this percentage had risen to 100%!

Conclusion : Saving a life is simple, but one has to know what to do in the case of sudden cardiac arrest. The German population is being gradually trained in resuscitation using campaigns such as 'Resuscitation Week' and 'Kids Save Lives' to break down barriers in the long term. However, lives are not only saved by training but also by refreshing knowledge and skills; thus, a further effective approach may be training all holders of a driving license in cardiopulmonary resuscitation in intervals of 5 years.

Conclusion (proposition de traduction) : Sauver une vie est simple, mais il faut savoir quoi faire en cas d'arrêt cardiaque inopiné. La population allemande est progressivement formée à la réanimation grâce à des campagnes telles que la « Semaine de la réanimation » et « Kids Save Lives » pour faire tomber les barrières à long terme. Cependant, les vies ne sont pas seulement sauvées par la formation mais aussi par le rafraîchissement des connaissances et des compétences ; ainsi, une autre approche efficace pourrait être de former tous les titulaires du permis de conduire à la réanimation cardio-pulmonaire à des intervalles de 5 ans.

Patient understanding of discharge instructions in the emergency department: do different patients need different approaches?.
Sheikh H, Brezar A, Dzwonek A, Yau L, Calder LA. | Int J Emerg Med. 2018 Feb 8;11(1):5
DOI: https://doi.org/10.1186/s12245-018-0164-0  | Télécharger l'article au format  
Keywords: Aucun

Original Research

Introduction : Previous studies have demonstrated that patients have poor understanding of the discharge instructions provided from the emergency department (ED). The aims of this study are to determine if patient factors, such as income and level of education, correlate with patient understanding of discharge instructions and to explore if different patient populations prefer different resources for receiving discharge instructions.

Méthode : We conducted live observations of physicians providing discharge instructions in the ED to 100 patients followed by a patient survey to determine their understanding in four domains (diagnosis, treatment plan, follow-up instructions, and return to ED (RTED) instructions) and collect patient demographics. We enrolled patients over the age of 18 being discharged home. We excluded non-English- or French-speaking patients and those with significant psychiatric history or cognitive impairment. We performed a two-way ANOVA analysis of patient factors and patient understanding.

Résultats : We found that patients had poor understanding of discharge instructions, ranging from 24.0% having poor understanding of their follow-up plan to 64.0% for RTED instructions. Almost half (42%) of patients did not receive complete discharge instructions. Lower income was correlated with a significant decrease in patient understanding of discharge diagnosis (p = 0.01) and RTED instructions (p = 0.04). Patients who did not complete high school trended towards lower levels of understanding of their diagnosis and treatment plan (p = 0.06). Lower income patients had a preference for receiving a follow-up phone call by a nurse, while higher income patients preferred online resources.

Conclusion : Lower income patients and those who have not completed high school are at a higher risk of poor understanding discharge instructions. As new technological solutions emerge to aid patient understanding of discharge instructions, our study suggests they may not aid those who are at the highest risk of failing to understand their instructions.

Conclusion (proposition de traduction) : Les patients à faible revenu et ceux qui n'ont pas terminé leurs études secondaires sont plus à risque de mal comprendre les instructions de sortie. Au fur et à mesure que de nouvelles solutions technologiques émergent pour aider les patients à mieux comprendre les instructions de sortie, notre étude suggère qu'elles pourraient ne pas aider ceux qui risquent le plus de ne pas comprendre leurs instructions.

Comparison of TIVA with different combinations of ketamine-propofol mixtures in pediatric patients.
Biricik E, Karacaer F, Güleç E, Sürmelioğlu Ö, Ilgınel M, Özcengiz D. | J Anesth. 2018 Feb;32(1):104-111
DOI: https://doi.org/10.1007/s00540-017-2438-8
Keywords: Ketofol; Pediatric anesthesia; Recovery; TIVA

Original Article

Introduction : Adding ketamine to propofol has been suggested to be useful for sedation and general anesthesia. This study aimed to determine the effect of TIVA with different ratios of ketofol on recovery in children.

Méthode : Seventy-five children aged 3-12 years and undergoing adenoidectomy and/or tonsillectomy surgery were randomized into three groups. Ratios of 1:5, 1:6.7 and 1:10 ketamine-propofol mixture (ketofol) were prepared in the same syringe for groups I, II and III, respectively. Induction and maintenance of anesthesia were performed with 1:5, 1:6.7 and 1:10 ratios of ketofol in groups I, II and III, respectively. A McFarlan infusion dose regimen was used (15 mg/kg/h for 15 min, 13 mg/kg/h for 15 min, 11 mg/kg/h for 30 min) and infusion rates were decreased for the different ratios. Infusion rates were reduced to 67, 80 and 90% of the McFarlan dose regimen for groups I, II and III, respectively. Extubating time, length of stay in PACU, postoperative PAED and FLACC scores were recorded.

Résultats : Extubating time was significantly lower [mean 254.3 ± 92.7 s (95% CI 216.6-292.6, p = 0.001)] in group III than in groups I and II [371.3 ± 153 s (308.1-434.48) and 343.2 ± 123.7 s (292.2-394.3), respectively]. Length of stay in the PACU was lower in group III [median 15 min (interquartile range 15-20, p = 0.001)] than in groups I and II: 20 (15-27.5) and 20 min (20-27.5), respectively.

Conclusion : TIVA with a 1:10 ratio of ketofol admixture with a 90% reduction of McFarlan regimen can provide improved recovery conditions.

Conclusion (proposition de traduction) : L'anesthésie intraveineuse totale (TIVA) avec un rapport de 1:10 du mélange de kétofol avec une réduction de 90 % du régime de perfusion McFarlan peut fournir des conditions de récupération améliorées.

Initial fluid resuscitation following adjusted body weight dosing is associated with improved mortality in obese patients with suspected septic shock.
Taylor SP, Karvetski CH, Templin MA, Heffner AC, Taylor BT. | J Crit Care. 2018 Feb;43:7-12
DOI: https://doi.org/10.1016/j.jcrc.2017.08.025
Keywords: Body mass index; Fluid therapy; Hospital mortality; Obesity; Sepsis; Septic shock

Sepsis/Infection

Introduction : The optimal initial fluid resuscitation strategy for obese patients with septic shock is unknown. We evaluated fluid resuscitation strategies across BMI groups.

Méthode : Retrospective analysis of 4157 patients in a multicenter activation pathway for treatment of septic shock between 2014 and 2016.

Résultats : 1293 (31.3%) patients were obese (BMI≥30). Overall, higher BMI was associated with lower mortality, however this survival advantage was eliminated in adjusted analyses. Patients with higher BMI received significantly less fluid per kilogram at 3h than did patients with lower BMI (p≤0.001). In obese patients, fluid given at 3h mimicked a dosing strategy based on actual body weight (ABW) in 780 (72.2%), adjusted body weight (AdjBW) in 95 (8.8%), and ideal body weight (IBW) in 205 (19.0%). After adjusting for condition- and treatment-related variables, dosing based on AdjBW was associated with improved mortality compared to ABW (OR 0.45; 95% CI [0.19, 1.07]) and IBW (OR 0.29; 95% CI [0.11,0.74]).

Conclusion : Using AdjBW to calculate initial fluid resuscitation volume for obese patients with suspected shock may improve outcomes compared to other weight-based dosing strategies. The optimal fluid dosing strategy for obese patients should be a focus of future prospective research.

Conclusion (proposition de traduction) : L'utilisation du poids corporel ajusté pour calculer le volume initial de réanimation liquidienne chez les patients obèses présentant une suspicion de choc peut améliorer les résultats par rapport à d'autres stratégies de dosage basées sur le poids. La stratégie de dosage optimal des liquides pour les patients obèses devrait faire l'objet de recherches prospectives futures.

Sepsis mortality score for the prediction of mortality in septic patients.
Shukeri WFWM, Ralib AM, Abdulah NZ, Mat-Nor MB. | J Crit Care. 2018 Feb;43:163-168
DOI: https://doi.org/10.1016/j.jcrc.2017.09.009
Keywords: Interleukin-6; Leukocytes count; Mortality; Paraoxonase-1; Procalcitonin; Sepsis

Sepsis/Infection

Introduction : To derive a prediction equation for 30-day mortality in sepsis using a multi-marker approach and compare its performance to the Sequential Organ Failure Assessment (SOFA) score.

Méthode : This study included 159 septic patients admitted to an intensive care unit. Leukocytes count, procalcitonin (PCT), interleukin-6 (IL-6), and paraoxonase (PON) and arylesterase (ARE) activities of PON-1 were assayed from blood obtained on ICU presentation. Logistic regression was used to derive sepsis mortality score (SMS), a prediction equation describing the relationship between biomarkers and 30-day mortality.

Résultats : The 30-day mortality rate was 28.9%. The SMS was [еlogit(p)/(1+еlogit(p))]×100; logit(p)=0.74+(0.004×PCT)+(0.001×IL-6)-(0.025×ARE)-(0.059×leukocytes count). The SMC had higher area under the receiver operating characteristic curve (95% Cl) than SOFA score [0.814 (0.736-0.892) vs. 0.767 (0.677-0.857)], but is not statistically significant. When the SMS was added to the SOFA score, prediction of 30-day mortality improved compared to SOFA score used alone [0.845 (0.777-0.899), p=0.022].

Conclusion : A sepsis mortality score using baseline leukocytes count, PCT, IL-6 and ARE was derived, which predicted 30-day mortality with very good performance and added significant prognostic information to SOFA score.

Conclusion (proposition de traduction) : Un score de mortalité par septicémie utilisant la numération leucocytaire de base, le PCT, l'IL-6 et l'arylesterase étaient calculés, ce qui a prédit une mortalité à 30 jours avec une très bonne performance et a ajouté des informations pronostiques significatives au score SOFA.

The comparative effectiveness of noninvasive and invasive ventilation in patients with pneumonia.
Stefan MS, Priya A, Pekow PS, Lagu T, Steingrub JS, Hill NS, Nathanson BH, Lindenauer PK. | J Crit Care. 2018 Feb;43:190-196
DOI: https://doi.org/10.1016/j.jcrc.2017.05.023
Keywords: Mechanical ventilation; Noninvasive ventilation; Noninvasive ventilation failure; Pneumonia

Original research article

Introduction : To compare the outcomes of patients hospitalized with pneumonia treated with noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV).

Méthode : Using the HealthFacts multihospital electronic medical record database, we included patients hospitalized with a diagnosis of pneumonia and treated with NIV or IMV. We developed a propensity model for receipt of initial NIV and assessed the outcomes in a propensity-matched cohort, and in a covariate adjusted and propensity score weighted models.

Résultats : Among 3971 ventilated patients, 1109 (27.9%) were initially treated with NIV. Patients treated with NIV were older, had lower acuity of illness score, and were more likely to have congestive heart failure and chronic pulmonary disease. Mortality was 15.8%, 29.8% and 25.9.0% among patients treated with initial NIV, initial IMV and among those with NIV failure. In the propensity matched analysis, the risk of death was lower in patients treated with NIV (relative risk: 0.71, 95% CI: 0.59-0.85). Subgroup analysis showed that NIV was beneficial among patients with cardiopulmonary comorbidities (relative risk 0.59, 95% CI: 0.47-0.75) but not in those without (relative risk 0.96, 95% CI: 0.74-0.1.25)NIV failure was significantly (p=0.002) more common in patients without cardiopulmonary conditions (21.3%) compared to those with these conditions (13.8%).

Conclusion : Initial NIV was associated with better survival among the subgroup of patients hospitalized with pneumonia who had COPD or heart failure. Patients who failed NIV had high in-hospital mortality, emphasizing the importance of careful patient selection monitoring when managing severe pneumonia with NIV.

Conclusion (proposition de traduction) : L'utilisation de la VNI initiale était associée à une meilleure survie dans le sous-groupe de patients hospitalisés pour une pneumopathie qui souffrait de BPCO ou d'insuffisance cardiaque. Les patients pour qui la VNI était un échec présentaient un taux de mortalité élevé à l'hôpital, soulignant l'importance d'une surveillance attentive de la sélection des patients lors de la prise en charge d'une pneumonie grave mise sous VNI.

Tranexamic acid for refractory gastrointestinal bleeds: A cohort study.
Stollings JL, Landsperger JS, Semler MW, Rice TW. | J Crit Care. 2018 Feb;43:128-132
DOI: https://doi.org/10.1016/j.jcrc.2017.08.035
Keywords: Aucun

Original research article

Introduction : Gastrointestinal (GI) bleeding is a common indication for admission to the intensive care unit (ICU). Severe GI bleeding can be life-threatening and often necessitates blood product transfusion. Advances in diagnostic and therapeutic endoscopy and angiography have improved the ability to localize and treat GI bleeds; however pharmacological therapy remains a key component of early management. We describe here a cohort of adults admitted to the ICU with GI bleeding that received tranexamic acid, focusing on requirements for blood product transfusions and adverse events related to tranexamic acid receipt.

Méthode : This retrospective case series included all patients in a single, academic medical ICU (MICU) who received tranexamic acid for GI bleeding between July 2012 and December 2016. The Vanderbilt University Institutional Review Board approved this study with waiver of informed consent.

Résultats : Our findings are consistent with previous data regarding the use of tranexamic acid in trauma-associated hemorrhage [4]. The effect of early tranexamic acid administration on mortality from trauma was demonstrated in the CRASH-2 randomized control trial. CRASH-2 randomized 10,096 adult trauma patients with, or at risk of significant bleeding within 8 h of injury to tranexamic acid or placebo. Death in the hospital within four weeks of injury was 14.5% in the tranexamic acid group vs. 16% in the placebo group, relative risk (RR) 0.91; p = 0.0035. Risk of death due to bleeding was 4.9% in the tranexamic acid group vs. 5.7% in the placebo group, RR 0.85; p = 0.007). Vascular occlusive events (myocardial infarction, stroke, pulmonary embolism, and deep venous thrombosis) occurred in 1.7% of patients that received tranexamic acid vs. 2.0% of patients that received placebo, (p = 0.084). Despite tranexamic acid improving survival, 50.4% of patients in the tranexamic group as compared to 51.3% of patients in the placebo group required transfusions (p = 0.21) and they averaged 6.06 vs. 6.29 units transfused, respectively.

Conclusion : Among 36 adults with GI bleeding, blood product transfusions were lower after administration of tranexamic acid. Although the patients were severely ill and experienced significant mortality, complications following tranexamic acid appeared to be minimal. To better understand the clinical effects of tranexamic acid on patients with gastrointestinal hemorrhage, a large, randomized trial is needed.

Conclusion (proposition de traduction) : Chez 36 adultes présentant un saignement gastro-intestinal, le nombre de transfusions sanguines étaient plus faibles après l'administration d'acide tranexamique. Même si les patients étaient gravement malades et présentaient une mortalité importante, les complications après l'administration d'acide tranexamique semblaient minimes. Pour mieux comprendre les effets cliniques de l'acide tranexamique sur les patients souffrant d'hémorragie gastro-intestinale, un vaste essai randomisé est nécessaire.

Utility of SOFA score, management and outcomes of sepsis in Southeast Asia: a multinational multicenter prospective observational study.
Lie KC, Lau CY, Van Vinh Chau N, West TE, Limmathurotsakul D; for Southeast Asia Infectious Disease Clinical Research Network. | J Intensive Care. 2018 Feb 14;6:9
DOI: https://doi.org/10.1186/s40560-018-0279-7  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : Sepsis is a global threat but insufficiently studied in Southeast Asia. The objective was to evaluate management, outcomes, adherence to sepsis bundles, and mortality prediction of maximum Sequential Organ Failure Assessment (SOFA) scores in patients with community-acquired sepsis in Southeast Asia.

Méthode : We prospectively recruited hospitalized adults within 24 h of admission with community-acquired infection at nine public hospitals in Indonesia (n = 3), Thailand (n = 3), and Vietnam (n = 3). In patients with organ dysfunction (total SOFA score ≥ 2), we analyzed sepsis management and outcomes and evaluated mortality prediction of the SOFA scores. Organ failure was defined as the maximum SOFA score ≥ 3 for an individual organ system.

Résultats : From December 2013 to December 2015, 454 adult patients presenting with community-acquired sepsis due to diverse etiologies were enrolled. Compliance with sepsis bundles within 24 h of admission was low: broad-spectrum antibiotics in 76% (344/454), ≥ 1500 mL fluid in 50% of patients with hypotension or lactate ≥ 4 mmol/L (115/231), and adrenergic agents in 71% of patients with hypotension (135/191). Three hundred and fifty-five patients (78%) were managed outside of ICUs. Ninety-nine patients (22%) died. Total SOFA score on admission of those who subsequently died was significantly higher than that of those who survived (6.7 vs. 4.6, p < 0.001). The number of organ failures showed a significant correlation with 28-day mortality, which ranged from 7% in patients without any organ failure to 47% in those with failure of at least four organs (p < 0.001). The area under the receiver operating characteristic curve of the total SOFA score for discrimination of mortality was 0.68 (95% CI 0.62-0.74).

Conclusion : Community-acquired sepsis in Southeast Asia due to a variety of pathogens is usually managed outside the ICU and with poor compliance to sepsis bundles. In this population, calculation of SOFA scores is feasible and SOFA scores are associated with mortality.

Conclusion (proposition de traduction) : En Asie du Sud-Est le sepsis d’origine communautaire est causé par plusieurs agents pathogènes et est généralement pris en charge en dehors de l'unité de soins intensifs et avec une faible conformité aux protocoles sur le sepsis. Dans cette population, le calcul des scores SOFA est faisable et les scores SOFA sont corrélé à la mortalité.

Effect of norepinephrine dosage on mortality in patients with septic shock.
Yamamura H, Kawazoe Y, Miyamoto K, Yamamoto T, Ohta Y, Morimoto T. | J Intensive Care. 2018 Feb 26;6:12
DOI: https://doi.org/10.1186/s40560-018-0280-1  | Télécharger l'article au format  
Keywords: Norepinephrine; Septic shock; Ventilator-free days

Research

Introduction : Use of high-dose norepinephrine is thought to have an immunosuppressive action that increases mortality. This study aimed to evaluate the correlation between norepinephrine dosage and prognosis of patients with septic shock.

Méthode : This study was a nested cohort of the DExmedetomidine for Sepsis in Intensive Care Unit Randomized Evaluation (DESIRE) trial. We evaluated 112 patients with septic shock and an initial Sequential Organ Failure Assessment Cardiovascular (SOFA-C) category score > 2 and initial lactate level > 2 mmol/L. We divided the patients into two groups according to the norepinephrine dosage administered over the initial 7 days: high dose (≥ 416 μg/kg/week) (H group, n = 56) and low dose (< 416 μg/kg/week) (L group, n = 56). The primary outcome of interest was 28-day mortality. Secondary outcomes were ventilator-free days, initial 24-h infusion volume, initial 24- to 48-h infusion volume, and the need for renal replacement therapy. For comparisons between the H group and L group, we used the chi-square test or Fisher's exact test for categorical variables and the t test or Wilcoxon rank sum test for continuous variables. For time-to-event outcomes, Cox proportional hazards models were used. Kaplan-Meier survival curves were created for graphical representation.

Résultats : Patient characteristics appeared to be similar between the two groups except for the SOFA-C score and fibrinogen degradation product level. The cumulative incidence of death at 28 days was 29.9% (16 patients) in the L group and 29.7% (15 patients) in the H group (p = 0.99). The median number of 28-day ventilator-free days was 20 (0, 25) in the L group and 16 (0, 22) in the H group (p < 0.05). Initial infusion volume at 0-24 h in the H group was significantly higher than that in the L group (p = 0.004). Infusion volume at 24-48 h in the H group was also significantly higher than that in the L group (p = 0.03).

Conclusion : No statistically significant difference was observed in 28-day mortality between patients with septic shock treated with high-dose norepinephrine compared with those treated with low-dose norepinephrine. However, the number of ventilator-free days in the L group was higher than that in the H group.

Conclusion (proposition de traduction) : Aucune différence statistiquement significative n'a été observée dans la mortalité à 28 jours entre les patients ayant subi un choc septique traités par la norépinépinéphrine à forte dose et ceux traités par la norépinépinéphrine à faible dose. Cependant, le nombre de jours sans ventilateur dans le groupe à faible dose était plus élevé que dans le groupe à forte dose.

The Correlation Between Arterial Lactate and Venous Lactate in Patients With Sepsis and Septic Shock.
Theerawit P, Na Petvicharn C, Tangsujaritvijit V, Sutherasan Y. | J Intensive Care Med. 2018 Feb;33(2):116-120
DOI: https://doi.org/10.1177/0885066616663169
Keywords: arterial lactate; blood lactate; lactate; peripheral venous lactate; venous lactate

Original Research

Introduction : Applying peripheral venous lactate instead of arterial lactate in clinical practice is questionable because of deviation between both values. We aimed to find the relationship between the arterial lactate and the peripheral venous lactate before reasoned that the venous lactate could be used in substitution to the arterial lactate in sepsis.

Méthode : We conducted a prospective, cross-sectional study at a university hospital. The patients with sepsis in ICU who required lactate level monitoring were enrolled in this research. The correlation and agreement between arterial lactate (A-LACT) and peripheral venous lactate (V-LACT) were the primary outcomes.

Résultats : A total of 63 paired samples were collected. The A-LACT and V-LACT were strongly correlated ( r = .934, P < .0001, r2 = .873). The regression equation was A-LACT = (0.934 × V-LACT) - 0.236. The mean difference between V-LACT and A-LACT was 0.66 ± 1.53 mmol/L. The 95% limits of agreement were between -3.66 and 2.33 mmol/L. The V-LACT ≥ 4 mmol/L can predict A-LACT level ≥ 4 mmol/L with 87.5% sensitivity and 91.5% specificity, and the area under receiver operating characteristic curve was 0.948.

Conclusion : The present study demonstrated a strong correlation between A-LACT and V-LACT, but an agreement between both parameters was poor. We suggest not to use the V-LACT in substitution to the A-LACT in sepsis regarding the absolute value and clearance rate, but the V-LACT ≥ 4.5 mmol/L may be used for predicting the A-LACT ≥ 4 mmol/L.

Conclusion (proposition de traduction) : L'étude a démontré une forte corrélation entre le lactate artériel et le lactate veineux, mais la concordance entre les deux paramètres était médiocre. Nous suggérons de ne pas utiliser le lactate veineux en remplacement du lactate artériel dans la septicémie en ce qui concerne la valeur absolue et le taux de clairance, mais le lactate veineux ≥ 4,5 mmol/L peut être utilisé pour prédire le lactate artériel ≥ 4 mmol/L.

Hyperacute Hemodynamic Effects of BiPAP Noninvasive Ventilation in Patients With Acute Heart Failure and Left Ventricular Systolic Dysfunction in Emergency Department.
Moret Iurilli C, Brunetti ND, Di Corato PR, Salvemini G, Di Biase M, Ciccone MM, Procacci V. | J Intensive Care Med. 2018 Feb;33(2):128-133
DOI: https://doi.org/10.1177/0885066617740849
Keywords: BiPAP; acute heart failure; hemodynamics; noninvasive ventilation

Techniques and Procedures

Introduction : Acute heart failure (AHF) is one of the leading causes of admission to emergency department (ED); severe hypoxemic AHF may be treated with noninvasive ventilation (NIV). Despite the demonstrated clinical efficacy of NIV in relieving symptoms of AHF, less is known about the hyperacute effects of bilevel positive airway pressure (BiPAP) ventilation on hemodynamics of patients admitted to ED for AHF. We therefore aimed to assess the effect of BiPAP ventilation on principal hemodynamic, respiratory, pulse oximetry, and microcirculation indexes in patients admitted to ED for AHF, needing NIV.

Méthode : Twenty consecutive patients admitted to ED for AHF and left ventricular systolic dysfunction, needing NIV, were enrolled in the study; all patients were treated with NIV in BiPAP mode. The following parameters were measured at admission to ED (T0, baseline before treatment), 3 hours after admission and initiation of BiPAP NIV (T1), and after 6 hours (T2): arterial blood oxygenation (pH, partial pressure of oxygen in the alveoli/fraction of inspired oxygen ratio, Paco2, lactate concentration, HCO3-), hemodynamics (tricuspid annular plane systolic excursion, transpulmonary gradient, transaortic gradient, inferior vena cava diameter, brain natriuretic peptide [BNP] levels), microcirculation perfusion (end-tidal CO2 [etco2], peripheral venous oxygen saturation [SpvO2]).

Résultats : All evaluated indexes significantly improved over time (analysis of variance, P < .001 in quite all cases.).

Conclusion : The BiPAP noninvasive ventilation may rapidly ameliorate several hemodynamic, arterial blood gas, and microcirculation indexes in patients with acute heart failure and left ventricular systolic dysfunction.

Conclusion (proposition de traduction) : La ventilation non invasive BiPAP peut rapidement améliorer plusieurs indices hémodynamiques, de gaz du sang artériel et de microcirculation chez les patients atteints d'insuffisance cardiaque aiguë et de dysfonction systolique ventriculaire gauche.

Anaphylactoid Reactions to Intravenous N-Acetylcysteine during Treatment for Acetaminophen Poisoning.
Yarema M, Chopra P, Sivilotti MLA, Johnson D, Nettel-Aguirre A, Bailey B, Victorino C, Gosselin S, Purssell R, Thompson M, Spyker D, Rumack B. | J Med Toxicol. 2018 Feb 8
DOI: https://doi.org/10.1007/s13181-018-0653-9
Keywords: Aucun

Original Article

Introduction : Anaphylactoid reactions to intravenous (IV) N-acetylcysteine (NAC) are well-recognized adverse events during treatment for acetaminophen (APAP) poisoning. Uncertainty exists regarding their incidence, severity, risk factors, and management. We sought to determine the incidence, risk factors, and treatment of anaphylactoid reactions to IV NAC in a large, national cohort of patients admitted to hospital for acetaminophen overdose.

Méthode : This retrospective medical record review included all patients initiated on the 21-h IV NAC protocol for acetaminophen poisoning in 34 Canadian hospitals between February 1980 and November 2005. The primary outcome was any anaphylactoid reaction, defined as cutaneous (urticaria, pruritus, angioedema) or systemic (hypotension, respiratory symptoms). We examined the incidence, severity and timing of these reactions, and their association with patient and overdose characteristics using multivariable analysis.

Résultats : An anaphylactoid reaction was documented in 528 (8.2%) of 6455 treatment courses, of which 398 (75.4%) were cutaneous. Five hundred four (95.4%) reactions occurred during the first 5 h. Of 403 patients administered any medication for these reactions, 371 (92%) received an antihistamine. Being female (adjusted OR 1.24 [95%CI 1.08, 1.42]) and having taken a single, acute overdose (1.24 [95%CI 1.10, 1.39]) were each associated with more severe reactions, whereas higher serum APAP concentrations were associated with fewer reactions (0.79 [95%CI 0.68, 0.92]).

Conclusion : Anaphylactoid reactions to the 21-h IV NAC protocol were uncommon and involved primarily cutaneous symptoms. While the protective effects of higher APAP concentrations are of interest in understanding the pathophysiology, none of the associations identified are strong enough to substantially alter the threshold for NAC initiation.

Conclusion (proposition de traduction) : Les réactions anaphylactiques au cours du protocole d’administration IV du N-Acetylcysteine pendant 21 h étaient rares et occasionnaient principalement des signes cutanés. Bien que les effets protecteurs de concentrations élevées de paracétamol aient un intérêt pour la compréhension de la physiopathologie, aucun des signes cliniques d’intoxication connus n'est assez pathognomonique pour changer de façon significative le seuil pour débuter le traitement par N-Acetylcysteine.

Association of Intracerebral Hemorrhage Among Patients Taking Non-Vitamin K Antagonist vs Vitamin K Antagonist Oral Anticoagulants With In-Hospital Mortality.
Inohara T, Xian Y, Liang L, Matsouaka RA, Saver JL, Smith EE, Schwamm LH, Reeves MJ, Hernandez AF, Bhatt DL, Peterson ED, Fonarow GC. | JAMA. 2018 Feb 6;319(5):463-473
DOI: https://doi.org/10.1001/jama.2017.21917
Keywords: Aucun

Original article

Introduction : Although non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used to prevent thromboembolic disease, there are limited data on NOAC-related intracerebral hemorrhage (ICH).

Méthode : To assess the association between preceding oral anticoagulant use (warfarin, NOACs, and no oral anticoagulants [OACs]) and in-hospital mortality among patients with ICH.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 141 311 patients with ICH admitted from October 2013 to December 2016 to 1662 Get With The Guidelines-Stroke hospitals.
EXPOSURES: Anticoagulation therapy before ICH, defined as any use of OACs within 7 days prior to hospital arrival.
MAIN OUTCOMES AND MEASURES: In-hospital mortality.

Résultats : Among 141 311 patients with ICH (mean [SD] age, 68.3 [15.3] years; 48.1% women), 15 036 (10.6%) were taking warfarin and 4918 (3.5%) were taking NOACs preceding ICH, and 39 585 (28.0%) and 5783 (4.1%) were taking concomitant single and dual antiplatelet agents, respectively. Patients with prior use of warfarin or NOACs were older and had higher prevalence of atrial fibrillation and prior stroke. Acute ICH stroke severity (measured by the National Institutes of Health Stroke Scale) was not significantly different across the 3 groups (median, 9 [interquartile range, 2-21] for warfarin, 8 [2-20] for NOACs, and 8 [2-19] for no OACs). The unadjusted in-hospital mortality rates were 32.6% for warfarin, 26.5% for NOACs, and 22.5% for no OACs. Compared with patients without prior use of OACs, the risk of in-hospital mortality was higher among patients with prior use of warfarin (adjusted risk difference [ARD], 9.0% [97.5% CI, 7.9% to 10.1%]; adjusted odds ratio [AOR], 1.62 [97.5% CI, 1.53 to 1.71]) and higher among patients with prior use of NOACs (ARD, 3.3% [97.5% CI, 1.7% to 4.8%]; AOR, 1.21 [97.5% CI, 1.11-1.32]). Compared with patients with prior use of warfarin, patients with prior use of NOACs had a lower risk of in-hospital mortality (ARD, -5.7% [97.5% CI, -7.3% to -4.2%]; AOR, 0.75 [97.5% CI, 0.69 to 0.81]). The difference in mortality between NOAC-treated patients and warfarin-treated patients was numerically greater among patients with prior use of dual antiplatelet agents (32.7% vs 47.1%; ARD, -15.0% [95.5% CI, -26.3% to -3.8%]; AOR, 0.50 [97.5% CI, 0.29 to 0.86]) than among those taking these agents without prior antiplatelet therapy (26.4% vs 31.7%; ARD, -5.0% [97.5% CI, -6.8% to -3.2%]; AOR, 0.77 [97.5% CI, 0.70 to 0.85]), although the interaction P value (.07) was not statistically significant.

Conclusion : Among patients with ICH, prior use of NOACs or warfarin was associated with higher in-hospital mortality compared with no OACs. Prior use of NOACs, compared with prior use of warfarin, was associated with lower risk of in-hospital

Conclusion (proposition de traduction) : Chez les patients présentant une hémorragie intracérébrale, l'utilisation antérieure d'anticoagulants oraux autres qu'antivitamine K ou de warfarine était associée à une mortalité hospitalière plus élevée que chez les patients n'ayant pas reçu d'anticoagulants oraux. L'utilisation préalable d'anticoagulants oraux autres que les AVK, comparativement à l'administration antérieure de warfarine, était associée à un risque moins élevé d'hospitalisation.

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest. A Randomized Clinical Trial.
Jabre P, Penaloza A, Pinero D, Duchateau FX, Borron SW, Javaudin F, Richard O, de Longueville D, Bouilleau G, Devaud ML, Heidet M, Lejeune C, Fauroux S, Greingor JL, Manara A, Hubert JC, Guihard B, Vermylen O, Lievens P, Auffret Y, Maisondieu C, Huet S, Claessens B, Lapostolle F, Javaud N, Reuter PG, Baker E, Vicaut E, Adnet F. | JAMA. 2018 Feb 27;319(8):779-787
DOI: https://doi.org/10.1001/jama.2018.0156  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : Bag-mask ventilation (BMV) is a less complex technique than endotracheal intubation (ETI) for airway management during the advanced cardiac life support phase of cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest. It has been reported as superior in terms of survival.
OBJECTIVES: To assess noninferiority of BMV vs ETI for advanced airway management with regard to survival with favorable neurological function at day 28.

Méthode : Multicenter randomized clinical trial comparing BMV with ETI in 2043 patients with out-of-hospital cardiorespiratory arrest in France and Belgium. Enrollment occurred from March 9, 2015, to January 2, 2017, and follow-up ended January 26, 2017.
INTERVENTION: Participants were randomized to initial airway management with BMV (n = 1020) or ETI (n = 1023).
MAIN OUTCOMES AND MEASURES: The primary outcome was favorable neurological outcome at 28 days defined as cerebral performance category 1 or 2. A noninferiority margin of 1% was chosen. Secondary end points included rate of survival to hospital admission, rate of survival at day 28, rate of return of spontaneous circulation, and ETI and BMV difficulty or failure.

Résultats : Among 2043 patients who were randomized (mean age, 64.7 years; 665 women [32%]), 2040 (99.8%) completed the trial. In the intention-to-treat population, favorable functional survival at day 28 was 44 of 1018 patients (4.3%) in the BMV group and 43 of 1022 patients (4.2%) in the ETI group (difference, 0.11% [1-sided 97.5% CI, -1.64% to infinity]; P for noninferiority = .11). Survival to hospital admission (294/1018 [28.9%] in the BMV group vs 333/1022 [32.6%] in the ETI group; difference, -3.7% [95% CI, -7.7% to 0.3%]) and global survival at day 28 (55/1018 [5.4%] in the BMV group vs 54/1022 [5.3%] in the ETI group; difference, 0.1% [95% CI, -1.8% to 2.1%]) were not significantly different. Complications included difficult airway management (186/1027 [18.1%] in the BMV group vs 134/996 [13.4%] in the ETI group; difference, 4.7% [95% CI, 1.5% to 7.9%]; P = .004), failure (69/1028 [6.7%] in the BMV group vs 21/996 [2.1%] in the ETI group; difference, 4.6% [95% CI, 2.8% to 6.4%]; P < .001), and regurgitation of gastric content (156/1027 [15.2%] in the BMV group vs 75/999 [7.5%] in the ETI group; difference, 7.7% [95% CI, 4.9% to 10.4%]; P < .001).

Conclusion : Among patients with out-of-hospital cardiorespiratory arrest, the use of BMV compared with ETI failed to demonstrate noninferiority or inferiority for survival with favorable 28-day neurological function, an inconclusive result. A determination of equivalence or superiority between these techniques requires further research.

Conclusion (proposition de traduction) : Chez les patients en arrêt cardio-respiratoire extra-hospitalier, l'utilisation de la ventilation au masque facial avec un BAVU comparée à l'intubation oro-trachéale n'a pas montré de non-infériorité ou d'infériorité sur la survie avec une fonction neurologique favorable à 28 jours, un résultat ne permettant pas de conclure. Déterminer l'équivalence ou la supériorité entre ces techniques nécessite d'autres recherches.

Commentaire : Cet essai multicentrique, randomisé conclu qu'il n'y a aucun bénéfice à la ventilation au ballon versus l'intubation oto-trachéale sur la survie et le pronostic neurologique, contrairement aux résultats de plusieurs études observationnelles qui suggéraient que la ventilation au ballon était plus efficace et plus sûre, incitant les équipes de secours pré-hospitalières à s’interroger sur un changement de pratique.
En termes de critères secondaires, le retour à la circulation spontanée était significativement supérieur dans le bras intubation, tout comme la survie à l’admission à l’hôpital (respectivement 34 % vs 39 % ; p=0,03 et 29 % vs 32,6 % ; p=0,07) et lors de la pratique des compressions thoraciques, l’intubation réalisée par des équipes entraînées n’induisait pas plus de pauses (> 2 secondes) que la ventilation (p < 0,01). Enfin, 15 % des patients du groupe ventilation au masque facial ont nécessité une aspiration pour régurgitations versus 7,5 % avec l’intubation.
Commentaire dans : Airway Management During Out-of-Hospital Cardiac Arrest  .

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial.
Jabre P, Penaloza A, Pinero D, Duchateau FX, Borron SW, Javaudin F, Richard O, de Longueville D, Bouilleau G, Devaud ML, Heidet M, Lejeune C, Fauroux S, Greingor JL, Manara A, Hubert JC, Guihard B, Vermylen O, Lievens P, Auffret Y, Maisondieu C, Huet S, Claessens B, Lapostolle F, Javaud N, Reuter PG, Baker E, Vicaut E, Adnet F. | JAMA. 2018 Feb 27;319(8):779-787
DOI: https://doi.org/10.1001/jama.2018.0156  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : Bag-mask ventilation (BMV) is a less complex technique than endotracheal intubation (ETI) for airway management during the advanced cardiac life support phase of cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest. It has been reported as superior in terms of survival.
OBJECTIVES: To assess noninferiority of BMV vs ETI for advanced airway management with regard to survival with favorable neurological function at day 28.

Méthode : Multicenter randomized clinical trial comparing BMV with ETI in 2043 patients with out-of-hospital cardiorespiratory arrest in France and Belgium. Enrollment occurred from March 9, 2015, to January 2, 2017, and follow-up ended January 26, 2017.
INTERVENTION: Participants were randomized to initial airway management with BMV (n = 1020) or ETI (n = 1023).
MAIN OUTCOMES AND MEASURES: The primary outcome was favorable neurological outcome at 28 days defined as cerebral performance category 1 or 2. A noninferiority margin of 1% was chosen. Secondary end points included rate of survival to hospital admission, rate of survival at day 28, rate of return of spontaneous circulation, and ETI and BMV difficulty or failure.

Résultats : Among 2043 patients who were randomized (mean age, 64.7 years; 665 women [32%]), 2040 (99.8%) completed the trial. In the intention-to-treat population, favorable functional survival at day 28 was 44 of 1018 patients (4.3%) in the BMV group and 43 of 1022 patients (4.2%) in the ETI group (difference, 0.11% [1-sided 97.5% CI, -1.64% to infinity]; P for noninferiority = .11). Survival to hospital admission (294/1018 [28.9%] in the BMV group vs 333/1022 [32.6%] in the ETI group; difference, -3.7% [95% CI, -7.7% to 0.3%]) and global survival at day 28 (55/1018 [5.4%] in the BMV group vs 54/1022 [5.3%] in the ETI group; difference, 0.1% [95% CI, -1.8% to 2.1%]) were not significantly different. Complications included difficult airway management (186/1027 [18.1%] in the BMV group vs 134/996 [13.4%] in the ETI group; difference, 4.7% [95% CI, 1.5% to 7.9%]; P = .004), failure (69/1028 [6.7%] in the BMV group vs 21/996 [2.1%] in the ETI group; difference, 4.6% [95% CI, 2.8% to 6.4%]; P < .001), and regurgitation of gastric content (156/1027 [15.2%] in the BMV group vs 75/999 [7.5%] in the ETI group; difference, 7.7% [95% CI, 4.9% to 10.4%]; P < .001).

Conclusion : Among patients with out-of-hospital cardiorespiratory arrest, the use of BMV compared with ETI failed to demonstrate noninferiority or inferiority for survival with favorable 28-day neurological function, an inconclusive result. A determination of equivalence or superiority between these techniques requires further research.

Conclusion (proposition de traduction) : Chez les patients en arrêt cardiorespiratoire hors hôpital, l'utilisation du BMV par rapport à l'IET n'a pas permis de démontrer la non-infériorité ou l'infériorité de survie avec une fonction neurologique favorable à 28 jours, résultat peu concluant. Une détermination de l’équivalence ou de la supériorité entre ces techniques nécessite des recherches plus poussées.

Commentaire : Le design de l’étude donne une réponse à la question posée un peu difficile à comprendre : La non-infériorité de la gestion des voies aériennes par BAVU par rapport à l’IOT dans l’ACR-e n’est pas démontrée. En d’autres termes, soit la ventilation au BAVU est inférieure à l’IOT dans cette situation soit la puissance de l’étude est trop faible (effet inférieur à 1 %) pour montrer la non-infériorité. 
La ventilation au BAVU était associée à une augmentation des complications dans la gestion des voies aériennes et des interruptions dans la réanimation. Cet effet n’était pas observé dans le groupe IOT alors que c’est le cas dans d’autres études. Ceci est probablement lié au fait que dans la plupart des études sur ce sujet l’IOT est réalisée par des paramédics seuls alors qu’ici l’équipe comportait systématiquement un médecin expérimenté dans l’IOT. Le taux d’IOT difficile était similaire aux autres études (9 à 11 %). Mal réalisée, la ventilation manuelle tout comme mécanique, peut-être délétère en particulier sur le plan hémodynamique et ce quelle que soit la méthode utilisée. Malheureusement, aucune donnée sur le mode de ventilation des patients intubés n’était disponible.
Pour la pratique cet article semble conforter le fait de proposer une IOT dans cette situation pour les praticiens qui ont l’habitude de cette technique. Pour les praticiens moins expérimentés, le risque de perte de temps voir d’échec d’IOT fait préférer la ventilation au BAVU avec canule de « guedel » et une optimisation des autres axes (MCE, défibrillation, réanimation médicamenteuse) qui ont fait preuve de leur intérêt sur la survie.

Hejl L, Perdriolle-Galet E, Gauchotte E, Callec R, Morel O. | La Revue Sage-Femme. 2018 February;17(1):22-32
DOI: https://doi.org/10.1016/j.sagf.2018.01.002
Keywords: Aucun

Travaux originaux

Introduction : La voie d’accouchement lors de présentations du siège est l’objet de polémiques depuis les années 2000, ce qui a conduit à un taux de césariennes élevé. Dans notre centre, la voie d’accouchement était laissée à l’appréciation du médecin suivant la grossesse avant 2012. À compter de 2012, la prise en charge de ces présentations était encadrée par un protocole permettant une prise en charge collégiale incitative à la voie basse. L’objectif de cette étude était d’évaluer l’impact de cette politique sur les issues des accouchements ainsi que sur les pratiques obstétricales.

Méthode : Une étude rétrospective comparant 2008 à 2014, avant puis après la mise en place du protocole, a été menée au sein d’une maternité universitaire de type III. Deux cent quarante-cinq patientes, dont le fœtus était en présentation du siège, à plus de 32 semaines d’aménorrhée ont été inclues. Le critère de jugement principal était le taux de tentative d’accouchement par voie basse (TAVB). Les critères secondaires étaient l’évolution des pratiques ainsi que de l’état néonatal.

Résultats : Cent vingt-six patientes ayant accouché en 2008 ont été comparées à 105 prises en charge en 2014. Le taux de réussite des TAVB a augmenté de 32,7 % (n = 16/49) à 63,8 % (n = 37/58) (p < 0,05) entre les 2 périodes, avec une baisse de 16,3 % du taux de césariennes programmées (77/126) versus (47/105) (p < 0,02) et de 6,2 % pour les césariennes en urgences (33/126) versus (21/105) (p < 0,001). Aucune différence significative n’a été observée concernant l’état néonatal.

Conclusion : Ce travail montre qu’il est possible de limiter le taux de césariennes programmées et en cours de travail grâce à une politique incitative de service sans impact sur la morbi-mortalité néonatale.

Commentaire : Article publié initialement dans : Gynecol Obstet Fertil Senol. 2017 Nov;45(11):596-603 
  

Roquilly A, Cinotti R, Asehnoune K. | Prat Anesth Reanim. 2018 February;22(1):4-9
DOI: https://doi.org/10.1016/j.pratan.2018.01.006
Keywords: Lésion cérébral, Coma, Ventilation mécanique, Volume courant, PEP

Mise au point

Editorial : Les patients admis en unité de soins intensifs dans les suites d’une lésion cérébrale aiguë nécessitent souvent le recours à une ventilation mécanique (VM) pour prévenir le développement de lésions cérébrales secondaires. Cependant, les taux des complications associés à la VM, telles que la pneumonie, le syndrome de détresse respiratoire aiguë et l’échec d’extubation, sont plus élevés chez ces patients que ceux observés dans d’autres populations de patients hospitalisés en réanimation. Alors que les complications respiratoires ont été associées à une augmentation du risque de décès et à une moins bonne récupération neurologique après une lésion cérébrale aiguë, les progrès récents dans la gestion de la VM chez ces patients laissent espérer une amélioration de leur pronostic à long terme. Notamment, la prévention des lésions pulmonaires induites par la ventilation par l’application de faibles volumes courants (6 mL/kg de poids corporel idéal) et d’une pression expiratoire positive modérée (> 5 cmH2O), ainsi qu’une meilleure prise en charge de l’extubation sont des stratégies prometteuses. Les études futures devront viser la prévention des extubations retardées, et définir la place de la trachéotomie chez les patients ayant des troubles prolongés.

Conclusion : Bien que la prise en charge de la ventilation ait un impact fort sur la récupération neurologique, il n’y a à ce jour aucune recommandation disponible sur la gestion de la ventilation invasive chez les cérébrolésés. L’implémentation en neuro-réanimation des données acquises en réanimation générale et au bloc opératoire sur l’optimisation des réglages de la ventilation invasive a récemment permis d’en démontrer la bonne tolérance neurologique. Des niveaux modérés de PEP (5–6 cmH2O) ont des effets mineurs sur la pression de perfusion cérébrale chez les patients en normo volémie et pourraient même avoir des conséquences positives sur l’oxygénation du tissu cérébral. L’implémentation de recommandations en faveur d’une ventilation protectrice, avec des volumes courants faibles (6 à 8 mL/kg de poids corporel idéal), est associée à une accélération du sevrage de la ventilation mécanique, avec un bon profil de sécurité neurologique. La décision d’extuber reste encore difficile dans le contexte de la neuro-réanimation. L’attente de la récupération neurologique complète du patient n’est pas obligatoire et certaines caractéristiques spécifiques comme la poursuite visuelle, la toux, la déglutition pourraient être prometteuses dans l’exécution réussie de l’extubation. Enfin, le développement de projets d’amélioration de la qualité des soins concernant la ventilation constitue une étape cruciale dans l’amélioration du devenir des patients cérébrolésés.

Ynineb Y | Prat Anesth Reanim. 2018 February;22(1):24-31
DOI: https://doi.org/10.1016/j.pratan.2018.01.010
Keywords: Vidéolaryngoscope, Intubation difficile, Airway control

Rubrique pratique

Editorial : Il existe aujourd’hui un large éventail de dispositifs de contrôle des voies aériennes. Le choix de chaque dispositif dépend des caractéristiques propres des dispositifs et des situations cliniques. L’usage des vidéoloaryngoscopes a modifié les schémas de contrôle des voies aériennes supérieures dans le cadre des intubations difficiles également en raison de leur intérêt pédagogique. La liste des situations où leur usage est préconisé s’étend, du fait probablement d’une réduction de la morbidité et d’une meilleure gestion des difficultés imprévues.

Conclusion : Le choix d’un vidéo-laryngoscope dépend de plusieurs paramètres : les caractéristiques du vidéo-laryngoscope, la situation clinique et l’anatomie du patient. Disposer d’un vidéo-laryngoscope de chaque groupe et en maîtriser l’usage semble être une bonne option pour faire face aux différentes situations possibles.

The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants.
Elkhunovich M, Sirody J, McCormick T, Goodarzian F, Claudius I. | Pediatr Emerg Care. 2018 Feb;34(2):96-101
DOI: https://doi.org/10.1097/PEC.0000000000000696
Keywords: Aucun

Original Articles

Introduction : The objective of this study was to evaluate the sensitivity and specificity of cranial ultrasound (CUS) for detection of intracranial hemorrhage (ICH) in infants with open fontanels.

Méthode : This was a retrospective study of infants younger than 2 years who had a CUS performed for the evaluation of potential ICH. We excluded patient with CUSs that were done for reasons related to prematurity, transplant or oncologic evaluations, routine follow-up or preoperative screen, or congenital and known perinatal anomalies. Two clinicians independently classified each of the patients with ICH into significant or insignificant based on the radiology reports.

Résultats : Of 4948 CUS studies performed during the 5-year study period, 283 studies fit the inclusion criteria. Patient age ranged from 0 to 458 days, with a median of 33 days. There were 39 total cases of ICH detected, with 27 significant bleeds and 12 insignificant bleeds. Using computed tomography, magnetic resonance imaging, or clinical outcome as criterion standard, the overall ultrasound sensitivity and specificity for bleed were 67% (confidence interval [CI], 50%-81%) and 99% (CI, 97%-100%), respectively. For those with significant bleeds, the overall sensitivity was 81% (CI, 62%-94%), and for those with insignificant bleeds, it was 33% (CI, 1%-65%).

Conclusion : The sensitivity of CUS is inadequate to justify its use as a screening tool for detection of ICH in young infants.

Conclusion (proposition de traduction) : La sensibilité de la CUS est insuffisante pour justifier son utilisation comme outil de dépistage pour la détection de l'hémorragie intracrânienne chez les nourrissons.

Point-of-Care Ultrasound Integrated Into a Staged Diagnostic Algorithm for Pediatric Appendicitis.
Doniger SJ, Kornblith A. | Pediatr Emerg Care. 2018 Feb;34(2):109-115
DOI: https://doi.org/10.1097/PEC.0000000000000773
Keywords: Aucun

Original Articles

Introduction : We hypothesized that point-of-care ultrasound (POCUS) is as accurate as radiology-performed ultrasound in evaluating children with clinical concern for appendicitis. As part of a staged approach, we further hypothesized that POCUS could ultimately decrease computed tomography (CT) utilization.

Méthode : This was a prospective, convenience sampling of patients aged 2 to 18 years presenting with abdominal pain to a pediatric emergency department. Those patients with prior abdominal imaging, pregnant, or unable to tolerate the examination were excluded. An algorithm was followed: POCUS was first performed, followed by a radiology-performed ultrasound, and then a CT as necessary. The main outcome measure was the accuracy of the POCUS in diagnosing of appendicitis. This was compared with radiology-performed ultrasound. We also examined whether certain patient or clinical characteristics influenced the performance of POCUS. Lastly, we determined the amount by which CT scans were decreased through this staged algorithm.

Résultats : Forty patients were enrolled and underwent a POCUS examination. A total of 16 (40%) had pathology-confirmed appendicitis. Point-of-care ultrasound had a sensitivity of 93.8% (95% confidence interval [CI], 69.7%-98.9%) and specificity of 87.5% (95% CI, 67.6%-97.2%). Radiology-performed ultrasound had a sensitivity of 81.25% (95% CI, 54.3%-95.7%) and specificity of 100% (95% CI, 85.6%-100%). The radiology-performed and POCUS examinations had very good agreement (κ = 0.83, P < 0.0005). Patient characteristics including body mass index did not have an affect on the POCUS. However, POCUS identified all patients with an Alvarado score higher than 6. Overall, the reduction in CT examinations was 55%.

Conclusion : In pediatric patients presenting with clinical concern for acute appendicitis, a staged algorithm that incorporates POCUS is accurate and has the potential to decrease CT scan utilization.

Conclusion (proposition de traduction) : Dans la population de patients pédiatriques présentant une suspicion clinique d'appendicite aiguë, l'étape d'un algorithme intégrant l'échographie au lit du malade est précis et peut réduire l'utilisation du scanner.

Image-Guided Resuscitation With Limited Transthoracic Echocardiogram in Pediatric Trauma Patients.
Plant V, Vanguri P, Anand R, Haynes J, Aboutanos M, Ferrada P. | Pediatr Emerg Care. 2018 Feb;34(2):121-124
DOI: https://doi.org/10.1097/PEC.0000000000000862
Keywords: Aucun

Original Articles

Introduction : Limited transthoracic echocardiogram (LTTE) has been shown to be a useful tool in guiding resuscitation in adult trauma patients. Our hypothesis is that image-guided resuscitation in pediatric trauma patients with LTTE is feasible.

Méthode : A retrospective chart review was performed on highest level pediatric trauma alerts (age 18 years or younger) at our level I trauma center during a 6-month period. Patients were divided into 2 groups as follows: those who had LTTE performed (LTTE group) and those who did not have LTTE performed (non-LTTE group).

Résultats : A total of 31 charts were reviewed; 4 patients were excluded because they died on arrival to the emergency department. Fourteen patients had LTTE performed (LTTE group); 13 patients did not have LTTE performed (non-LTTE group). There was no difference in mechanism of injury, age, injury severity score, weight, or intensive care unit admission between the groups. The LTTE group received significantly less intravenous fluid than the non-LTTE group (1.2 vs 2.3 L, P = 0.0013).Within the LTTE group, 8 patients had "full" inferior vena cava (IVC) and 6 patients had "empty" IVC. There was no difference in injury severity score between these subgroups (P = 0.1018). Less fluid was given in the group labeled with full IVC [1.1 L (0.8-1.2)] than the group with empty IVC [2.4 L (1.7-2.6)], P = 0.0005. Four of the 6 patients with "empty" IVC had a confirmed source of bleeding.

Conclusion : Limited transthoracic echocardiogram can limit the amount of unnecessary crystalloid resuscitation given to pediatric trauma patients who are not hypovolemic.

Conclusion (proposition de traduction) : L'échocardiographique « focalisé » peut limiter les quantités de perfusion de cristalloïdes inutiles administrée aux patients traumatisés pédiatriques qui ne sont pas hypovolémiques.

Commentaire : A, B, C, D, echo: limited transthoracic echocardiogram is a useful tool to guide therapy for hypotension in the trauma bay--a pilot study  

Does the Application of Heat Gel Pack After Eutectic Mixture of Local Anesthetic Cream Improve Venipuncture or Intravenous Cannulation Success Rate in Children? A Randomized Control Trial.
Schreiber S, Cozzi G, Patti G, Taddio A, Montico M, Pierobon C, Barbi E. | Pediatr Emerg Care. 2018 Feb;34(2):e24-e27
DOI: https://doi.org/10.1097/PEC.0000000000001248
Keywords: Aucun

Original articles

Introduction : Needle-related procedures are the most common sources of pain for children in the hospital setting. The most used topical anesthetic, eutectic mixture of local anesthetic (EMLA) cream, may cause transient vasoconstriction. It has been postulated that this vasoconstriction may decrease vein visualization. The application of heat gel pack after removal of EMLA cream in the site of venipuncture counteracts the vasoconstriction, improving vein visualization. We assessed using a prospective randomized controlled trial whether the application of heat gel pack increases the needle procedure success rate. The primary study outcome was procedural success rate at the first attempt.

Méthode : The study enrolled 400 children, 200 of whom applied heat gel pack after removing EMLA (treatment group) and 200 did not (control group). Procedural success rate at the first attempt, vein perception before procedure, procedural pain, and adverse events were recorded in both groups.

Résultats : Eighty-eight percent of the procedures were successful at the first attempt in the treatment group and 89% in the control group (P = 0.876). Vein perception was not significantly different in the 2 groups (P = 0.081). Pain score after the procedure was similar in the 2 groups.

Conclusion : This study shows that the application of heat gel pack after removal of EMLA cream does not improve venipuncture or intravenous cannulation success rate.

Conclusion (proposition de traduction) : Cette étude montre que l'application d'un pack de gel de chaleur après l'élimination de la crème EMLA n'améliore pas le taux de réussite de la ponction veineuse ou de la canulation intraveineuse.

Epinephrine in Anaphylaxis: Preclinical Study of Pharmacokinetics after Sublingual Administration of Taste-Masked Tablets for Potential Pediatric Use.
Rachid O, Rawas-Qalaji M, Simons KJ. | Pharmaceutics. 2018 Feb 11;10(1):24
DOI: https://doi.org/10.3390/pharmaceutics10010024  | Télécharger l'article au format  
Keywords: adrenaline; allergy; anaphylaxis; auto-injector; bioavailability; bioequivalence; epinephrine; intramuscular; rapidly-disintegrating; sublingual delivery; tablets.

Article

Introduction : Epinephrine is a life-saving treatment in anaphylaxis. In community settings, a first-aid dose of epinephrine is injected from an auto-injector (EAI). Needle phobia highly contributes to EAI underuse, leading to fatalities-especially in children.

Méthode : A novel rapidly-disintegrating sublingual tablet (RDST) of epinephrine was developed in our laboratory as a potential alternative dosage form. The aim of this study was to evaluate the sublingual bioavailability of epinephrine 30 mg as a potential pediatric dose incorporated in our novel taste-masked RDST in comparison with intramuscular (IM) epinephrine 0.15 mg from EAI, the recommended and only available dosage form for children in community settings. We studied the rate and extent of epinephrine absorption in our validated rabbit model (n = 5) using a cross-over design. The positive control was IM epinephrine 0.15 mg from an EpiPen Jr®. The negative control was a placebo RDST. Tablets were placed under the tongue for 2 min. Blood samples were collected at frequent intervals and epinephrine concentrations were measured using HPLC with electrochemical detection.

Résultats : The mean ± SEM maximum plasma concentration (Cmax) of 16.7 ± 1.9 ng/mL at peak time (Tmax) of 21 min after sublingual epinephrine 30 mg did not differ significantly (p > 0.05) from the Cmax of 18.8 ± 1.9 ng/mL at a Tmax of 36 min after IM epinephrine 0.15 mg. The Cmax of both doses was significantly higher than the Cmax of 7.5 ± 1.7 ng/mL of endogenous epinephrine after placebo.

Conclusion : These taste-masked RDSTs containing a 30 mg dose of epinephrine have the potential to be used as an easy-to-carry, palatable, non-invasive treatment for anaphylactic episodes for children in community settings.

Conclusion (proposition de traduction) : Ces comprimés sublinguaux au goût masqué et à désintégration rapide contenant une dose de 30 mg d'adrénaline ont le potentiel d'être utilisés comme traitement facile à transporter, agréable au goût et non invasif pour les épisodes anaphylactiques chez les enfants en milieu communautaire.

Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States.
Buckland DM, Crowe RP, Cash RE, Gondek S, Maluso P, Sirajuddin S, Smith ER, Dangerfield P, Shapiro G, Wanka C, Panchal AR, Sarani B. | Prehosp Disaster Med. 2018 Feb;33(1):23-28
DOI: https://doi.org/10.1017/S1049023X17007142  | Télécharger l'article au format  
Keywords: EMS Emergency Medical Services; IM intramuscular; IN intranasal; IV intravenous; NREMT National Registry of Emergency Medical Technicians; NRP nationally certified paramedic; RSI rapid sequence intubation; Emergency Medical Services; ketamine; paramedic; prehospital

Original Research

Introduction : Use of ketamine in the prehospital setting may be advantageous due to its potent analgesic and sedative properties and favorable risk profile. Use in the military setting has demonstrated both efficacy and safety for pain relief. The purpose of this study was to assess ketamine training, use, and perceptions in the civilian setting among nationally certified paramedics (NRPs) in the United States.

Méthode : A cross-sectional survey of NRPs was performed. The electronic questionnaire assessed paramedic training, authorization, use, and perceptions of ketamine. Included in the analysis were completed surveys of paramedics who held one or more state paramedic credentials, indicated "patient care provider" as their primary role, and worked in non-military settings. Descriptive statistics were calculated.

Résultats : A total of 14,739 responses were obtained (response rate=23%), of which 10,737 (73%) met inclusion criteria and constituted the study cohort. Over one-half (53%) of paramedics reported learning about ketamine during their initial paramedic training. Meanwhile, 42% reported seeking ketamine-related education on their own. Of all respondents, only 33% (3,421/10,737) were authorized by protocol to use ketamine. Most commonly authorized uses included pain management (55%), rapid sequence intubation (RSI; 72%), and chemical restraint/sedation (72%). One-third of authorized providers (1,107/3,350) had never administered ketamine, with another 32% (1,070/3,350) having administered ketamine less than five times in their career. Ketamine was perceived to be safe and effective as the vast majority reported that they were comfortable with the use of ketamine (94%) and would, in similar situations (95%), use it again.

Conclusion : This was the first large, national survey to assess ketamine training, use, and perceptions among paramedics in the civilian prehospital setting. While training related to ketamine use was commonly reported among paramedics, few were authorized to administer the drug by their agency's protocols. Of those authorized to use ketamine, most paramedics had limited experience administering the drug. Future research is needed to determine why the prevalence of ketamine use is low and to assess the safety and efficacy of ketamine use in the prehospital setting.

Conclusion (proposition de traduction) : Il s'agissait de la première grande enquête nationale visant à évaluer la formation, l'utilisation et les perceptions de la kétamine chez les ambulanciers paramédicaux en milieu préhospitalier civil. Bien que la formation relative à l'utilisation de la kétamine ait été fréquemment rapportée chez les ambulanciers paramédicaux, peu d'entre eux étaient autorisés à administrer le médicament selon les protocoles de leur organisme. Parmi les personnes autorisées à utiliser de la kétamine, la plupart des ambulanciers paramédicaux avaient une expérience limitée de l'administration du médicament. Des recherches futures sont nécessaires pour déterminer pourquoi la prévalence de l'utilisation de la kétamine est faible et pour évaluer la sécurité et l'efficacité de l'utilisation de la kétamine en milieu préhospitalier.

Prehospital Modified HEART Score Predictive of 30-Day Adverse Cardiac Events.
Stopyra JP, Harper WS, Higgins TJ, Prokesova JV, Winslow JE, Nelson RD, Alson RL, Davis CA, Russell GB, Miller CD, Mahler SA. | Prehosp Disaster Med. 2018 Feb;33(1):58-62
DOI: https://doi.org/10.1017/S1049023X17007154  | Télécharger l'article au format  
Keywords: ACS acute coronary syndrome; AMI acute myocardial infarction; Age; ECG; ECG electrocardiogram; ED emergency department; EMS Emergency Medical Services; HEAR History; HEART History; MACE major adverse cardiac events; MI myocardial infarction; NPV negative predictive value; POC point-of-care; Risk Factors; STEMI ST-elevation myocardial infarction; and Troponin; Emergency Medical Services; acute coronary syndrome; chest pain; decision support techniques

Original Research

Introduction : Introduction The History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting. Hypothesis A prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.

Méthode : A retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.

Résultats : Over the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.

Conclusion : Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted.

Conclusion (proposition de traduction) : Le score HEART préhospitalier modifiés a une valeur prédictive négative élevée pour les événements cardiaques indésirables majeurs à 30 jours. Une étude dans laquelle les intervenants préhospitaliers appliquent prospectivement cette aide à la décision est justifiée.

Prehospital Identification of Patients with a Final Hospital Diagnosis of Stroke.
Andersson E, Bohlin L, Herlitz J, Sundler AJ, Fekete Z, Andersson Hagiwara M. | Prehosp Disaster Med. 2018 Feb;33(1):63-70
DOI: https://doi.org/10.1017/S1049023X17007178
Keywords: CT computer tomography; ECG electrocardiogram; EMS Emergency Medical Service; ESS emergency signs and symptoms; TIA transitory ischemic attack; rt-PA recombinant tissue plasminogen activator; EMS; assessment; prehospital; stroke

Original Research

Introduction : Introduction the early phase of stroke, minutes are critical. Since the majority of patients with stroke are transported by the Emergency Medical Service (EMS), the early handling and decision making by the EMS clinician is important. Problem The study aim was to evaluate the frequency of a documented suspicion of stroke by the EMS nurse, and to investigate differences in the clinical signs of stroke and clinical assessment in the prehospital setting among patients with regard to if there was a documented suspicion of stroke on EMS arrival or not, in patients with a final hospital diagnosis of stroke.

Méthode : The study had a retrospective observational design. Data were collected from reports on patients who were transported by the EMS and had a final diagnosis of stroke at a single hospital in western Sweden (630 beds) in 2015. The data sources were hospital and prehospital medical journals.

Résultats : In total, 454 patients were included. Among them, the EMS clinician suspected stroke in 52%. The findings and documentation on patients with a suspected stroke differed from the remaining patients as follows: a) More frequently documented symptoms from the face, legs/arms, and speech; b) More frequently assessments of neurology, face, arms/legs, speech, and eyes; c) More frequently addressed the major complaint with regard to time and place of onset, duration, localization, and radiation; d) Less frequently documented symptoms of headache, vertigo, and nausea; and e) More frequently had an electrocardiogram (ECG) recorded and plasma glucose sampled. In addition to the 52% of patients who had a documented initial suspicion of stroke, seven percent of the patients had an initial suspicion of transitory ischemic attack (TIA) by the EMS clinician, and a neurologist was approached in another 10%.

Conclusion : Among 454 patients with a final diagnosis of stroke who were transported by the EMS, an initial suspicion of stroke was not documented in one-half of the cases. These patients differed from those in whom a suspicion of stroke was documented in terms of limited clinical signs of stroke, a less extensive clinical assessment, and fewer clinical investigations.

Conclusion (proposition de traduction) : Parmi les 454 patients pour lesquels un diagnostic final d'accident vasculaire cérébral a été retenu et qui ont été transportés par un Service médical d'urgence, une suspicion initiale d'AVC n'a pas été documentée dans la moitié des cas.
Ces patients différaient de ceux chez lesquels une suspicion d'accident vasculaire cérébral était documentée en termes de signes cliniques limités d'AVC, une évaluation clinique moins étendue et moins d'investigations cliniques.

Triage of Septic Patients Using qSOFA Criteria at the SAMU Regulation: A Retrospective Analysis.
Jouffroy R, Saade A, Carpentier A, Ellouze S, Philippe P, Idialisoa R, Carli P, Vivien B. | Prehosp Emerg Care. 2018 Jan-Feb;22(1):84-90
DOI: https://doi.org/10.1080/10903127.2017.1347733  | Télécharger l'article au format  
Keywords: incidence; sepsis; severity; triage

nternational EMS

Introduction : One of the major prognostic factors in the management of sepsis is the early initiation of appropriate treatment. To serve this purpose, early identification and triage of patients are crucial steps, which are still not optimal. The objective of this study was to determine whether the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score is an accurate method for prehospital triaging of septic patients. We evaluated whether the use of qSOFA criteria collected by the Service Mobile d'Urgence et de Réanimation 15 (SAMU 15) regulation call center during prehospital care would facilitate appropriate intensive care unit (ICU) admission of patients with septic syndromes.

Méthode : We conducted a retrospective observational register-based study using data collected between April 01 and May 31 2011. These data are based on call registry reports of calls received by the Paris Emergency regulation call centre during prehospital management of patients. All patients with suspected infection were included in the study and evaluated using qSOFA and systemic inflammatory response syndrome (SIRS) criteria. The primary outcome was Intensive Care Unit (ICU) admission.

Résultats : Among the 30 642 reports received, 141 patients with presumed sepsis were included. Twenty-two patients were admitted to an ICU. The qSOFA and SIRS scores were the same in predicting admission to an ICU (p = 0.26). The qSOFA had a sensitivity of 75% and a specificity of 68% for ICU admission whereas the SIRS had a sensitivity of 87% and a specificity of 43%. At day 28, 12 patients (9%) had died, 5 of them in the ICU. The negative predictive value reached 93% and 94% for pre-hospital qSOFA and SIRS respectively. Pre-hospital systolic blood pressure (SBP) ≤100 mmHg was significantly associated with ICU admission (OR = 4.19 [1.89-9.84]), while all other criteria were not.

Conclusion : The current study reports no difference between the SIRS and the qSOFA scores for prehospital triage of septic patients to predict ICU admission. Both scores have comparable, pertinent, negative predictive value for ICU admission. Nevertheless, an improved score for pre-hospital triaging is needed to predict ICU admission of septic patients.

Conclusion (proposition de traduction) : Cette étude ne retrouve aucune différence entre les scores SIRS et les scores qSOFA pour le triage préhospitalier des patients septiques pour prédire l'admission aux soins intensifs. Les deux scores ont une valeur prédictive négative, pertinente et comparable pour l'admission aux soins intensifs.
Néanmoins, un score amélioré pour le triage pré-hospitalier est nécessaire pour prédire l'admission des patients septiques à l'USI.

The use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review.
Paiva EF, Paxton JH, O'Neil BJ. | Resuscitation. 2018 Feb;123:1-7
DOI: https://doi.org/10.1016/j.resuscitation.2017.12.003
Keywords: Advanced cardiac life support; Capnography; Cardiac arrest; End tidal carbon dioxide; Meta-analysis; Prognostication; Systematic review

Reviews

Introduction : To identify whether any level of end-tidal carbon dioxide (ETCO2) measured during cardiopulmonary resuscitation (CPR) correlates with return of spontaneous circulation (ROSC) or survival in adults experiencing cardiac arrest in any setting.

Méthode : Systematic review. We included randomized controlled trials, cohort studies, and case-control studies of adult cardiac arrest in any setting that reported specific (rather than pooled) ETCO2 values and attempted to correlate those values with prognosis. Full-text articles were searched on EmBASE, MEDLINE, and Cochrane Database. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) guidelines were followed, assigning levels of quality to all evidence used in the meta-analysis.

Résultats : Seventeen observational studies, describing a total of 6198 patients, were included in the qualitative synthesis, and five studies were included in the meta-analysis. The available studies provided consistent but low-quality evidence that ETCO2 measurements ≥10mmHg, obtained at various time points during CPR, are substantially related to ROSC. Additional cut-off values were also found. Initial ETCO2 or 20-min ETCO2>20mmHg appears to be a better predictor of ROSC than the 10mmHg cut off value. A ETCO2<10mmHg after 20min of CPR is associated with a 0.5% likelihood of ROSC.

Conclusion : Based upon existing evidence, ETCO2 levels do seem to provide limited prognostic information for patients who have experienced cardiac arrest. Given the many potential confounders that can influence initial ETCO2 levels, extreme or trending values may be more useful than static mid-range levels. Additional well-designed studies are needed to define optimal timing for the measurement of ETCO2 for prognostic purposes.

Conclusion (proposition de traduction) : D'après les données probantes existantes, les niveaux d'ETCO2 semblent fournir des renseignements pronostiques limités pour les patients qui ont subi un arrêt cardiaque. Étant donné les nombreux facteurs de confusion potentiels qui peuvent influencer les niveaux initiaux d'ETCO2, les valeurs extrêmes ou les tendances peuvent être plus utiles que les niveaux statiques moyens. D'autres études bien conçues sont nécessaires pour définir le moment optimal pour la mesure de l'ETCO2 à des fins pronostiques.

Commentaire : Je vous rappelle l'article de Heradstveit BE, PQRST - a unique aide-memoire for capnography interpretation during cardiac arrest dans Resuscitation. 2014 Nov;85(11):1619-20  

Early coronary angiography and percutaneous coronary intervention are associated with improved outcomes after out of hospital cardiac arrest.
Jentzer JC, Scutella M, Pike F, Fitzgibbon J, Krehel NM, Kowalski L, Callaway CW, Rittenberger JC, Reynolds JC, Barsness GW, Dezfulian C. | Resuscitation. 2018 Feb;123:15-21
DOI: https://doi.org/10.1016/j.resuscitation.2017.12.004
Keywords: Cardiac arrest; Coronary angiography; Coronary artery disease; Percutaneous coronary intervention; Survival

Clinical Papers

Introduction : Early coronary angiography (CAG) and percutaneous coronary intervention (PCI) are associated with better outcomes in subjects resuscitated from out-of-hospital cardiac arrest (OHCA). We sought to determine the relative contributions of early CAG and PCI to outcomes and adverse events after OHCA.

Méthode : We analyzed 599 OHCA subjects from a prospective two-center registry. Hospital survival, functional outcomes and adverse events were compared between subjects undergoing early CAG (within 24h) with or without PCI and subjects not undergoing early CAG. We adjusted for propensity to perform early CAG and PCI and for post-resuscitation illness severity and care.

Résultats : Early CAG subjects had improved rates of hospital survival (56.2% versus 31.0%, OR 2.85 [95% CI 2.04-4.00]; p<0.0001) and better functional outcomes compared to no early CAG. Early PCI was associated with improved survival compared to early CAG without PCI (65.6% versus 45.5%, OR 2.29 [95% CI 1.41-3.69]; p<0.001). After multivariate adjustment and propensity matching, early PCI remained significantly associated with improved survival compared with early CAG without PCI and no early CAG, but early CAG without PCI was no longer significantly associated with improved outcome compared with no early CAG. Early CAG and early PCI were not associated with an increase in transfusions or acute kidney injury.

Conclusion : Early CAG and PCI are associated with improved survival and functional outcomes after OHCA, but only early PCI was associated with a significant benefit after statistical adjustment. Our analysis supports the performance of immediate CAG to determine the need for PCI in selected patients following resuscitation from OHCA.

Conclusion (proposition de traduction) : L'angiographie coronarienne précoce et l'intervention coronarienne percutanée sont associées à une amélioration de la survie et des résultats fonctionnels après un arrêt cardiaque extrahospitalier, mais seule l'intervention coronarienne percutanée précoce était associée à un avantage significatif après ajustement statistique. Notre analyse appuie l'exécution d'une angiographie coronarienne immédiate pour déterminer la nécessité d'une intervention coronarienne percutanée chez des patients sélectionnés après une réanimation à la suite d'un arrêt cardiaque extrahospitalier.

Warning symptoms preceding out-of-hospital cardiac arrest: Do patient delays matter?.
Nehme Z, Bernard S, Andrew E, Cameron P, Bray JE, Smith K. | Resuscitation. 2018 Feb;123:65-70
DOI: https://doi.org/10.1016/j.resuscitation.2017.12.019
Keywords: Cardiac arrest; Emergency medical services; Patient delay time; Prodromal symptoms; Treatment delay

Clinical Papers

Introduction : Although increasing patient delays between symptom onset and activation of emergency medical services (EMS) can lead to poorer outcomes following acute myocardial infarction, its effect in out-of-hospital cardiac arrest (OHCA) populations is unclear.

Méthode : Between 1st January 2003 and 31st December 2011, we included adult patients with anginal warning symptoms and subsequent EMS witnessed OHCA of presumed cardiac aetiology from the Victorian Ambulance Cardiac Arrest Registry. Multivariable logistic regression was used to assess the impact of patient delay time (i.e. symptom onset to EMS call time) on survival to hospital discharge.

Résultats : A total of 1056 EMS witnessed OHCA were screened, of which 515 (48.8%) reported chest pain or anginal equivalent symptoms. The median patient delay time was 25min (interquartile range [IQR] 9-89min), and did not differ across survivors and non-survivors. However, patients in lowest quartile of patient delay (≤8min) also experienced significantly higher rates of non-shockable arrest rhythms and circulatory compromise. A total of 16 baseline and clinical characteristics were tested in a multivariable model of survival to hospital discharge, of which, only six were retained in the final model, including: age, dyspnoea, vomiting, shockable arrest rhythm, systolic blood pressure, and patient delay time. Every 30min increase in patient delay time was independently associated with a 2.3% (95% CI: 0.4%, 4.1%; p=0.02) reduction in the odds of survival to hospital discharge. Among patients with ST-segment deviation on the pre-arrest ECG, every 30min increase in patient delay time was associated with a 3.4% reduction in the odds of survival (OR 0.966, 95% CI: 0.937, 0.996; p=0.03).

Conclusion : Increasing delays in activating EMS before the onset OHCA may be associated with reduced survival. Future research could explore whether increasing public awareness of the warning symptoms leads to earlier medical contact for OHCA.

Conclusion (proposition de traduction) : Des retards croissants dans l’activation des services médicaux d’urgence avant l’arrêt cardiaque extrahospitalier peuvent être associés à une diminution de la survie. Des recherches futures pourraient examiner si une sensibilisation accrue du public aux symptômes avant-coureurs conduit à un contact médical plus précoce pour un arrêt cardiaque extrahospitalier.

Hunt-Hess 5 subarachnoid haemorrhage presenting with cardiac arrest is associated with larger volume bleeds.
Morris NA, Robinson D, Schmidt JM, Frey HP, Park S, Agarwal S, Connolly ES, Claassen J. | Resuscitation. 2018 Feb;123:71-76
DOI: https://doi.org/10.1016/j.resuscitation.2017.12.015
Keywords: Cardiac arrest; Cerebral perfusion pressure; Mortality; Multimodality monitoring; Subarachnoid haemorrhage

Clinical Papers

Introduction : The mechanism, effects, and outcomes of cardiac arrest (CA) caused by subarachnoid haemorrhage (SAH) remain unclear. We compared SAH patients presenting with CA to other high-grade SAH patients presenting without CA in order to better understand (1) the cause of CA, (2) cerebral pathophysiology following CA, and (3) outcomes of CA in patients with SAH.

Méthode : We performed a retrospective analysis of a prospectively collected observational cohort. 31 Hunt-Hess 5 patients that presented with CA were compared to 146 Hunt-Hess 5 patients that presented without CA. Clinical and imaging findings were predefined and adjudicated. Cerebral physiology measures were available for a subset of patients, matched 1:1 by age.

Résultats : Twenty-two (71%) CA patients had pulseless electrical activity/asystole compared to 2 (6%) with a shockable rhythm. The CA patients were younger (OR 0.96, 95% CI 0.93-0.99, p=0.009), had more SAH on CT (OR 1.07, 95% CI 1.01-1.13, p=0.02), and had higher in-hospital mortality (87% vs. 58%, OR 6.2 (2.1-26.6), p=0.004). There were no differences in aneurysm location, cerebral herniation, or ictal seizures. Despite similar cerebral perfusion pressure, CA patients had pathologically lower brain tissue oxygenation, lower glucose, and higher lactate to pyruvate ratios.

Conclusion : CA in SAH is associated with larger volume bleeds. Despite normal cerebral perfusion pressures, CA patients show compromised cerebral physiology.

Conclusion (proposition de traduction) : L'arrêt cardiaque en cas d'hémorragie sous-arachnoïdienne est associé à des saignements de plus grand volume. Malgré les pressions normales de perfusion cérébrale, les patients victimes d'un arrêt cardiaque présentent une physiologie cérébrale compromise.

Commentaire : Les patients en classe 5 de la classification de Hent-Hess ont une mortalité d'environ 90 %.
L'article princeps sur la classification de Hunt & Hess a été publiée dans J Neurosurg. 1968 Jan;28(1):14-20   (Surgical risk as related to time of intervention in the repair of intracranial aneurysms).

Quality of audio-assisted versus video-assisted dispatcher-instructed bystander cardiopulmonary resuscitation: A systematic review and meta-analysis.
Lin YY, Chiang WC, Hsieh MJ, Sun JT, Chang YC, Ma MH. | Resuscitation. 2018 Feb;123:77-85
DOI: https://doi.org/10.1016/j.resuscitation.2017.12.010
Keywords: Audio-assisted DI-CPR; Bystander CPR; Cardiopulmonary resuscitation (CPR); Dispatch-instructed CPR (DI-CPR); Emergency medical service (EMS); Out-of-hospital cardiac arrest (OHCA); Video-assisted DI-CPR

Clinical papers

Introduction : This study aimed to conduct a systematic review and meta-analysis comparing the effect of video-assistance and audio-assistance on quality of dispatcher-instructed cardiopulmonary resuscitation (DI-CPR) for bystanders.

Méthode : Five databases were searched, including PubMed, Cochrane library, Embase, Scopus and NIH clinical trial, to find randomized control trials published before June 2017. Qualitative analysis and meta-analysis were undertaken to examine the difference between the quality of video-instructed and audio-instructed dispatcher-instructed bystander CPR.

Résultats : The database search yielded 929 records, resulting in the inclusion of 9 relevant articles in this study. Of these, 6 were included in the meta-analysis. Initiation of chest compressions was slower in the video-instructed group than in the audio-instructed group (median delay 31.5 s; 95% CI: 10.94-52.09). The difference in the number of chest compressions per minute between the groups was 19.9 (95% CI: 10.50-29.38) with significantly faster compressions in the video-instructed group than in the audio-instructed group (104.8 vs. 80.6). The odds ratio (OR) for correct hand positioning was 0.8 (95% CI: 0.53-1.30) when comparing the audio-instructed and video-instructed groups. The differences in chest compression depth (mm) and time to first ventilation (seconds) between the video-instructed group and audio-instructed group were 1.6 mm (95% CI: -8.75, 5.55) and 7.5 s (95% CI: -56.84, 71.80), respectively.

Conclusion : Video-instructed DI-CPR significantly improved the chest compression rate compared to the audio-instructed method, and a trend for correctness of hand position was also observed. However, this method caused a delay in the commencement of bystander-initiated CPR in the simulation setting.

Conclusion (proposition de traduction) : La réanimation cardio-pulmonaire à l'aide d'un moniteur vidéo a significativement amélioré le taux de compression thoracique par rapport à la méthode d'instructions audio et une tendance à la correction de la position des mains a également été observée. Toutefois, cette méthode a retardé le début de la RCP à l'initiative des témoins dans le cadre de la simulation.

Timing of coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac causes.
Staudacher II, den Uil C, Jewbali L, van Zandvoort L, Zijlstra F, Van Mieghem N, Boersma E, Daemen J. | Resuscitation. 2018 Feb;123:98-104
DOI: https://doi.org/10.1016/j.resuscitation.2017.11.046
Keywords: Cardiogenic shock; Coronary angiography; Myocardial infarction; Out-of-hospital cardiac arrest; Percutaneous coronary intervention

Clinical papers

Introduction : Indications and timing of coronary angiography in patients surviving out-of-hospital cardiac arrest (OHCA) remain controversial. The aim of the present study was to assess the impact of an early invasive strategy in patients presenting with an OHCA and no obvious extracardiac cause.

Méthode : Between January 1st 2009 and December 31st 2014 a total 612 survivors of OHCA were admitted to our institution. Patients with no obvious extracardiac cause (n=507) were stratified into two groups: patients that underwent cardiac catheterization ≤3h (early invasive; n=291) and patients not undergoing cardiac catheterization within 3h (non-early invasive; n=216). Primary endpoint was all-cause mortality at 30days.

Résultats : All-cause 30-day mortality was 28.9% in the early invasive group vs. 36.6% in the non-early invasive group (log-rank p=0.071). After propensity analyses, an early invasive strategy, as compared to a non-early strategy, was not associated with 30-day mortality (adjusted Hazard ratio [HR] 0.69; 95% CI 0.35-1.37; p=0.029). Cox multivariable regression analyses demonstrated age (HR 1.04/year; 95% CI 1.02-1.07) and presentation with cardiogenic shock (HR 5.1; 95% CI 1.8-14.0) to be the sole independent predictors of 30-day mortality.

Conclusion : In this retrospective study, early coronary angiography (<3h), as compared to a non-early invasive strategy, was not associated with reduced 30-day mortality in patients hospitalized after OHCA, irrespective of the presence of ST segment elevation or cardiogenic shock at presentation.

Conclusion (proposition de traduction) : Dans cette étude rétrospective, la coronarographie précoce (< 3 h), comparée à une stratégie non invasive précoce, n'a pas été associée à une réduction de la mortalité à 30 jours chez les patients hospitalisés après un arrêt cardiaque extrahospitalier, indépendamment de la présence d'une élévation du segment ST ou d'un choc cardiogène à l'admission.

Blanc C, Martin PY. | Rev Med Suisse. 2018 Feb;14:406-410
DOI: https://www.revmed.ch/RMS/2018/RMS-N-595/Traitement-de-l-hyperkaliemie-version-2.0
Keywords: Aucun

Néphrologie

Editorial : L’hyperkaliémie est un trouble électrolytique grave favorisé par certaines comorbidités, comme l’insuffisance rénale chronique ou certains traitements tels que les bloqueurs du système rénine-angiotensine-aldostérone. Les nouveaux traitements oraux par chélation du potassium intestinal ont prouvé : 1) leur efficacité dans la gestion de la kaliémie en maintenant les traitements aux posologies optimales ; 2) leur sécurité d’emploi par l’absence d’effet indésirable grave et 3) la facilité d’emploi avec une prise quotidienne.

Conclusion (proposition de traduction) : L’hyperkaliémie est un trouble électrolytique fréquemment rencontré chez les patients insuffisants rénaux. La complication majeure redoutée est le trouble du rythme cardiaque malin pouvant entraîner le décès. Les causes d’hyperkaliémie sont variées, mais peuvent être bien souvent expliquées par les comorbidités du patient ou ses traitements. Certains médicaments, comme ceux agissant sur le système rénine–angiotensine-aldostérone (SRAA), sont bénéfiques dans l’insuffisance cardiaque (IC) ou l’insuffisance rénale chronique (IRC) mais sont source d’hyperkaliémie dont les stratégies actuelles n’offrent pas une prise en charge optimale au patient.

Lactate and Immunosuppression in Sepsis.
Nolt B, Tu F, Wang X, Ha T, Winter R, Williams DL, Li C. | Shock. 2018 Feb;49(2):120-125
DOI: https://doi.org/10.1097/SHK.0000000000000958  | Télécharger l'article au format  
Keywords: Aucun

Review Articles

Editorial : Serum lactate levels are traditionally interpreted as a marker of tissue hypoxia and often used clinically as an indicator of severity and outcome of sepsis/septic shock. Interestingly, recent studies involving the effects of tumor-derived lactate suggest that lactate itself may have an immunosuppressive effect in its local environment. This finding adds to the recent advances in immunometabolism that shed light on the importance of metabolism and metabolic intermediates in the regulation of innate immune and inflammatory responses in sepsis. In this article, we summarize recent studies, showing that the activation of immune cells requires aerobic glycolytic metabolism and that lactate produced by aerobic glycolysis may play an immunosuppressive role in sepsis.

Conclusion : We have highlighted some of the current research surrounding the potential role of lactate as an immunosuppressive metabolite. Although there are clearly a number of contributing factors to the development of immune suppression in sepsis, the recent developments in other fields of research suggest that lactate could be a potential and critical contributory factor in the regulation of immune function in sepsis.

Conclusion (proposition de traduction) : Nous avons mis en évidence certaines des recherches actuelles sur le rôle potentiel du lactate en tant que métabolite immunosuppresseur. Bien qu'il y ait manifestement un certain nombre de facteurs contribuant au développement de l'immunosuppression dans le sepsis, les développements récents dans d'autres domaines de recherche suggèrent que le lactate pourrait être un facteur potentiel et critique contribuant à la régulation de la fonction immunitaire dans la septicémie.

Identification of Hypotensive Emergency Department Patients with Cardiogenic Etiologies.
Henning DJ, Kearney KE, Hall MK, Mahr C, Shapiro NI, Nichol G. | Shock. 2018 Feb;49(2):131-136
DOI: https://doi.org/10.1097/SHK.0000000000000945
Keywords: Aucun

Clinical Science Aspects

Introduction : Identify predictors of cardiogenic etiology among emergency department (ED) patients with hypotension, and use these predictors to create a clinical tool to discern cardiogenic etiology of hypotension.

Méthode : This secondary analysis evaluated a prospective cohort of consecutive patients with hypotension in an urban, academic, tertiary care ED from November 2012 to September 2013. We included adults with hypotension, defined as a new vasopressor requirement, systolic blood pressure (SBP) < 90 mm Hg after at least 1 L of crystalloid or 2 units packed red blood cells, or SBP < 90 mm Hg and fluids withheld due to concern for fluid overload. The primary outcome was cardiogenic etiology, adjudicated by two physician chart review, with 25% paired chart review (kappa = 0.92). We used multivariable logistic regression to predict cardiogenic etiology, utilizing clinical data abstracted from the electronic medical record. We created a prediction score from significant covariates and calculated its test characteristics for cardiogenic hypotension.

Résultats : Of 700 patients with hypotension, 107 (15.3%, 95% CI: 12.6%-18.0%) had cardiogenic etiology. Independent predictors of cardiogenic etiology were shortness of breath (OR 4.1, 95% CI: 2.5-6.7), troponin > 0.1 ng/mL (37.5, 7.1-198.2), electrocardiographic ischemia (8.9, 4.0-19.8), history of heart failure (2.0, 1.1-3.3), and absence of fever (4.5, 2.3-8.7) (area under the curve [AUC] = 0.83). The prediction score created from these predictors yielded 78% sensitivity and 77% specificity for cardiogenic etiology (AUC = 0.827).

Conclusion : Clinical predictors offer reasonable ED screening sensitivity for cardiogenic hypotension, while demonstrating sufficient specificity to facilitate early cardiac interventions.

Conclusion (proposition de traduction) : Les cliniques prédictifs offrent une sensibilité raisonnable au dépistage des urgences cardiogéniques au service des urgences, tout en démontrant une spécificité suffisante pour faciliter les interventions cardiaques précoces.

Commentaire : Les facteurs prédictifs indépendants de l'étiologie cardiogénique étaient :
- une dyspnée ;
- un taux de troponine > 0,1 ng/ml ;
- une ischémie à l'électrocardiogramme ;
- des antécédents d'insuffisance cardiaque ;
- l'absence de fièvre.

Optimal Blood Pressure After Intracerebral Hemorrhage: Still a Moving Target.
Rabinstein AA | Stroke. 2018 Feb;49(2):275-276
DOI: https://doi.org/10.1161/STROKEAHA.117.020058  | Télécharger l'article au format  
Keywords: Editorials; blood pressure; hematoma; hypertension; odds ratio; risk

Editorial

Editorial : If you have been following the literature in recent years and feel confused about how to manage acute hyperten- sion in patients with intracerebral hemorrhage (ICH), you are not alone. Two similar randomized controlled trials reach- ing seemingly different conclusions can confuse anybody. However, as always, the devil is in the details. It is not just about the blood pressure (BP) target, but also about how and when you reach it.

Conclusion : The optimal management of acute hypertension after ICH remains undefined. Large randomized trials did not provide consistent evidence that aiming for one particular BP target is broadly beneficial and informed us that very rapid and aggressive BP reduction can be harmful. Meanwhile, exploratory analyses like the one reported by Chung et al indicate that excessive BP fluctuations portend poor outcome and suggest that avoiding these fluctuations could represent a valid therapeutic target. As we keep learning, we should follow the advice of the old sages who always preached the merits of moderation and lower BP after ICH neither too fast nor too low.

Conclusion (proposition de traduction) : La prise en charge optimale de l'hypertension aiguë après une hémorragie intracérébrale reste indéfinie. Les essais randomisés à grande échelle n'ont pas fourni de preuves cohérentes indiquant que la recherche d'une cible de pression artérielle particulière est largement bénéfique et nous a informé qu'une réduction très rapide et agressive de la pression artérielle peut être nocive. Dans le même temps, des analyses exploratrices telles que celle rapportée par Chung and al indiquent que les fluctuations excessives de la pression artérielle entraînent des résultats médiocres et suggèrent qu’éviter ces fluctuations pourrait représenter une cible thérapeutique valable. Comme nous continuons à apprendre, nous devrions suivre les conseils des anciens sages qui ont toujours prêché les mérites de la modération et de la pression artérielle plus basse après une hémorragie intracérébrale ni trop vite ni trop bas.

Cerebrovascular Outcomes With Proton Pump Inhibitors and Thienopyridines: A Systematic Review and Meta-Analysis.
Malhotra K, Katsanos AH, Bilal M, Ishfaq MF, Goyal N, Tsivgoulis G. | Stroke. 2018 Feb;49(2):312-318
DOI: https://doi.org/10.1161/STROKEAHA.117.019166  | Télécharger l'article au format  
Keywords: ischemic stroke; myocardial infarction; pharmacovigilance; proton pump inhibitors; thienopyridines

Original Contributions

Introduction : Pharmacokinetic and prior studies on thienopyridine and proton pump inhibitors (PPI) coadministration provide conflicting data for cardiovascular outcomes, whereas there is no established evidence on the association of concomitant use of PPI and thienopyridines with adverse cerebrovascular outcomes.

Méthode : We conducted a systematic review and meta-analysis of randomized controlled trials and cohort studies from inception to July 2017, reporting following outcomes among patients treated with thienopyridine and PPI versus thienopyridine alone (1) ischemic stroke, (2) combined ischemic or hemorrhagic stroke, (3) composite outcome of stroke, myocardial infarction (MI), and cardiovascular death, (4) MI, (5) all-cause mortality, and (6) major or minor bleeding events. After the unadjusted analyses of risk ratios, we performed additional analyses of studies reporting hazard ratios adjusted for potential confounders.

Résultats : We identified 22 studies (12 randomized controlled trials and 10 cohort studies) comprising 131 714 patients. Concomitant use of PPI with thienopyridines was associated with increased risk of ischemic stroke (risk ratio, 1.74; 95% confidence interval [CI], 1.41-2.16; P<0.001), composite stroke/MI/cardiovascular death (risk ratio, 1.14; 95% CI, 1.01-1.29; P=0.04), and MI (risk ratio, 1.19; 95% CI, 1.00-1.40; P=0.05). Likewise, in adjusted analyses concomitant use of PPI with thienopyridines was again associated with increased risk of stroke (hazard ratios adjusted, 1.30; 95% CI, 1.04-1.61; P=0.02), composite stroke/MI/cardiovascular death (hazard ratios adjusted, 1.23; 95% CI, 1.03-1.47; P=0.02), but not with MI (hazard ratios adjusted, 1.19; 95% CI, 0.93-1.52; P=0.16).

Conclusion : Co-prescription of PPI and thienopyridines increases the risk of incident ischemic strokes and composite stroke/MI/cardiovascular death. Our findings corroborate the current guidelines for PPI deprescription and pharmacovigilance, especially in patients treated with thienopyridines.

Conclusion (proposition de traduction) : La co-prescription d'inhibiteurs de la pompe à protons et de thiénopyridines augmente le risque d'accidents vasculaires cérébraux ischémiques et d'accidents vasculaires cérébraux/IDM/décès cardiovasculaires.
Nos résultats corroborent les directives actuelles sur la déprescription et la pharmacovigilance des inhibiteurs de la pompe à protons, en particulier chez les patients traités par les thiénopyridines.

Association Between Hyperacute Stage Blood Pressure Variability and Outcome in Patients With Spontaneous Intracerebral Hemorrhage.
Chung PW, Chung PW, Kim JT, Sanossian N, Starkmann S, Hamilton S, Gornbein J, Conwit R, Eckstein M, Pratt F, Stratton S, Liebeskind DS, Saver JL; FAST-MAG Investigators and Coordinators. | Stroke. 2018 Feb;49(2):348-354
DOI: https://doi.org/10.1161/STROKEAHA.117.017701  | Télécharger l'article au format  
Keywords: blood pressure; cerebral hemorrhage; humans; odds ratio; stroke

Original Contributions

Introduction : Increased blood pressure (BP) variability, in addition to high BP, may contribute to adverse outcome in intracerebral hemorrhage. However, degree and association with outcome of BP variability (BPV) in the hyperacute period, 15 minutes to 5 hours after onset, have not been delineated.

Méthode : Among consecutive patients with intracerebral hemorrhage enrolled in the FAST-MAG trial (Field Administration of Stroke Therapy-Magnesium), BPs were recorded by paramedics in the field and during the first 24 hours of hospital course. BP was analyzed in the hyperacute period, from 0 to 4-6 hours, and in the acute period, from 0 to 24-26 hours after onset. BPV was analyzed by SD, coefficient of variation, and successive variation.

Résultats : Among 386 patients with intracerebral hemorrhage, first systolic BP at median 23 minutes (interquartile range, 14-38.5) after onset was median 176 mm Hg, second systolic BP on emergency department arrival at 57 minutes (interquartile range, 45-75) after onset was 178 mm Hg, and systolic BP 24 hours after arrival was 138 mm Hg. Unfavorable outcome at 3 months (modified Rankin Scale, 3-6) occurred in 270 (69.9%). Neither mean nor maximum systolic BP was associated with outcome in multivariable analysis. However, all 3 parameters of BPV, in both the hyperacute and the acute stages, were associated with poor outcome. In the hyperacute phase, BPV was associated with poor outcome with adjusted odds ratios of 3.73 for the highest quintile of SD, 4.78 for the highest quintile of coefficient of variation, and 3.39 for the highest quintile of successive variation.

Conclusion : BPV during the hyperacute first minutes and hours after onset in patients with intracerebral hemorrhage was independently associated with poor functional outcome. Stabilization of BPV during this vulnerable period, in the pre-hospital and early emergency department course, is a potential therapeutic target for future clinical trials.

Conclusion (proposition de traduction) : La variabilité de la pression artérielle au cours des premières minutes au stade suraigu et des heures après le début du traitement chez les patients présentant une hémorragie intracérébrale était indépendamment associée à un mauvais résultat fonctionnel.
La stabilisation de la variabilité de la pression artérielle au cours de cette période vulnérable, au cours des prises en charge préhospitalières et précoces, constitue une cible thérapeutique potentielle pour les futurs essais cliniques.

Periodontal Disease, Regular Dental Care Use, and Incident Ischemic Stroke.
Sen S, Giamberardino LD, Moss K, Morelli T, Rosamond WD, Gottesman RF, Beck J, Offenbacher S. | Stroke. 2018 Feb;49(2):355-362
DOI: https://doi.org/10.1161/STROKEAHA.117.018990  | Télécharger l'article au format  
Keywords: atherosclerosis; dental care; gingivitis; risk factors; stroke

Original contributions

Introduction : Periodontal disease is independently associated with cardiovascular disease. Identification of periodontal disease as a risk factor for incident ischemic stroke raises the possibility that regular dental care utilization may reduce the stroke risk.

Méthode : In the ARIC (Atherosclerosis Risk in Communities) study, pattern of dental visits were classified as regular or episodic dental care users. In the ancillary dental ARIC study, selected subjects from ARIC underwent fullmouth periodontal measurements collected at 6 sites per tooth and classified into 7 periodontal profile classes (PPCs).

Résultats : In the ARIC study 10 362 stroke-free participants, 584 participants had incident ischemic strokes over a 15-year period. In the dental ARIC study, 6736 dentate subjects were assessed for periodontal disease status using PPC with a total of 299 incident ischemic strokes over the 15-year period. The 7 levels of PPC showed a trend toward an increased stroke risk (χ2 trend P<0.0001); the incidence rate for ischemic stroke/1000-person years was 1.29 for PPC-A (health), 2.82 for PPC-B, 4.80 for PPC-C, 3.81 for PPC-D, 3.50 for PPC-E, 4.78 for PPC-F, and 5.03 for PPC-G (severe periodontal disease). Periodontal disease was significantly associated with cardioembolic (hazard ratio, 2.6; 95% confidence interval, 1.2-5.6) and thrombotic (hazard ratio, 2.2; 95% confidence interval, 1.3-3.8) stroke subtypes. Regular dental care utilization was associated with lower adjusted stroke risk (hazard ratio, 0.77; 95% confidence interval, 0.63-0.94).

Conclusion : We confirm an independent association between periodontal disease and incident stroke risk, particularly cardioembolic and thrombotic stroke subtype. Further, we report that regular dental care utilization may lower this risk for stroke.

Conclusion (proposition de traduction) : Nous confirmons une association indépendante entre la maladie parodontale et le risque d'accident vasculaire cérébral, en particulier le sous-type d'accident vasculaire cérébral cardioembolique et thrombotique.
De plus, nous signalons que l'utilisation régulière des soins dentaires peut réduire ce risque d'accident vasculaire cérébral.

STARTING-SICH Nomogram to Predict Symptomatic Intracerebral Hemorrhage After Intravenous Thrombolysis for Stroke.
Cappellari M, Turcato G, Forlivesi S, Zivelonghi C, Bovi P, Bonetti B, Toni D. | Stroke. 2018 Feb;49(2):397-404
DOI: https://doi.org/10.1161/STROKEAHA.117.018427  | Télécharger l'article au format  
Keywords: calibration; clopidogrel; hemorrhage; nomograms; stroke

Original contributions

Introduction : Symptomatic intracerebral hemorrhage (sICH) is a rare but the most feared complication of intravenous thrombolysis for ischemic stroke. We aimed to develop and validate a nomogram for individualized prediction of sICH in intravenous thrombolysis-treated stroke patients included in the multicenter SITS-ISTR (Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register).

Méthode : All patients registered in the SITS-ISTR by 179 Italian centers between May 2001 and March 2016 were originally included. The main outcome measure was sICH per the European Cooperative Acute Stroke Study II definition (any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline or death <7 days). On the basis of multivariate logistic model, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver-operating characteristic curve and calibration of risk prediction model by using the Hosmer-Lemeshow test.

Résultats : A total of 15 949 patients with complete data for generating the nomogram was randomly dichotomized into training (3/4; n=12 030) and test (1/4; n=3919) sets. After multivariate logistic regression, 10 variables remained independent predictors of sICH to compose the STARTING-SICH (systolic blood pressure, age, onset-to-treatment time for thrombolysis, National Institutes of Health Stroke Scale score, glucose, aspirin alone, aspirin plus clopidogrel, anticoagulant with INR ≤1.7, current infarction sign, hyperdense artery sign) nomogram. The area under the receiver-operating characteristic curve of STARTING-SICH was 0.739. Calibration was good (P=0.327 for the Hosmer-Lemeshow test).

Conclusion : The STARTING-SICH is the first nomogram developed and validated in a large SITS-ISTR cohort for individualized prediction of sICH in intravenous thrombolysis-treated stroke patients.

Conclusion (proposition de traduction) : Le STARTING-SICH est le premier nomogramme mis au point et validé dans une grande cohorte SITS-ISTR (Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register : Mise en œuvre sûre de la thrombolyse dans un AVC - Registre international sur la thrombolyse dans l'AVC) pour la prédiction individualisée de la survenue d'une hémorragie intracérébrale symptomatique chez les patients ayant subi un AVC traité par thrombolyse par voie intraveineuse.

Efficacy of corticosteroid treatment for severe community-acquired pneumonia: A meta-analysis.
Wu WF, Fang Q, He GJ. | Am J Emerg Med. 2018 Feb;36(2):179-184
DOI: https://doi.org/10.1016/j.ajem.2017.07.050
Keywords: Clinical trials; Community-acquired pneumonia; Corticosteroids

Original Contribution

Introduction : The benefits and adverse effects of corticosteroids in the treatment of severe community-acquired pneumonia (CAP) have not been well assessed. The aim of this systematic review of the literature and meta-analysis was to evaluate the clinical efficacy of adjuvant corticosteroid therapy in patients with severe CAP.

Méthode : The following databases were searched: PubMed, the Cochrane database, Embase, Wanfang, the China National Knowledge Infrastructure (CNKI), and the WeiPu (VIP) database in Chinese. Published randomized controlled clinical trial results were identified that compared corticosteroid therapy with conventional therapy for patients with severe CAP, up to November 2016. The relative risk (RR), weighted mean difference (WMD), and 95% confidence interval (CI) were evaluated. Statistical analysis was performed using STATA 10.0. The quality of the published studies was evaluated using the Oxford quality scoring system (Jadad scale).

Résultats : Ten randomized controlled trials (RCTs) were identified that included 729 patients with severe CAP. Data analysis showed that corticosteroid therapy did not have a statistically significant clinical effect in patients with severe CAP (RR: 1.19; 95% CI: 0.99-1.42), mechanical ventilation time (WMD: -2.30; 95% CI: -6.09-1.49). However, corticosteroids treatment was significantly associated with reduced in-hospital mortality (RR: 0.49; 95% CI: 0.29-0.85), reduced length of hospital stay (WMD: -4.21; 95% CI: -6.61 to -1.81).

Conclusion : Corticosteroids adjuvant therapy in patients with severe CAP may reduce the rate of in-hospital mortality, reduce the length of hospital stay, and reduce CRP levels.

Conclusion (proposition de traduction) : Le traitement adjuvant par corticostéroïdes chez les patients atteints d'une pneumopathie communautaire sévère peut réduire le taux de mortalité hospitalière, réduire la durée du séjour à l'hôpital et réduire les taux de CRP.

Integrating heart rate variability, vital signs, electrocardiogram, and troponin to triage chest pain patients in the ED.
Sakamoto JT, Liu N, Koh ZX, Guo D, Heldeweg MLA, Ng JCJ, Ong MEH. | Am J Emerg Med. 2018 Feb;36(2):185-192
DOI: https://doi.org/10.1016/j.ajem.2017.07.054
Keywords: Chest pain; Electrocardiogram; Emergency department; Heart rate variability; Triage

Original Contribution

Introduction : Current triage methods for chest pain patients typically utilize symptoms, electrocardiogram (ECG), and vital sign data, requiring interpretation by dedicated triage clinicians. In contrast, we aimed to create a quickly obtainable model integrating the objective parameters of heart rate variability (HRV), troponin, ECG, and vital signs to improve accuracy and efficiency of triage for chest pain patients in the emergency department (ED).

Méthode : Adult patients presenting to the ED with chest pain from September 2010 to July 2015 were conveniently recruited. The primary outcome was a composite of revascularization, death, cardiac arrest, cardiogenic shock, or lethal arrhythmia within 72-h of presentation to the ED. To create the chest pain triage (CPT) model, logistic regression was done where potential covariates comprised of vital signs, ECG parameters, troponin, and HRV measures. Current triage methods at our institution and modified early warning score (MEWS) were used as comparators.

Résultats : A total of 797 patients were included for final analysis of which 146 patients (18.3%) met the primary outcome. Patients were an average age of 60years old, 68% male, and 56% triaged to the most acute category. The model consisted of five parameters: pain score, ST-elevation, ST-depression, detrended fluctuation analysis (DFA) α1, and troponin. CPT model>0.09, CPT model>0.15, current triage methods, and MEWS≥2 had sensitivities of 86%, 74%, 75%, and 23%, respectively, and specificities of 45%, 71%, 48%, and 78%, respectively.

Conclusion : The CPT model may improve current clinical triage protocols for chest pain patients in the ED.

Conclusion (proposition de traduction) : Le modèle proposé peut améliorer les protocoles de triage cliniques actuels pour les patients souffrant de douleurs thoraciques aux urgences.

The occurrence of aspiration pneumonia after emergency endotracheal intubation.
Driver BE, Klein LR, Schick AL, Prekker ME, Reardon RF, Miner JR. | Am J Emerg Med. 2018 Feb;36(2):193-196
DOI: https://doi.org/10.1016/j.ajem.2017.07.066
Keywords: Aucun

Original Contribution

Introduction : Adverse events, including aspiration, occur during Emergency Department (ED) intubation, but their contemporary incidence is not well described. We sought to estimate the rate of aspiration pneumonia potentially related to emergency intubation.

Méthode : We conducted a prospective observational study of adult patients who were endotracheally intubated in the ED. Using a standard definition, we determined the proportion of patients who developed aspiration pneumonia after intubation. Aspiration pneumonia was defined as any of the following in patients without a diagnosis of community acquired pneumonia, healthcare-associated pneumonia, or aspiration prior to intubation: pathogenic growth in sputum culture, unexplained hypoxemia, or radiographic evidence of pneumonia in the first 48h after intubation. Baseline characteristics and intubation details were compared for those with and without aspiration pneumonia.

Résultats : 879 patients were enrolled over a 30-month period. Intubation was facilitated by video laryngoscopy (49%), direct laryngoscopy (45%), nasal intubation (4%), a intubating laryngeal mask airway (1%), and a surgical airway (0.1%). 85% were intubated on the first attempt, 12% on the second, 3% on the third or more attempts. 25% of patients experienced an oxygen saturation <90% during the intubation. After excluding patients not eligible for the outcome assessment (those who died within 48h without findings of pneumonia), 66/823 (8%) developed aspiration pneumonia potentially related to ED intubation. In comparing those with and without aspiration pneumonia, there were no differences between first intubation attempt parameters and the occurrence of aspiration pneumonia.

Conclusion : Aspiration pneumonia occurred commonly in this cohort. Although we did not identify any intubation factors that differed between those with and without with aspiration pneumonia, these findings should remind emergency physicians that emergency endotracheal intubation remains a high-risk procedure, and all care should be taken to minimize the risk of peri-intubation complications.

Conclusion (proposition de traduction) : La pneumonie d'inhalation est fréquente dans cette cohorte. Bien que nous n'ayons identifié aucun facteur d'intubation différent chez les patients avec ou sans pneumonie d'inhalation, ces résultats devraient rappeler aux urgentistes que l'intubation endotrachéale aux urgences demeure une procédure à haut risque et que tous les soins doivent être pris pour minimiser les risques de complications péri-intubation.

Effects of intravenous administration of fentanyl and lidocaine on hemodynamic responses following endotracheal intubation.
Hashemian AM, Zamani Moghadam Doloo H, Saadatfar M, Moallem R, Moradifar M, Faramarzi R, Sharifi MD. | Am J Emerg Med. 2018 Feb;36(2):197-201
DOI: https://doi.org/10.1016/j.ajem.2017.07.069
Keywords: Endotracheal intubation; Fentanyl; Hemodynamics; Lidocaine

Original Contribution

Introduction : To compare the effects of intravenous fentanyl and lidocaine on hemodynamic changes following endotracheal intubation in patients requiring Rapid Sequence Intubation (RSI) in the emergency department (ED).

Méthode : A single-centered, prospective, simple non-randomized, double-blind clinical trial was conducted on 96 patients who needed RSI in Edalatian ED. They were randomly divided into three groups (fentanyl group (F), lidocaine group (L), and fentanyl plus lidocaine (M) as our control group). M was administered with 3 μgr/kg intravenous fentanyl and 1.5 μgr/kg intravenous lidocaine, F was injected with 3g/kg intravenous fentanyl and L received 1.5mg/kg intravenous lidocaine prior to endotracheal intubation. Heart rate (HR) and mean arterial pressure (MAP) were assessed four times with the chi-square test: before, immediately after, 5 and 10 min after intubation. Intervention was discontinued for five people due to unsuccessful CPR.

Résultats : HR was notably different in F, L and M groups during four time courses (p<0.05). Comparison of MAP at measured points in all groups exhibited no significant difference (p>0.05). In fentanyl group both HR and MAP increased immediately after intubation, and significantly decreased 10 min after intubation (p<0.05).

Conclusion : Overall, the result of this study shows that lidocaine effectively prevents MAP and HR fluctuations following the endotracheal intubation. According to our findings, lidocaine or the combination of fentanyl and lidocaine are able to diminish hemodynamic changes and maintain the baseline conditions of the patient, thus could act more effectively than fentanyl alone.

Conclusion (proposition de traduction) : Dans l'ensemble, le résultat de cette étude montre que la lidocaïne prévient efficacement les fluctuations de pression artérielle moyenne et de rythme cardiaque après une intubation endotrachéale.
Selon nos résultats, la lidocaïne ou la combinaison de fentanyl et de lidocaïne sont capables de diminuer les modifications hémodynamiques et de maintenir les conditions de base du patient, ce qui pourrait agir plus efficacement que le fentanyl seul.

The effect of high-flow nasal cannula in reducing the mortality and the rate of endotracheal intubation when used before mechanical ventilation compared with conventional oxygen therapy and noninvasive positive pressure ventilation. A systematic review and meta-analysis.
Ni YN, Luo J, Yu H, Liu D, Liang BM, Liang ZA. | Am J Emerg Med. 2018 Feb;36(2):226-233
DOI: https://doi.org/10.1016/j.ajem.2017.07.083
Keywords: Endotracheal intubation; High flow nasal cannula; Meta-analysis; Mortality

Original contribution

Introduction : The effects of high flow nasal cannula (HFNC) on adult patients when used before mechanical ventilation (MV) are unclear. We aimed to determine the effectiveness of HFNC when used before MV by comparison to conventional oxygen therapy (COT) and noninvasive positive pressure ventilation (NIPPV).

Méthode : The Pubmed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all the controlled studies that compared HFNC with NIPPV and COT when used before MV in adult patients. The primary outcome was the rate of endotracheal intubation and the secondary outcomes were intensive care unit (ICU) mortality and length of ICU stay (ICU LOS).

Résultats : Eight trials with a total of 1084 patients were pooled in our final studies. No significant heterogeneity was found in outcome measures. Compared both with COT and NIPPV, HFNC could reduce both of the rate of endotracheal intubation (OR 0.62, 95% CI 0.38-0.99, P=0.05; OR 0.48, 95% CI 0.31-0.73, P=0.0006) and ICU mortality (OR 0.47, 95% CI 0.24-0.93, P=0.03; OR 0.36, 95% CI 0.20-0.63, P=0.0004). As for the ICU LOS, we did not find any advantage of HFNC over COT or NIPPV.

Conclusion : When used before MV, HFNC can improve the prognosis of patients compared both with the COT and NIPPV.

Conclusion (proposition de traduction) : Lorsqu'elle est utilisé avant la ventilation mécanique, l’oxygénothérapie à haut débit (HFNC) peut améliorer le pronostic des patients par rapport à l'oxygénothérapie conventionnelle et à la ventilation non-invasive (VNI).

Commentaire : HFNC, OHD, HFOT, NHF... de nombreux acronymes sont utilisés pour l’oxygénothérapie à haut débit, un laboratoire propose le moyen de le fournir : Optiflow™  

The effect of team-based CPR on outcomes in out of hospital cardiac arrest patients: A meta-analysis.
Kim S, Ahn KO, Jeong S. | Am J Emerg Med. 2018 Feb;36(2):248-252
DOI: https://doi.org/10.1016/j.ajem.2017.07.089
Keywords: Cardiopulmonary resuscitation; Out of hospital cardiac arrest; Team

Original contribution

Introduction : The objective of this systematic review and meta-analysis was to determine the effects of team cardiopulmonary resuscitation (CPR) on outcomes of patients with out-of-hospital cardiac arrest (OHCA).

Méthode : A systematic literature review was performed using PubMed, EMBASE, and the Cochrane database to identify relevant articles for this meta-analysis. All studies that described the implementation of team CPR performed by emergency medical services for OHCA patients with presumed cardiac etiology were included in this study. Outcomes included return of spontaneous circulation (ROSC), survival to hospital discharge, and good neurological recovery.

Résultats : A total of 2504 studies were reviewed. After excluding studies according to exclusion criteria, 4 studies with 15,455 OHCA patients were included in this study. The odds of survival and neurologic recovery for patients who received team CPR were higher than those for patients who did not (survival odds ratio [OR]: 1.68; 95% confidence interval [CI]: 1.48-1.91; neurologic recovery OR: 1.52; 95% CI: 1.31-1.77). There was no significant difference in the odds of ROSC between the two patient groups (OR: 1.59; 95% CI: 0.76-3.33).

Conclusion : In this meta-analysis, team CPR improved the outcomes of OHCA patients, consistently increasing their odds of survival to discharge and neurologic recovery.

Conclusion (proposition de traduction) : Dans cette méta-analyse, la pratique de la RCP en équipe a amélioré les résultats des patients en arrêt cardiaque extrahospitalier, augmentant constamment leurs chances de survie à la sortie et la récupération neurologique.

Prevalence of pulmonary embolism in patients presenting to the emergency department with syncope.
Frizell A, Fogel N, Steenblik J, Carlson M, Bledsoe J, Madsen T. | Am J Emerg Med. 2018 Feb;36(2):253-256
DOI: https://doi.org/10.1016/j.ajem.2017.07.090
Keywords: Aucun

Original contribution

Introduction : A recent study reported a high prevalence of pulmonary embolism (PE) among patients admitted with syncope. We sought to determine whether these findings were validated in our patient population.

Méthode : We performed a retrospective, secondary analysis of prospectively gathered data from patients presenting with syncope to an academic emergency department (ED) from July 2010 to December 2015. We analyzed baseline information from the time of the ED visit, recorded outcomes during the hospital stay, and contacted patients by phone at least 30days after the ED visit. The primary study outcome was the diagnosis of acute PE in the ED, during inpatient admission or ED observation unit stay, or by patient report over a 30-day follow-up period.

Résultats : Over the 5.5-year study period, 348 patients with syncope agreed to participate in the study. 52% of patients were female [95% confidence interval (CI): 46.6-57.4] and the average age was 48.4years. Of the enrolled patients, 50.1% (CI: 44.8-55.2) underwent further evaluation for syncope beyond the ED stay: 27% (CI: 22.6-31.9) of patients were admitted to an inpatient unit for further work-up and 23.9% (CI: 19.7-28.6) of patients were placed in the ED observation unit. The overall rate of PE among patients presenting to the ED with syncope was 1.4% (CI: 0.6-3.3%). 2 patients (0.6%, CI: 0.2-2.1) were diagnosed with a PE while in the ED. None of the patients were diagnosed with a PE during hospital admission or the observation stay associated with the index ED visit. 3 patients (0.9%, CI: 0.3-2.5) reported they had been diagnosed with a PE during the 30days following their ED visit, two of whom had been admitted to the hospital at the index ED visit but were not diagnosed with a PE at that time. All patients diagnosed with a PE at the time of the ED visit or during the follow-up period were Pulmonary Embolism Rule Out Criteria (PERC) positive and reported shortness of breath in the ED.

Conclusion : In contrast to a previous study, our findings do not support a high rate of PE among ED patients presenting with syncope.

Conclusion (proposition de traduction) : Contrairement à une étude précédente, nos résultats ne trouvent pas un taux élevé d'embolie pulmonaire parmi les patients se présentant aux urgences pour syncope.

Incidence and risk factors of delayed intracranial hemorrhage in the emergency department.
Kim B, Jeong H, Kim J, Kim T, Kim K, Lee H, Ahn S, Jo YH, Lee JH, Hwang JE. | Am J Emerg Med. 2018 Feb;36(2):271-276
DOI: https://doi.org/10.1016/j.ajem.2017.08.009
Keywords: Aucun

Original contribution

Introduction : This study was performed to identify the risk factors for delayed intracranial hemorrhage and develop a risk stratification system for disposition of head trauma patients with negative initial brain imaging.

Méthode : The data source was National Health Insurance Service-National Sample Cohort of Korea. We analyzed adult patients presenting to the ER from January 2004 to September 2012, who underwent brain imaging and discharged with or without short-term observation no longer than two days. The primary outcome was defined as any intracranial bleeding within a month defined by a new appearance of any of the diagnostic codes for intracranial hemorrhage accompanied by a new claim for brain imaging(s) within a month of the index visit. We performed a multivariable logistic regression analysis and built a parsimonious model for variable selection to develop a simple scoring system for risk stratification.

Résultats : During the study period, a total of 19,723 head injury cases were identified from the cohort and a total of 149 cases were identified as having delayed intracranial hemorrhage within 30days. In multivariable logistic regression model, old age, craniofacial fracture, neck injury, diabetes mellitus and hypertension were independent risk factors for delayed intracranial hemorrhage. We constructed the parsimonious model included age, craniofacial fracture and diabetes mellitus. The score showed area under the curve of 0.704 and positive predictive value of the score system was 0.014 when the score≥2.

Conclusion : We found old age, associated craniofacial fracture, any neck injury, diabetes mellitus and hypertension are the independent risk factors of delayed intracranial hemorrhage.

Conclusion (proposition de traduction) : Nous avons trouvé comme facteurs de risque indépendants de survenue d'un hémorragie intracrânienne retardée, l'âge élevé, une fracture craniofaciale associée, toute blessure du cou, un diabète sucré et une hypertension.

Syncope on presentation is a surrogate for submassive and massive acute pulmonary embolism.
Omar HR, Mirsaeidi M, Weinstock MB, Enten G, Mangar D, Camporesi EM. | Am J Emerg Med. 2018 Feb;36(2):297-300
DOI: https://doi.org/10.1016/j.ajem.2017.11.014
Keywords: Aucun

Brief Reports

Introduction : There are conflicting data regarding the prognostic value of syncope in patients with acute pulmonary embolism (APE).

Méthode : We retrospectively reviewed data of 552 consecutive adults with computed tomography pulmonary angiogram-confirmed APE to determine the correlates and outcome of the occurrence of syncope at the time of presentation.

Résultats : Among 552 subjects with APE (mean age 54years, 47% men), syncope occurred in 12.3% (68/552). Compared with subjects without syncope, those with syncope were more likely to have admission systolic blood pressure<90mmHg (odds ratio (OR) 5.788, P<0.001), and an oxygen saturation<88% on room air (OR 5.560, P<0.001), right ventricular dilation (OR 2.480, P=0.006), right ventricular hypokinesis (OR 2.288, P=0.018), require mechanical ventilation for respiratory failure (OR 3.152, P=0.014), and more likely to receive systemic thrombolysis (OR 4.722, P=0.008). On multivariate analysis, syncope on presentation was an independent predictor of a massive APE (OR 2.454, 95% CI 1.109-5.525, P=0.03) after adjusting for patients' age, sex, requirement of antibiotics throughout hospitalization, peak serum creatinine, admission oxygen saturation<88% and admission heart rate>100bpm. There was no difference in mortality in cases with APE with or without syncope (P=0.412).

Conclusion : Syncope at the onset of pulmonary embolization is a surrogate for submassive and massive APE but is not associated with higher in-hospital mortality.

Conclusion (proposition de traduction) : La constatation d'une syncope au début de l'apparition d'une embolisation pulmonaire est un signe d'embolie pulmonaire à risque de décès à court terme haut, intermédiaire ou faible, mais n'est pas associée à une mortalité hospitalière plus élevée.

Factors associated with imaging overuse in the emergency department: A systematic review.
Tung M, Sharma R, Hinson JS, Nothelle S, Pannikottu J, Segal JB. | Am J Emerg Med. 2018 Feb;36(2):301-309
DOI: https://doi.org/10.1016/j.ajem.2017.10.049
Keywords: Emergency department; Health care costs; Imaging; Overuse; Quality measurement

Reviews

Introduction : Emergency departments (ED) are sites of prevalent imaging overuse; however, determinants that drive imaging in this setting are not well-characterized. We systematically reviewed the literature to summarize the determinants of imaging overuse in the ED.

Méthode : We searched MEDLINE® and Embase® from January 1998 to March 2017. Studies were included if they were written in English, contained original data, pertained to a U.S. population, and identified a determinant associated with overuse of imaging in the ED.

Résultats : Twenty relevant studies were included. Fourteen evaluated computerized tomography (CT) scanning in patents presenting to a regional ED who were then transferred to a level 1 trauma center; incomplete transfer of data and poor image quality were the most frequently described reasons for repeat scanning. Unnecessary pre-transfer scanning or repeated scanning after transfer, in multiple studies, was highest among older patients, those with higher Injury Severity Scores (ISS) and those being transferred further. Six studies explored determinants of overused imaging in the ED in varied conditions, with overuse greater in older patients and those having more comorbid diseases. Defensive imaging reportedly influenced physician behavior. Less integration of services across the health system also predisposed to overuse of imaging.

Conclusion : The literature is heterogeneous with surprisingly few studies of determinants of imaging in minor head injury or of spine imaging. Older patient age and higher ISS were the most consistently associated with ED imaging overuse. This review highlights the need for precise definitions of overuse of imaging in the ED.

Conclusion (proposition de traduction) : La littérature est hétérogène et l'on trouve étonnamment peu d'études sur les indications de l'imagerie dans les traumatismes crâniens mineurs ou dans l'imagerie de la colonne vertébrale. L'âge des patients et un ISS (Injury Severity Scores) plus élevé étaient les plus systématiquement associés à la sur-utilisation de l'imagerie aux urgences.
Cette revue met en évidence le besoin de définitions précises de la sr-rutilisation de l'imagerie aux urgences.

The use of intranasal analgesia for acute pain control in the emergency department: A literature review.
Sin B, Wiafe J, Ciaramella C, Valdez L, Motov SM. | Am J Emerg Med. 2018 Feb;36(2):310-318
DOI: https://doi.org/10.1016/j.ajem.2017.11.043
Keywords: Aucun

Reviews

Introduction : Traditional routes for administration of pain medications include oral (PO), intravenous (IV), or intramuscular routes (IM). When these routes are not feasible, the intranasal (IN) route may be considered. The objectives of this evidence-based review were: to review the literature which compared the safety and efficacy of IN analgesia to traditional routes and to determine if IN analgesia should be considered over traditional routes for acute pain control in the ED.

Méthode : The MEDLINE and EMBASE databases from July 1970 to July 2017 were searched. Randomized controlled trials (RCT) that evaluated the use of IN analgesia for acute pain in the ED were included. Methodological quality of the trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation criteria.

Résultats : Eleven randomized controlled trials (RCT) met the inclusion criteria. Four trials found significant reductions in pain scores, favoring IN analgesia. However, in all of the trials, pain relief was not sustained. Three trials reported superior pain reduction with comparators and three trials reported no statistical significance. One trial described effective pain relief with IN analgesia but did not provide data on statistical analysis.

Conclusion : Eleven randomized controlled trials with various methodological flaws revealed conflicting conclusions. There is limited evidence to support the use of the IN analgesia over traditional routes for acute pain in the ED. The IN route may be a good alternative in scenarios where IV access is not feasible, patients are refusing injectable medications, or a fast onset of pain relief is needed.

Conclusion (proposition de traduction) : Onze études contrôlées randomisées avec des défauts méthodologiques différents ont montré des conclusions divergentes.
Il y a des preuves limitées pour proposer l'utilisation d’une analgésie intranasale par rapport aux modes d’administrations traditionnelles pour la douleur aiguë aux urgences. La voie nasale pour l'analgésie peut être une bonne alternative lorsque la voie IV n'est pas accessible, lorsque les patients refusent les injections, ou lorsqu’il est nécessaire de commencer rapidement à soulager la douleur.

Commentaire : L'utilisation de la voie nasale pour l'antalgie peut être particulièrement intéressante pour l'IAO pour soulager rapidement une douleur intense à l'arrivée du patient en secteur de tri (pas besoin de voie IV, rapidité de l'action antalgique, moindre morbidité par rapport à la pose d'une voie veineuse…). Reste à évaluer le coût de ces dispositifs.

Preventive effects of motorcycle helmets on intracranial injury and mortality from severe road traffic injuries.
Kim S, Ro YS, Shin SD, Song KJ, Hong KJ, Jeong J. | Am J Emerg Med. 2018 Feb;36(2):173-178
DOI: https://doi.org/10.1016/j.ajem.2017.07.044
Keywords: Accident prevention; Helmet; Intracranial injury; Mortality

Original Contribution

Introduction : Road traffic injuries caused by motorcycle crashes are one of the major public health burdens leading to high mortality, functional disability, and high medical costs. The helmet is crucial protective equipment for motorcyclists. This study aimed to measure the protective effect of motorcycle helmets on clinical outcomes and to compare the effects of high- and low-speed motorcycle crashes.

Méthode : A cross-sectional observational study was conducted using a nationwide registry of severe trauma patients treated by emergency medical services (EMS) providers in Korea. The study population consisted of severe trauma patients injured in motorcycle crashes between January and December 2013. The primary and secondary outcomes were intracranial injury and in-hospital mortality. We calculated adjusted odds ratios (AORs) of helmet use and motorcycle speeds for study outcomes after adjusting for potential confounders.

Résultats : Among 495 eligible patients, 105 (21.2%) patients were wearing helmets at the time of the crash, and 256 (51.7%) patients had intracranial injuries. The helmeted group was less likely to have an intracranial injury compared with the un-helmeted group (41.0% vs. 54.6%, AOR: 0.53 (0.33-0.84)). However, there was no significant difference in in-hospital mortality between the two groups (16.2% vs. 16.9%, AOR: 0.91 (0.49-1.69)). In the interaction analysis, there was a significant preventive effect of motorcycle helmet use on intracranial injury when the speed of the motorcycle was <30km/h (AOR: 0.50 (0.27-0.91)).

Conclusion : Wearing helmets for severe trauma patients in motorcycle crashes reduced intracranial injuries. The preventive effect on intracranial injury was significant in low-speed motorcycle crashes.

Conclusion (proposition de traduction) : Le port de casques chez les patients traumatisés sévères dans les accidents de moto réduit les blessures intracrâniennes. L'effet préventif sur les blessures intracrâniennes était plus significatif dans les accidents de motocyclette à basse vitesse.

Prognosticating Clinical Prediction Scores Without Clinical Gestalt for Patients With Chest Pain in the Emergency Department..
Wong CP, Lui CT, Sung JG, Lam H, Fung HT, Yam PW. | J Emerg Med. 2018 Feb;54(2):176-185
DOI: https://doi.org/10.1016/j.jemermed.2017.10.006
Keywords: acute coronary syndrome; chest pain; decision support techniques; myocardial infarction

Original Contributions

Introduction : Assessment of patients with chest pain is a regular challenge in the emergency department (ED). Recent guidelines recommended quantitative assessment of ischemic risk by means of risk scores.
OBJECTIVE: Our aim was to assess the performance of Thrombosis in Myocardial Infarction (TIMI); Global Registry of Acute Coronary Events (GRACE); history, electrocardiogram, age, risk factors, and troponin (HEART) scores; and the North America Chest Pain Rule (NACPR) without components of clinical gestalt in predicting 30-day major adverse cardiac events (MACE).

Méthode : We performed a prospective cohort study in adult patients who attended the ED with undifferentiated chest pain. Clinical prediction rules were applied and calculated. The clinical prediction rules were modified from the original ones, excluding components requiring judgment by clinical gestalt. The primary outcome was MACE. Performance of the tests were evaluated by receive operating characteristic curves and the area under curves (AUC).

Résultats : There were 1081 patients included in the study. Thirty-day MACE occurred in 164 (15.2%) patients. The AUC of the GRACE score was 0.756, which was inferior to the TIMI score (AUC 0.809) and the HEART score (AUC 0.845). A TIMI score ≥ 1 had a sensitivity of 97% and a specificity of 45.7%. A GRACE score ≥ 50 had a sensitivity of 99.4% and a specificity of 7.5%. A HEART score ≥ 1 had a sensitivity of 98.8% and a specificity of 11.7%. The NACPR had a sensitivity of 93.3% and a specificity of 51.5%.

Conclusion : Without clinical gestalt, the modified HEART score had the best discriminative capacity in predicting 30-day MACE.

Conclusion (proposition de traduction) : Dans les situation sans forme clinique typique, le score HEART modifié avait la meilleure capacité discriminante à prédire les événements cardiaques majeurs indésirables à 30 jours.

Alternative Treatment Options for Atrioventricular-Nodal-Reentry Tachycardia: An Emergency Medicine Review.
Brubaker S, Long B, Koyfman A. | J Emerg Med. 2018 Feb;54(2):198-206
DOI: https://doi.org/10.1016/j.jemermed.2017.10.003
Keywords: Valsalva; adenosine; atrioventricular-nodal-reentry tachycardia; beta-blocker; cardiology; dysrhythmia; nondihydropyridine calcium channel blocker; supraventricular tachycardia

Clinical Reviews

Introduction : Atrioventricular-nodal-reentry tachycardia (AVNRT) is a form of supraventricular tachycardia (SVT) that is relatively common in the emergency department (ED). It is rarely indicative of underlying electrical or structural pathology.

Méthode : This review evaluates the literature and controversies concerning treatment of AVNRT in the ED.

Discussion : For treatment of narrow-complex tachycardia, Advanced Cardiovascular Life Support guidelines recommend the use of vagal maneuvers, followed by adenosine. Recent literature suggests that nondihydropyridine calcium channel blockers, such as verapamil and diltiazem, may be as effective as adenosine, without the negative short-term side effects. Multiple studies have demonstrated that although adenosine is rapid acting, there is no statistically significant difference in conversion rate between adenosine and calcium channel blockers. Both medications result in a conversion rate above 90%, but there are significantly more minor adverse effects, such as flushing or chest discomfort, with adenosine. Calcium channel blockers are a viable option for treatment for AVNRT, especially in refractory states. Beta-blockers have been evaluated but should not be used routinely due to lower efficacy. AVNRT is the most common tachydysrhythmia in pregnancy, and vagal maneuvers and adenosine are first line. Electrical cardioversion should be utilized for hemodynamically unstable patients. Most patients with AVNRT may be discharged with appropriate follow-up.

Conclusion : Several studies demonstrate that nondihydropyridine calcium channels (verapamil and diltiazem) are equally as efficacious as adenosine in converting AVNRT to sinus rhythm, without the negative (albeit short-lived) side effects. If given over 20 min, the risk for hypotension is low.

Conclusion (proposition de traduction) : Plusieurs études démontrent que les inhibiteurs calciques de structure non dihydropyridinique (vérapamil et diltiazem) sont aussi efficaces que l'adénosine pour réduire une tachycardie supraventriculaire en rythme sinusal, sans les effets secondaires négatifs (bien que de courte durée) de l'adénosine.
Si l'inhibiteur calcique est administré en 20 minutes, le risque d'hypotension est faible.

Ultrasound for the Diagnosis and Management of Suspected Urolithiasis in the Emergency Department.
Mills L, Morley EJ, Soucy Z, Vilke GM, Lam SHF. | J Emerg Med. 2018 Feb;54(2):215-220
DOI: https://doi.org/10.1016/j.jemermed.2017.09.020
Keywords: emergency department; kidney calculi; systemic review; ultrasonography

Clinical Reviews

Introduction : This review provides practicing emergency physicians updated information regarding point-of-care ultrasound (POCUS) imaging of patients with suspected urolithiasis.

Méthode : A PubMed literature search was conducted for articles published between January 1, 1996 and May 31, 2017 and limited to human clinical trials written in English with relevant keywords. High-quality studies identified then underwent a structured review. Recommendations herein are made based on the literature review.

Résultats : Two hundred seventy-two abstracts fulfilling the search criteria were screened and 10 appropriate articles were rigorously reviewed in detail. There were 8 prospective studies and 2 retrospective studies. Only 1 of them was a multi-institutional randomized trial. POCUS performed in the emergency department (ED) is moderately sensitive and specific in making the diagnosis of urolithiasis in symptomatic patients. Suspected urolithiasis patients evaluated initially with ED POCUS have complication rates compatible with those evaluated initially with computed tomography.

Conclusion : POCUS has moderate accuracy in making the diagnosis of urolithiasis. Nevertheless, it may be safely used as a first line of imaging in ED patients with suspected symptomatic urolithiaisis.

Conclusion (proposition de traduction) : L'échographie au lit du malade a une précision modérée dans le diagnostic de la lithiase urinaire. Néanmoins, il peut être utilisé en toute sécurité comme première ligne d'imagerie chez les patients atteints d'une lithiase urinaire suspectée d'être symptomatique.

Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma study.
Ley EJ, Leonard SD, Barmparas G, Dhillon NK, Inaba K, Salim A, OʼBosky KR, Tatum D, Azmi H, Ball CG, Engels PT, Dunn JA, Carrick MM, Meizoso JP, Lombardo S, Cotton BA, Schroeppel TJ, Rizoli S, Chang DSJ, de León LA, Rezende-Neto J, Jacome T, Xiao J, Mallory G, Rao K, Widdel L, Godin S, Coates A, Benedict LA, Nirula R, Kaul S, Li T; Beta Blockers TBI Study Group Collaborators. | J Trauma Acute Care Surg. 2018 Feb;84(2):234-244
DOI: https://doi.org/10.1097/TA.0000000000001747
Keywords: Aucun

AAST 2017 Podium Paper

Introduction : Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers.

Méthode : The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration.

Résultats : From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p < 0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p < 0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p < 0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p < 0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003).

Conclusion : Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial.

Conclusion (proposition de traduction) : L'administration de bêta-bloquants après une lésion cérébrale traumatique était associée à une amélioration de la survie, avant et après ajustement pour les blessures les plus graves observées dans la cohorte de traitement.
Cette étude fournit une évaluation robuste des effets des bêta-bloquants sur les lésions traumatiques cérébrales, ce qui permet de lancer un essai clinique randomisé multi-institutionnel.

No intravenous access, no problem: Intraosseous administration of tranexamic acid is as effective as intravenous in a porcine hemorrhage model.
Lallemand MS, Moe DM, McClellan JM, Loughren M, Marko S, Eckert MJ, Martin MJ. | J Trauma Acute Care Surg. 2018 Feb;84(2):379-385
DOI: https://doi.org/10.1097/TA.0000000000001741
Keywords: Aucun

Original Articles

Introduction : The acute coagulopathy of trauma is often accompanied by hyperfibrinolysis. Tranexamic acid (TXA) can reverse this phenomenon, and, when given early, decreases mortality from bleeding. Establishing intravenous (IV) access can be difficult in trauma and intraosseous (IO) access is often preferred for drug administration. Currently, there are no data on the efficacy of IO administered TXA. Our objectives were to compare serum concentrations of TXA when given IV and IO and to compare the efficacy of IO administered TXA to IV at reversing hyperfibrinolysis.

Méthode : Using a porcine hemorrhage and ischemia-reperfusion model, 18 swine underwent hemorrhagic shock followed by a tissue plasminogen activator infusion to induce hyperfibrinolysis. Animals then received an IV or tibial IO infusion of TXA over 10 minutes. Blood was then analyzed using rotational thromboelastometry to monitor reversal of hyperfibrinolysis. Serum was analyzed for drug concentrations.

Résultats : After hemorrhage and ischemia-reperfusion, there were no significant differences in mean arterial pressure (48 vs. 49.5), lactate (11.1 vs. 10.8), and pH (7.20 vs. 7.22) between groups. Intraosseous TXA corrected the lysis index at 30 minutes in EX-TEM and IN-TEM, like IV infusion. Peak serum levels of TXA after IV and IO administration show concentrations of 160.9 μg/mL and 132.57 μg/mL respectively (p = 0.053). Peak levels occurred at the completion of infusion. Drug levels were tracked for four hours. At the end of monitoring, plasma concentrations of TXA were equivalent.

Conclusion : Intraosseous administration of TXA is as effective as IV in reversing hyperfibrinolysis in a porcine model of hemorrhagic shock. Intraosseous administration was associated with a similar peak levels, pharmacokinetics, and clearance. Intraosseous administration of TXA can be considered in hemorrhagic shock when IV access cannot be established.

Conclusion (proposition de traduction) : L'administration intra-osseuse d'acide tranexamique est aussi efficace que l'injection intraveineuse pour inverser l'hyperfibrinolyse dans un modèle porcin de choc hémorragique. L'administration intraosseuse était associée à des pics, pharmacocinétiques et clairances similaires.
L'administration intra-osseuse d'acide tranexamique peut être envisagée lors d'un choc hémorragique lorsque l'accès IV ne peut être mis en place.