Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism.
Kabrhel C, Van Hylckama Vlieg A, Muzikanski A, Singer A, Fermann GJ, Francis S, Lim Kakeng A, Chang AM, Giordano N, Parry B. | Acad Emerg Med. 2018 Mar 31
DOI: https://doi.org/10.1111/acem.13417
Keywords: D-dimer; Diagnosis; Emergency Department; Pulmonary Embolism; Venous Thromboembolism

Original article

Introduction : It may be possible to safely rule out pulmonary embolism (PE) in patients with low pre-test probability (PTP) using a higher than standard D-dimer threshold. The YEARS criteria, which includes three questions from the Wells PE Score to identify low PTP patients and a variable D-dimer threshold, was recently shown to decrease the need for imaging to rule out PE by 14% in a multicenter study in the Netherlands. However, the YEARS approach has not been studied in the United States.

Méthode : Prospective, observational study of consecutive adult patients evaluated for PE in 17 U.S. emergency departments. Prior to diagnostic testing, we collected the YEARS criteria:

Résultats : Of 1789 patients, 84 (4%) had PE, 1134 (63%) were female, 1038 (58%) were White and mean age was 48 years. Using the standard D-dimer threshold, 940 (53%) would not have had imaging, with 2 (0.2%, 95% CI: 0.02%, 0.60%

Conclusion : D-dimer adjustment based on pre-test probability may result in a reduced need for imaging to evaluate possible PE, with some additional

Conclusion (proposition de traduction) : L'ajustement des D-dimères en fonction de la probabilité clinique avant le test peut entraîner une diminution des besoins d'imagerie pour le diagnostic d'une suspicion d'EP, avec un taux d'embolie pulmonaire non diagnostiqué supplémentaire mais sans aucune diminution de la valeur prédictive négative.

Behavioral Changes in Children After Emergency Department Procedural Sedation.
Pearce JI, Brousseau DC, Yan K, Hainsworth KR, Hoffmann RG, Drendel AL. | Acad Emerg Med. 2018 Mar;25(3):267-274
DOI: https://doi.org/10.1111/acem.13332  | Télécharger l'article au format  
Keywords: Aucun

Original contributions

Introduction : The purpose of this study was to determine the proportion of children undergoing procedural sedation for fracture reduction in the emergency department (ED) observed to experience negative postdischarge behaviors. Predictors of negative behaviors were evaluated, including anxiety.

Méthode : This was a prospective cohort study of children receiving intravenous ketamine sedation for ED fracture reduction. The child's anxiety prior to sedation was measured with the Modified Yale Preoperative Anxiety Scale. Negative behavioral changes were measured with the Post-Hospitalization Behavior Questionnaire 1 to 2 weeks after discharge. Descriptive statistics and odds ratios (ORs) were calculated. Chi-square test was used for comparisons between groups. Multivariable logistic regression models evaluated predictors of negative behavioral change after discharge.

Résultats : Ninety-seven patients were enrolled; 82 (85%) completed follow-up. Overall, 33 (40%) children were observed to be highly anxious presedation and 18 (22%) had significant negative behavior changes after ED discharge. Independent predictors for negative behaviors were high anxiety (OR = 9.0, 95% confidence interval [CI] = 2.3-35.7) and nonwhite race (OR = 6.5, 95% CI = 1.7-25.0).

Conclusion : For children undergoing procedural sedation in the ED, two in five children have high preprocedure anxiety and almost one in four have significant negative behaviors 1 to 2 weeks after discharge. Highly anxious and nonwhite children have increased risk of negative behavioral changes that have not been previously recognized in the ED setting.

Conclusion (proposition de traduction) : Chez les enfants qui bénéficient d'une sédation procédurale aux urgences, deux enfants sur cinq avaient une anxiété pré-procédure élevée et près d'un sur quatre ont eu des comportements négatifs significatifs 1 à 2 semaines après la sortie.
Les enfants très anxieux et qui n'étaient pas de type européen ont un risque accru de changements comportementaux négatifs qui n'avaient pas été identifiés auparavant dans le cadre du Service des urgences.

Early Recurrence of First Unprovoked Seizures in Children.
Goldberg LR, Kernie CG, Lillis K, Bennett J, Conners G, Macias CG, Callahan J, Akman C, Allen Hauser W, Kuppermann N, Dayan PS. | Acad Emerg Med. 2018 Mar;25(3):275-282
DOI: https://doi.org/10.1111/acem.13341  | Télécharger l'article au format  
Keywords: Aucun

Original contributions

Introduction : The risk of early seizure recurrences after first unprovoked seizures in children is largely unknown. We aimed to determine the rate of seizure recurrence within 14 days of first unprovoked seizures in children and identify associated risk factors. Secondarily, we aimed to determine the risk of recurrence at 48 hours and 4 months.

Méthode : We conducted a secondary analysis of a multicenter cohort study of children 29 days to 18 years with first unprovoked seizures. Emergency department (ED) clinicians completed standardized histories and physical examinations. The primary outcome, recurrent seizure at 14 days, and the secondary outcomes, recurrence at 48 hours and 4 months, were assessed by telephone follow-up and medical record review. For each recurrence time point, we excluded those patients for whom no seizure had recurred but chronic antiepileptic drugs had been initiated.

Résultats : A total of 475 patients were enrolled in the parent study. Of evaluable patients for this secondary analysis, 26 of 392 (6.6%, 95% confidence interval [CI] = 4.4%-9.6%) had recurrences within 48 hours of the incident seizures, 58 of 366 (15.8%, 95% CI = 12.3%-20.0%) had recurrences within 14 days, and 107 of 340 (31.5%, 95% CI = 26.6%-36.7%) had recurrences within 4 months. On logistic regression analysis, age younger than 3 years was independently associated with a higher risk of 14-day recurrence (adjusted odds ratio [OR] = 2.1, 95% CI = 1.2-3.7; p = 0.01). Having had more than one seizure within the 24 hours prior to ED presentation was independently associated with a higher risk of seizure recurrence at 48 hours (adjusted OR = 4.3, 95% CI = 1.9-9.8; p < 0.001).

Conclusion : Risk of seizure recurrence 14 days after first unprovoked seizures in children is substantial, with younger children at higher risk. Prompt completion of an electroencephalogram and evaluation by a neurologist is appropriate for these children.

Conclusion (proposition de traduction) : Le risque de récidive de convulsions 14 jours après la première crises convulsive non fébriles chez les enfants est important, avec les plus jeunes enfants à risque plus élevé. La réalisation rapide d'un électroencéphalogramme et l'évaluation par un neurologue est nécessaire pour ces enfants.

Commentaire : Etude observationnelle multicentrique ayant inclue 475 enfants. Le risque de récidive est majoré pour les plus jeunes.

Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children.
Sills MR, Macy ML, Kocher KE, Sabbatini AK. | Acad Emerg Med. 2018 Mar;25(3):283-292
DOI: https://doi.org/10.1111/acem.13324
Keywords: Aucun

Original contribution

Introduction : The objective was to test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit.

Méthode : This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as "ED return admissions" (discharged at ED index visit and admitted at return visit) or "readmissions" (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to "index admissions without return admission" (admitted at ED index visit without 7-day return visit admission).

Résultats : Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = -$193; 95% CI = -$479 to $93) compared to index admissions without return admission.

Conclusion : Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.

Conclusion (proposition de traduction) : Comparativement aux enfants consultant initialement, les enfants ré-admis avaient une sévérité moindre et un coût similaire, ce qui suggère que les ré-admissions aux Service des urgences n'entraînent pas de plus mauvais résultats que les consultant initiaux.

Commentaire : Les publications jusqu'à présent allaient plutôt dans le sens contraire !?

Impact of a Shared Decision Making Intervention on Health Care Utilization: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial.
Schaffer JT, Hess EP, Hollander JE, Kline JA, Torres CA, Diercks DB, Jones R, Owen KP, Meisel ZF, Demers M, Leblanc A, Inselman J, Herrin J, Montori VM, Shah ND. | Acad Emerg Med. 2018 Mar;25(3):293-300
DOI: https://doi.org/10.1111/acem.13355
Keywords: Aucun

Original contributions

Introduction : Patients at low risk for acute coronary syndrome are frequently admitted for observation and cardiac testing, resulting in substantial burden and cost to the patient and the health care system.
OBJECTIVES: The purpose of this investigation was to measure the effect of the Chest Pain Choice (CPC) decision aid on overall health care utilization as well as utilization of specific services both during the index emergency department (ED) visit and in the subsequent 45 days.

Méthode : This was a planned secondary analysis of data from a pragmatic multicenter randomized trial of shared decision making in adults presenting to the ED with chest pain who were being considered for observation unit admission for cardiac stress testing or coronary computed tomography angiography. The trial compared an intervention group engaged in shared decision making facilitated by the CPC decision aid to a control group receiving usual care. Hospital-level billing data were used to measure utilization for the index ED visit and during the following 45 days. Patients in both groups also were asked to keep a diary recording health care utilization over the same 45-day period. Outcomes assessed included length of time in the ED and observation, ED visits, office visits, hospitalizations, testing, imaging, and procedures.

Résultats : Of the 898 patients included in the original trial, we were able to contact 834 (92.9%) patients for 45-day health care diary review. There was no difference in patient-reported health care utilization between the study arms. Hospital-level billing data were obtained for all 898 (100%) patients. During the initial ED visit the length of stay (LOS) was similar, and there was no difference in the frequency of observation unit admission between study arms. However, the mean observation unit LOS was 95 minutes (95% confidence interval [CI] = 40.8-149.8) shorter in the CPC arm and the mean number of tests was lower in the CPC arm (decrease in 19.4 imaging studies per 100 patients, 95% CI = 15.5-23.3). When evaluating the entire encounter and follow-up period, the intervention arm underwent fewer tests (decrease in 125.6 tests per 100 patients, 95% CI = 29.3-221.6). More specifically, there were fewer advanced cardiac imaging tests completed (25.8 fewer per 100 patients, 95% CI = 3.74-47.9) in the intervention arm.

Conclusion : Shared decision making in low-risk chest pain can lead to decreased diagnostic testing without worsening outcomes measured over 45 days.

Conclusion (proposition de traduction) : La prise de décision partagée en cas de douleur thoracique à faible risque peut entraîner une diminution des tests de diagnostic sans aggravation des résultats mesurés sur 45 jours.

Commentaire :  Pain Choice Multicenter Randomized Trial. Trials. 2014 May 10;15:166  

Fluid Resuscitation in Patients With Severe Burns: A Meta-analysis of Randomized Controlled Trials.
Kao Y, Loh EW, Hsu CC, Lin HJ, Huang CC, Chou YY, Lien CC, Tam KW. | Acad Emerg Med. 2018 Mar;25(3):320-329
DOI: https://doi.org/10.1111/acem.13333
Keywords: Aucun

Original Contribution

Introduction : Fluid resuscitation is the mainstay treatment to reconstitute intravascular volume and maintain end-organ perfusion in patients with severe burns. The use of a hyperosmotic or isoosmotic solution in fluid resuscitation to manage myocardial depression and increased capillary permeability during burn shock has been debated. We conducted a systematic review and meta-analysis to compare the efficacies of hyperosmotic and isoosmotic solutions in restoring hemodynamic stability after burn injuries.

Méthode : PubMed, Embase, Cochrane Library, Scopus, and ClinicalTrials.gov registry were searched. Randomized control trials evaluating the efficacy and safety of hyperosmotic and isoosmotic fluid resuscitation in patients with burn injuries were selected. Eligible trials were abstracted and assessed for the risk of bias by two reviewers and results of hemodynamic indicators in the included trials were analyzed.

Résultats : Ten trials including 502 participants were published between 1983 and 2013. Compared with isoosmotic group, the hyperosmotic group exhibited a significant decrease in the fluid load (vol/% total body surface area [TBSA]/weight) at 24 hours postinjury, with a mean difference of -0.54 (95% confidence interval = -0.92 to -0.17). No differences were observed in the urine output, creatinine level, and mortality at 24 hours postinjury between groups.

Conclusion : Hyperosmotic fluid resuscitation appears to be an attractive choice for severe burns in terms of TBSA or burn depth. Further investigation is recommended before conclusive recommendation.

Conclusion (proposition de traduction) : La réanimation liquidienne hyperosmotique semble être un choix intéressant pour les brûlures sévères en fonction de la surface brûlée ou de la profondeur de la brûlure.
Une étude plus approfondie est recommandée avant la publication d'une recommandation.

Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial.
Zahed R, Mousavi Jazayeri MH, Naderi A, Naderpour Z, Saeedi M. | Acad Emerg Med. 2018 Mar;25(3):261-266
DOI: https://doi.org/10.1111/acem.13345  | Télécharger l'article au format  
Keywords: Aucun

Editor's pick

Introduction : We evaluated the efficacy of topical application of the injectable form of tranexamic acid (TXA) compared with anterior nasal packing (ANP) for the treatment of epistaxis in patients taking antiplatelet drugs (aspirin, clopidogrel, or both) who presented to the emergency department (ED).

Méthode : A randomized, parallel-group clinical trial was conducted at two EDs. A total of 124 participants were randomized to receive topical TXA (500 mg in 5 mL) or ANP, 62 patients per group. The primary outcome was the proportion of patients in each group whose bleeding had stopped at 10 minutes. Secondary outcomes were the rebleeding rate at 24 hours and 1 week, ED length of stay (LOS), and patient satisfaction.

Résultats : Within 10 minutes of treatment, bleeding was stopped in 73% of the patients in the TXA group, compared with 29% in the ANP group (difference = 44%, 95% confidence interval, 26% to 57%; p < 0.001). Additionally, rebleeding was reported in 5 and 10% of patients during the first 24 hours in the TXA and the ANP groups, respectively. At 1 week, 5% of patients in the TXA group and 21% of patients in the ANP group had experienced recurrent bleeding (p = 0.007). Patients in the TXA group reported higher satisfaction scores (median [interquartile range {IQR}], 9 [8-9.25]) compared with the ANP group (median [IQR] = 4 [3-5]; p < 0.001). Discharge from the ED in <2 hours was achieved in 97% of patients in the TXA group versus 13% in the ANP group (p < 0.001). There were no adverse events reported in either group.

Conclusion : In our study population, epistaxis treatment with topical application of TXA resulted in faster bleeding cessation, less rebleeding at 1 week, shorter ED LOS, and higher patient satisfaction compared with ANP.

Conclusion (proposition de traduction) : Dans notre étude, le traitement d’une épistaxis par application topique d'acide tranexamique a entraîné un arrêt plus rapide des saignements, moins de récidive à 1 semaine, une durée d'hospitalisation plus courte et une plus grande satisfaction des patients par rapport au méchage nasal antérieur.

Commentaire : Résultats intéressants, surtout au vue de l'inconfort de la pose et du maintien du méchage nasal antérieur.

Cardiac Arrest in the Operating Room: Part 2-Special Situations in the Perioperative Period.
McEvoy MD, Thies KC, Einav S, Ruetzler K, Moitra VK, Nunnally ME, Banerjee A, Weinberg G, Gabrielli A, Maccioli GA, Dobson G, O'Connor MF. | Anesth Analg. 2018 Mar;126(3):889-903
DOI: https://doi.org/10.1213/ANE.0000000000002595
Keywords: Aucun

Narrative Review Article

Editorial : As noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer-providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes.

Conclusion : The causes, logistics, and management of periprocedural crises and arrest differ substantially from those taught in the American Heart Association ACLS guidelines. Furthermore, current evidence illustrates the need for educational updates on concerning PPCA among the anesthesiology community, including review of current evidence, use of checklists, and simulation. The purpose of this review is to present the latest evidence and practical recommendations for managing 7 high-stakes perioperative events that can lead to significant circulatory disturbance and PPCA. These are core topics for all practitioners who care for patients in the periprocedural setting, but they by no means represent an exhaustive list of emergency conditions. It is incumbent upon all anesthesiologists to have a working knowledge of these clinical scenario and understanding of the current therapeutic options to maximize patient outcomes.

Conclusion (proposition de traduction) : Les causes, la logistique et la prise en charge des situations de détresses et des arrêts cardiaques péri-opératoires diffèrent considérablement de celles proposées dans les directives sur la réanimation cardio-pulmonaire avancée proposée par l'American Heart Association. De plus, on peut dégager des données actuelles, la nécessité de mises à jour concernant la formation de l'arrêt cardiaque péri-opératoire au sein de la communauté des anesthésistes, y compris l'examen des données probantes actualisées, l'utilisation de listes de vérification (checklists) et la simulation.
Le but de cette revue est de présenter les dernières preuves et les recommandations pratiques pour la prise en charge de 7 événements péri-opératoires à enjeux élevés pouvant entraîner des détresses circulatoires importantes ou un arrêt cardiaque péri-opératoire. Ce sont des sujets de base pour tous les praticiens qui prennent en charge des patients dans le cadre péri-anesthésique, mais ils ne représentent en aucun cas une liste exhaustive des conditions en urgence. Il incombe à tous les anesthésistes d'avoir une connaissance pratique de ces scénarios cliniques et de comprendre les options thérapeutiques actuelles afin de maximiser les résultats pour les patients.

Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1.
Moitra VK, Einav S, Thies KC, Nunnally ME, Gabrielli A, Maccioli GA, Weinberg G, Banerjee A, Ruetzler K, Dobson G, McEvoy MD, O'Connor MF. | Anesth Analg. 2018 Mar;126(3):876-888
DOI: https://doi.org/10.1213/ANE.0000000000002596
Keywords: Aucun

Narrative Review Article

Editorial : Cardiac arrest in the operating room and procedural areas has a different spectrum of causes (ie, hypovolemia, gas embolism, and hyperkalemia), and rapid and appropriate evaluation and management of these causes require modification of traditional cardiac arrest algorithms. There is a small but growing body of literature describing the incidence, causes, treatments, and outcomes of circulatory crisis and perioperative cardiac arrest. These events are almost always witnessed, frequently known, and involve rescuer providers with knowledge of the patient and their procedure. In this setting, there can be formulation of a differential diagnosis and a directed intervention that treats the likely underlying cause(s) of the crisis while concurrently managing the crisis itself. Management of cardiac arrest of the perioperative patient is predicated on expert opinion, physiologic rationale, and an understanding of the context in which these events occur. Resuscitation algorithms should consider the evaluation and management of these causes of crisis in the perioperative setting.

Conclusion : Cardiac arrest in the periprocedural setting is rarer than previously believed, and it arises from unique causes specific to the operating room or procedural environment. Circulatory crisis and cardiac arrest in this setting are usually managed by practitioners who are familiar with the patient, knowledgeable of the patient’s medical condition, and familiar with the details of their procedure, which allows them to intervene in a directed, effective, and timely manner. Management of perioperative crisis is predicated on expert opinion and an understanding of a distinct physiologic milieu.

Conclusion (proposition de traduction) : L'arrêt cardiaque dans le contexte péri-opératoire est plus rare qu'on ne le croyait auparavant, et il résulte de causes uniques spécifiques à la salle d'opération ou à l'environnement procédural. Les détresses circulatoires et les arrêts cardiaques dans ce contexte sont généralement gérés par des praticiens familiers avec le patient, connaissant l'état de santé du patient et connaissant les détails de leur procédure, ce qui leur permet d'intervenir de manière ciblée, efficace et opportune. La gestion de crise périopératoire repose sur l'opinion d'experts et la compréhension d'un milieu physiologique distinct.

Targeted Temperature Management After Cardiac Arrest: Systematic Review and Meta-analyses.
Kalra R, Arora G, Patel N, Doshi R, Berra L, Arora P, Bajaj NS. | Anesth Analg. 2018 Mar;126(3):867-875
DOI: https://doi.org/10.1213/ANE.0000000000002646
Keywords: Aucun

Critical Care and Resuscitation

Introduction : Targeted temperature management (TTM) with therapeutic hypothermia is an integral component of postarrest care for survivors. However, recent randomized controlled trials (RCTs) have failed to demonstrate the benefit of TTM on clinical outcomes. We sought to determine if the pooled data from available RCTs support the use of prehospital and/or in-hospital TTM after cardiac arrest.

Méthode : A comprehensive search of SCOPUS, Elsevier's abstract and citation database of peer-reviewed literature, from 1966 to November 2016 was performed using predefined criteria. Therapeutic hypothermia was defined as any strategy that aimed to cool post-cardiac arrest survivors to a temperature ≤34°C. Normothermia was temperature of ≥36°C. We compared mortality and neurologic outcomes in patients by categorizing the studies into 2 groups: (1) hypothermia versus normothermia and (2) prehospital hypothermia versus in-hospital hypothermia using standard meta-analytic methods. A random effects modeling was utilized to estimate comparative risk ratios (RR) and 95% confidence intervals (CIs).

Résultats : The hypothermia and normothermia strategies were compared in 5 RCTs with 1389 patients, whereas prehospital hypothermia and in-hospital hypothermia were compared in 6 RCTs with 3393 patients. We observed no difference in mortality (RR, 0.88; 95% CI, 0.73-1.05) or neurologic outcomes (RR, 1.26; 95% CI, 0.92-1.72) between the hypothermia and normothermia strategies. Similarly, no difference was observed in mortality (RR, 1.00; 95% CI, 0.97-1.03) or neurologic outcome (RR, 0.96; 95% CI, 0.85-1.08) between the prehospital hypothermia versus in-hospital hypothermia strategies.

Conclusion : Our results suggest that TTM with therapeutic hypothermia may not improve mortality or neurologic outcomes in postarrest survivors. Using therapeutic hypothermia as a standard of care strategy of postarrest care in survivors may need to be reevaluated.

Conclusion (proposition de traduction) : Nos résultats suggèrent que la gestion ciblée de la température avec hypothermie thérapeutique n'améliore pas la mortalité ou les résultats neurologiques chez les survivants après un arrêt cardiaque. L'utilisation de l'hypothermie thérapeutique comme stratégie standard de soins après un arrêt cardiaque chez les survivants nécessiterait d'être réévaluée.

Does Lactate Affect the Association of Early Hyperglycemia and Multiple Organ Failure in Severely Injured Blunt Trauma Patients?.
Richards JE, Scalea TM, Mazzeffi MA, Rock P, Galvagno SM Jr. | Anesth Analg. 2018 Mar;126(3):904-910
DOI: https://doi.org/10.1213/ANE.0000000000002626
Keywords: Aucun

Original Clinical Research Report

Introduction : Early hyperglycemia is associated with multiple organ failure (MOF) after traumatic injury; however, few studies have considered the contribution of depth of clinical shock. We hypothesize that when considered simultaneously, glucose and lactate are associated with MOF in severely injured blunt trauma patients.

Méthode : We performed a retrospective investigation at a single tertiary care trauma center. Inclusion criteria were patient age ≥18 years, injury severity score (ISS) >15, blunt mechanism of injury, and an intensive care unit length of stay >48 hours. Patients with a history of diabetes or who did not survive the initial 48 hours were excluded. Demographics, injury severity, and physiologic data were recorded. Blood glucose and lactate values were collected from admission through the initial 24 hours of hospitalization. Multiple metrics of glucose and lactate were calculated: the first glucose (Glucadm, mg/dL) and lactate (Lacadm, mmol/L) at hospital admission, the mean initial 24-hour glucose (Gluc24hMean, mg/dL) and lactate (Lac24hMean, mmol/L), and the time-weighted initial 24-hour glucose (Gluc24hTW) and lactate (Lac24hTW). These metrics were divided into quartiles. The primary outcome was MOF. Separate Cox proportional hazard models were generated to assess the association of each individual glucose and lactate metric on MOF, after controlling for ISS, admission shock index, and disposition to the operating room after hospital admission. We assessed the interaction between glucose and lactate metrics in the multivariable models. Results are reported as hazard ratios (HRs) for an increase in the quartile level of glucose and lactate measurements, with 95% confidence intervals (CIs).

Résultats : A total of 507 severely injured blunt trauma patients were evaluated. MOF occurred in 46 of 507 (9.1%) patients and was associated with a greater median ISS (33.5, interquartile range [IQR]: 22-41 vs 27, IQR: 21-34; P < .001) and a greater median admission shock index (0.82, IQR: 0.68-1.1 vs 0.73, IQR: 0.60-0.91; P = .02). Patients who were transferred to the operating room after the initial trauma resuscitation were also more likely to develop MOF (20 of 119, 14.4% vs 26 of 369, 7.1%; P = .01). Three separate Cox proportional regression models demonstrated the following HR for an increase in the individual glucose metric quartile and MOF, while controlling for confounding variables: Glucadm HR: 1.35, 95% CI, 1.02-1.80; Gluc24hMean HR: 1.63, 95% CI, 1.14-2.32; Gluc24hTW HR: 1.14, 95% CI, 0.86-1.50. Three separate Cox proportional hazards models also demonstrated the following HR for each individual lactate metric quartile while controlling for the same confounders, with MOF again representing the dependent variable: Lacadm HR: 1.94, 95% CI, 1.38-2.96; Lac24hMean HR: 1.68, 95% CI, 1.22-2.31; Lac24hTW HR: 1.49, 95% CI, 1.10-2.02. When metrics of both glucose and lactate were entered into the same model only lactate remained significantly associated with MOF: Lacadm HR: 1.86, 95% CI, 1.29-2.69, Lac24hMean HR: 1.54, 95% CI, 1.11-2.12, and Lac24hTW HR: 1.48, 95% CI, 1.08-2.01. There was no significant interaction between lactate and glucose variables in relation to the primary outcome.

Conclusion : When glucose and lactate are considered simultaneously, only lactate remained significantly associated with MOF in severely injured blunt trauma patients.

Conclusion (proposition de traduction) : Lorsque le glucose et le lactate sont analysés simultanément, seul le lactate reste significativement associé au syndrome de défaillance multiviscérale chez les patients avec traumatismes fermés sévères.

Evaluation of the Augmented Infant Resuscitator: A Monitoring Device for Neonatal Bag-Valve-Mask Resuscitation.
Bennett DJ, Itagaki T, Chenelle CT, Bittner EA, Kacmarek RM. | Anesth Analg. 2018 Mar;126(3):947-955
DOI: https://doi.org/10.1213/ANE.0000000000002432
Keywords: Aucun

Original Laboratory Research Report

Introduction : Annually, 6 million newborns require bag-valve-mask resuscitation, and providing live feedback has the potential to improve the quality of resuscitation. The Augmented Infant Resuscitator (AIR), a real-time feedback device, has been designed to identify leaks, obstructions, and inappropriate breath rates during bag-valve-mask resuscitation. However, its function has not been evaluated.

Méthode : The resistance of the AIR was measured by attaching it between a ventilator and a ventilator tester. To test the device's reliability in training and clinical-use settings, it was placed in-line between a ventilation bag or ventilator and a neonatal manikin and a clinical lung model simulator. The lung model simulator simulated neonates of 3 sizes (2, 4, and 6 kg). Leaks, obstructions, and respiratory rate alterations were introduced.

Résultats : At a flow of 5 L/min, the pressure drop across the AIR was only 0.38 cm H2O, and the device had almost no effect on ventilator breath parameters. During the manikin trials, it was able to detect all leaks and obstructions, correctly displaying an alarm 100% of the time. During the simulated clinical trials, the AIR performed best on the 6-kg neonatal model, followed by the 4-kg model, and finally the 2-kg model. Over all 3 clinical models, the prototype displayed the correct indicator 73.5% of the time, and when doing so, took 1.6 ± 0.9 seconds.

Conclusion : The AIR is a promising innovation that has the potential to improve neonatal resuscitation. It introduces only marginal resistance and performs well on neonatal manikins, but its firmware should be improved before clinical use.

Conclusion (proposition de traduction) : L'insufflateur néonatal amélioré (AIR) est une innovation prometteuse qui a le potentiel d'améliorer la réanimation néonatale. Il présente seulement une résistance marginale et fonctionne bien sur les mannequins néonatals, mais son progiciel doit être amélioré avant l'utilisation clinique.

Respiratory Gas Analysis-Technical Aspects.
Jaffe MB | Anesth Analg. 2018 Mar;126(3):839-845
DOI: https://doi.org/10.1213/ANE.0000000000002384
Keywords: Aucun

Systematic Review Article

Editorial : A technology-focused review of respiratory gas analysis, with an emphasis on carbon dioxide analysis, is presented. The measurement technologies deployed commercially are highlighted, and the basic principles and technical concerns of infrared spectroscopy and mainstream versus sidestream gas sampling are discussed. The specifications of particular interest to the clinician, accuracy and response time, and the related standard, with typical values for a capnometer, are presented. Representative time and volumetric capnograms are shown with the clinically relevant parameters described. Aspects of the terminology in present-day use and the need for clarity in defining what is a breath and an end-tidal value are reviewed. The applications of capnography of particular interest to the anesthesiologist are noted, and key references are provided. Ongoing developments with respect to respiratory gas analysis, and those that will impact it, are noted.

Conclusion : -

Macintosh Blade Videolaryngoscopy Combined With Rigid Bonfils Intubation Endoscope Offers a Suitable Alternative for Patients With Difficult Airways.
Pieters BM, Theunissen M, van Zundert AA. | Anesth Analg. 2018 Mar;126(3):988-994
DOI: https://doi.org/10.1213/ANE.0000000000002739
Keywords: Aucun

Original Clinical Research Report

Introduction : In the armamentarium of an anesthesiologist, videolaryngoscopy is a valuable addition to secure the airway. However, when the videolaryngoscope (VLS) offers no solution, few options remain. Earlier, we presented an intubation technique combining Macintosh blade VLS and Bonfils intubation endoscope (BIE) for a patient with a history of very difficult intubation. In the present study, we evaluated this technique to establish whether it is a valuable alternative.

Méthode : In this single-blinded nonrandomized study, 38 patients with a history of difficult intubation or 1 or more predictors of difficult intubation, scoring a Cormack & Lehane (C&L) grade III or IV using Macintosh blade VLS, were included. Patients were intubated combining the VLS with the BIE. The C&L grade was scored 3 times during (1) direct laryngoscopy; (2) indirect videolaryngoscopy; and (3) using the combined technique (VLS + BIE). Afterward, 2 blinded anesthesiologists assessed the C&L grade using the pictures taken during the procedure.

Résultats : Data of 38 patients were analyzed. An improvement of the C&L grade with the combined technique occurred in 33 of 38 patients (86.8%; 95% confidence interval, 71.9%-95.6%). Reviewer 1 reported an improvement of the C&L grade with the combined technique in 37 of 38 patients. Reviewer 2 reported improvement in 33 and deterioration in 2 of the patients. No complications occurred.

Conclusion : The combined use of a VLS with Macintosh blade and BIE gives the anesthesiologist a valuable alternative intubation option in patients with extremely difficult airways.

Conclusion (proposition de traduction) : L'utilisation combinée d'un videolaryngoscope avec lame de Macintosh et d'un endoscope d'intubation à mandrin rigide donne à l'anesthésiste une alternative d'intubation alternative intéressante chez les patients ayant des voies respiratoires extrêmement difficiles à intuber.

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018.
[No authors listed], A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. | Anesthesiology. 2018 Mar;128(3):437-479
DOI: https://doi.org/10.1097/ALN.0000000000002043  | Télécharger l'article au format  
Keywords: Aucun

Practice Parameter

Conclusion : This document replaces the “Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: An Updated Report by the American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia by Non-Anesthesiologists,” adopted in 2001 and published in 2002.

Conclusion (proposition de traduction) : Ce document remplace les « Recommandations pour la pratique de la sédation et de l'analgésie par les non-anesthésiologistes : rapport mis à jour par le groupe de travail sur la sédation et l'analgésie par des non-anesthésiologistes de l'American Society of Anesthesiologists :», adopté en 2001 et publié en 2002

Temporal Trends in Difficult and Failed Tracheal Intubation in a Regional Community Anesthetic Practice.
Schroeder RA, Pollard R, Dhakal I, Cooter M, Aronson S, Grichnik K, Buhrman W, Kertai MD, Mathew JP, Stafford-Smith M. | Anesthesiology. 2018 Mar;128(3):502-510
DOI: https://doi.org/10.1097/ALN.0000000000001974  | Télécharger l'article au format  
Keywords: Aucun

Clinical Science

Introduction : When tracheal intubation is difficult or unachievable before surgery or during an emergent resuscitation, this is a critical safety event. Consensus algorithms and airway devices have been introduced in hopes of reducing such occurrences. However, evidence of improved safety in clinical practice related to their introduction is lacking. Therefore, we selected a large perioperative database spanning 2002 to 2015 to look for changes in annual rates of difficult and failed tracheal intubation.

Méthode : Difficult (more than three attempts) and failed (unsuccessful, requiring awakening or surgical tracheostomy) intubation rates in patients 18 yr and older were compared between the early and late periods (pre- vs. post-January 2009) and by annual rate join-point analysis. Primary findings from a large, urban hospital were compared with combined observations from 15 smaller facilities.

Résultats : Analysis of 421,581 procedures identified fourfold reductions in both event rates between the early and late periods (difficult: 6.6 of 1,000 vs. 1.6 of 1,000, P < 0.0001; failed: 0.2 of 1,000 vs. 0.06 of 1,000, P < 0.0001), with join-point analysis identifying two significant change points (2006, P = 0.02; 2010, P = 0.03) including a pre-2006 stable period, a steep drop between 2006 and 2010, and gradual decline after 2010. Data from 15 affiliated practices (442,428 procedures) demonstrated similar reductions.

Conclusion : In this retrospective assessment spanning 14 yr (2002 to 2015), difficult and failed intubation rates by skilled providers declined significantly at both an urban hospital and a network of smaller affiliated practices. Further investigations are required to validate these findings in other data sets and more clearly identify factors associated with their occurrence as clues to future airway management advancements.

Conclusion (proposition de traduction) : Dans cette étude rétrospective sur 14 ans (2002 à 2015), les taux d'intubation difficiles et impossibles par des intervenants qualifiés ont diminué significativement à la fois dans un hôpital urbain et dans un réseau de cabinets affiliés plus petits.
Des investigations complémentaires sont nécessaires pour valider ces résultats dans d'autres ensembles de données et identifier plus clairement les facteurs associés à leur apparition comme indices de progrès futurs dans la gestion des voies respiratoires.

Four Types of Pulse Oximeters Accurately Detect Hypoxia during Low Perfusion and Motion.
Louie A, Feiner JR, Bickler PE, Rhodes L, Bernstein M, Lucero J. | Anesthesiology. 2018 Mar;128(3):520-530
DOI: https://doi.org/10.1097/ALN.0000000000002002  | Télécharger l'article au format  
Keywords: Aucun

Clinical Science

Introduction : Pulse oximeter performance is degraded by motion artifacts and low perfusion. Manufacturers developed algorithms to improve instrument performance during these challenges. There have been no independent comparisons of these devices.

Méthode : We evaluated the performance of four pulse oximeters (Masimo Radical-7, USA; Nihon Kohden OxyPal Neo, Japan; Nellcor N-600, USA; and Philips Intellivue MP5, USA) in 10 healthy adult volunteers. Three motions were evaluated: tapping, pseudorandom, and volunteer-generated rubbing, adjusted to produce photoplethsmogram disturbance similar to arterial pulsation amplitude. During motion, inspired gases were adjusted to achieve stable target plateaus of arterial oxygen saturation (SaO2) at 75%, 88%, and 100%. Pulse oximeter readings were compared with simultaneous arterial blood samples to calculate bias (oxygen saturation measured by pulse oximetry [SpO2] - SaO2), mean, SD, 95% limits of agreement, and root mean square error. Receiver operating characteristic curves were determined to detect mild (SaO2 < 90%) and severe (SaO2 < 80%) hypoxemia.

Résultats : Pulse oximeter readings corresponding to 190 blood samples were analyzed. All oximeters detected hypoxia but motion and low perfusion degraded performance. Three of four oximeters (Masimo, Nellcor, and Philips) had root mean square error greater than 3% for SaO2 70 to 100% during any motion, compared to a root mean square error of 1.8% for the stationary control. A low perfusion index increased error.

Conclusion : All oximeters detected hypoxemia during motion and low-perfusion conditions, but motion impaired performance at all ranges, with less accuracy at lower SaO2. Lower perfusion degraded performance in all but the Nihon Kohden instrument. We conclude that different types of pulse oximeters can be similarly effective in preserving sensitivity to clinically relevant hypoxia.

Conclusion (proposition de traduction) : Tous les oxymètres ont détecté une hypoxémie pendant les mouvements et les conditions d'hypo-perfusion, mais les performances ont été altérées par le mouvement à toutes les plages, avec moins de précision pour la mesure des SaO2 inférieures. Une hypo-perfusion a dégradé les performances chez tous les instruments sauf le Nihon Kohden.
Nous concluons que les différents types d'oxymètres de pouls peuvent être également efficaces pour préserver la sensibilité à l'hypoxie clinique.

Guillot O, Le Borgne1 P, Kauffmann P, Steinmetz JP, Schaeffer M, Kam C, Lavoignet CE, Adam P, Bilbault P. | Ann Fr Med Urgence. 2018 Mar;8:7-14
DOI: https://doi.org/10.1007/s13341-017-0805-6
Keywords: Luxation aiguë d'épaule / Sédation procédurale / Antalgie

Article original

Méthode : Les luxations d'épaule sont des pathologies fréquentes aux urgences, parmi les plus douloureuses et pour lesquelles il n'existe pas de recommandations spécifiques. Elles représentent 45 % de l'ensemble des luxations. L'objectif principal de cette étude était d'analyser la gestion de la douleur dans cette pathologie.

Résultats : Nous avons conduit une étude observationnelle, monocentrique et rétrospective colligeant 238 patients ayant consulté aux urgences pour une luxation aiguë d'épaule (01/01/2012-30/04/2015). Les luxations réduites spontanément, les luxations sur prothèse et les luxations chroniques étaient exclues de l'étude.

Discussion : Les luxations aiguës d'épaule étaient majoritairement réduites aux urgences (90 %, IC95 % : [86-94]). Il s'agissait d'une pathologie hyperalgique (Echelle numérique médiane : 8/10, [EIC : 6-9]) touchant plutôt les sujets jeunes (âge médian : 48 ans, EIC : 28-73). Il existait une grande hétérogénéité dans la répartition des antalgiques utilisés, le mélange équimolaire d'oxygène et de protoxyde d'azote (MEOPA) était l'antalgique le plus prescrit (50 % (IC95 % : [42-55])), suivi par le paracétamol (25 %) et le néfopam (15 %). Dans le sous-groupe des luxations compliquées d'une fracture, le MEOPA était également le plus prescrit. La répartition des autres antalgiques était par ailleurs similaire. Enfin, la comparaison entre les deux équipes médicales (urgentiste vs orthopédiste) ne retrouvait aucune différence de prescription en dehors du midazolam davantage utilisé par les urgentistes (16 % vs 4 %, p=0,001).

Conclusion (proposition de traduction) : Il existait une grande hétérogénéité des pratiques et une sous-utilisation d'antalgiques et d'hypnotiques malgré des douleurs importantes dès l'admission. Un chemin clinique visant à améliorer cette prise en charge est proposé afin d'homogénéiser les pratiques.

Commentaire : Etude mono-centrique, rétrospective sur 238 patients. L'effet antalgique n'est pas rapporté, peut-être à cause des ré-évaluations trop à distance (87 min.) non compatible avec cette ré-évaluation.
L'utilisation du MEOPA majoritaire, probablement par « économie » de voie veineuse périphérique n'est peut-être pas le meilleur choix ( Reduction of anterior shoulder dislocation in emergency department; is entonox(®) effective? 
  ) ? L'intensité élevé de la douleur pourrait faire mettre en place une analgésie morphinique par voie nasale (The use of intranasal analgesia for acute pain control in the emergency department: A literature review
  ) dès l'admission par l'IAO sur protocole de délégation ?

Assessing Bleeding Risk in Patients With Intentional Overdoses of Novel Antiplatelet and Anticoagulant Medications.
Levine M, Beuhler MC, Pizon A, Cantrel FL, Spyres MB, LoVecchio F, Skolnik AB, Brooks DE. | Ann Emerg Med. 2018 Mar;71(3):273-278
DOI: https://doi.org/10.1016/j.annemergmed.2017.08.046
Keywords: Aucun

Toxicology/original research

Introduction : In recent years, the use of novel anticoagulants and antiplatelet agents has become widespread. Little is known about the toxicity and bleeding risk of these agents after acute overdose. The primary objective of this study is to evaluate the relative risk of all bleeding and major bleeding in patients with acute overdose of novel antiplatelet and anticoagulant medications.

Méthode : This study is a retrospective study of acute ingestion of apixaban, clopidogrel, ticlopidine, dabigatran, edoxaban, prasugrel, rivaroxaban, and ticagrelor reported to 7 poison control centers in 4 states during a 10-year span. The prevalence of bleeding for each agent was calculated, and hemorrhage was classified as trivial, minor, or major.

Résultats : A total of 322 acute overdoses were identified, with the majority of cases involving clopidogrel (260; 80.7%). Hemorrhage occurred in 16 cases (4.9%), including 7 cases of clopidogrel, 6 cases of rivaroxaban, 2 cases of dabigatran, and 1 case of apixaban. Most cases of hemorrhage were classified as major (n=9). Comparing the novel anticoagulants with the P2Y12 receptor inhibitors, the relative risk for any bleeding with novel anticoagulant was 6.68 (95% confidence interval 2.63 to 17.1); the relative risk of major bleeding was 18.1 (95% confidence interval 3.85 to 85.0).

Conclusion : Acute overdose of novel anticoagulants or antiplatelet agents is associated with a small risk of significant hemorrhage. The risk is greater with the factor Xa inhibitors and direct thrombin inhibitors than with the P2Y12 receptor antagonists.

Conclusion (proposition de traduction) : Un surdosage aigu par les nouveaux anticoagulants ou agents antiplaquettaires est associé à un faible risque d'hémorragie significatif.
Le risque est plus important avec les inhibiteurs du facteur Xa et les inhibiteurs directs de la thrombine qu'avec les antagonistes du récepteur P2Y12.

Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication.
Klein LR, Cole JB, Driver BE, Battista C, Jelinek R, Martel ML. | Ann Emerg Med. 2018 Mar;71(3):279-288
DOI: https://doi.org/10.1016/j.annemergmed.2017.07.021
Keywords: Aucun

Original research article

Introduction : Emergency department (ED) visits for acute alcohol intoxication are common, but this population is at risk for decompensation and occult critical illness. The purpose of this study is to describe the incidence and predictors of unsuspected critical illness among patients with acute alcohol intoxication.

Méthode : This was a retrospective observational study of ED patients from 2011 to 2016 with acute alcohol intoxication. The study cohort included patients presenting for alcohol intoxication, whose initial assessment was uncomplicated alcohol intoxication without any other active acute medical or traumatic complaints. The primary outcome was defined as the unanticipated subsequent use of critical care resources during the encounter or admission to an ICU. We investigated potential predictors for this outcome with generalized estimating equations.

Résultats : We identified 31,364 eligible patient encounters (median age 38 years; 71% men; median breath alcohol concentration 234 mg/dL); 325 encounters (1%) used critical care resources. The most common diagnoses per 1,000 ED encounters were acute hypoxic respiratory failure (3.1), alcohol withdrawal (1.7), sepsis or infection (1.1), and intracranial hemorrhage (1.0). Three patients sustained a cardiac arrest. Presence of the following had an increased adjusted odds ratio (aOR) of developing critical illness: hypoglycemia (aOR 9.2), hypotension (aOR 3.8), tachycardia (aOR 1.8), fever (aOR 7.6), hypoxia (aOR 3.8), hypothermia (aOR 4.2), and parenteral sedation (aOR 2.4). The initial blood alcohol concentration aOR was 1.0.

Conclusion : Critical care resources were used for 1% of ED patients with alcohol intoxication who were initially assessed by physicians to have low risk. Abnormal vital signs, hypoglycemia, and chemical sedation were associated with increased odds of critical illness.

Conclusion (proposition de traduction) : Des ressources en soins intensifs ont été utilisées pour 1 % des patients du service des urgences admis pour une intoxication alcoolique après avoir été initialement évalués par les médecins urgentistes comme ayant un faible risque.
Les signes vitaux anormaux, l'hypoglycémie et la sédation médicamenteuse étaient associés à une augmentation des risques de criticité.

Commentaire : « Pierre et le loup »  !

Expert Consensus Guidelines for Stocking of Antidotes in Hospitals That Provide Emergency Care.
Dart RC, Goldfrank LR, Erstad BL, Huang DT, Todd KH, Weitz J, Bebarta VS, Caravati EM, Henretig FM, Delbridge TR, Banner W, Schneider SM, Anderson VE. | Ann Emerg Med. 2018 Mar;71(3):314-325.e1
DOI: https://doi.org/10.1016/j.annemergmed.2017.05.021  | Télécharger l'article au format  
Keywords: Aucun

Toxicology/concepts

Editorial : We provide recommendations for stocking of antidotes used in emergency departments (EDs). An expert panel representing diverse perspectives (clinical pharmacology, medical toxicology, critical care medicine, hematology/oncology, hospital pharmacy, emergency medicine, emergency medical services, pediatric emergency medicine, pediatric critical care medicine, poison centers, hospital administration, and public health) was formed to create recommendations for antidote stocking. Using a standardized summary of the medical literature, the primary reviewer for each antidote proposed guidelines for antidote stocking to the full panel. The panel used a formal iterative process to reach their recommendation for both the quantity of antidote that should be stocked and the acceptable timeframe for its delivery. The panel recommended consideration of 45 antidotes; 44 were recommended for stocking, of which 23 should be immediately available. In most hospitals, this timeframe requires that the antidote be stocked in a location that allows immediate availability. Another 14 antidotes were recommended for availability within 1 hour of the decision to administer, allowing the antidote to be stocked in the hospital pharmacy if the hospital has a mechanism for prompt delivery of antidotes. The panel recommended that each hospital perform a formal antidote hazard vulnerability assessment to determine its specific need for antidote stocking. Antidote administration is an important part of emergency care. These expert recommendations provide a tool for hospitals that offer emergency care to provide appropriate care of poisoned patients.

Conclusion : The stocking of antidotes has remained a persistent concern for at least 25 years.7 The use of the recommendations of the consensus panel, combined with a hospital antidote hazard vulnerability assessment, will allow a hospital to prepare appropriately for the treatment of poisoned patients.

Conclusion (proposition de traduction) : Le stockage des antidotes demeure une préoccupation persistante depuis au moins 25 ans.
L'utilisation de ces recommandations, associée à une évaluation de la vulnérabilité au risque d'antidote en milieu hospitalier, permettra à un hôpital de se préparer de manière adéquate pour le traitement des patients intoxiqués.

Commentaire : Mise à jour de la recommandation de 2009 : Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care 
  .

Opioid Prescribing for Opioid-Naive Patients in Emergency Departments and Other Settings: Characteristics of Prescriptions and Association With Long-Term Use.
Jeffery MM, Hooten WM, Hess EP, Meara ER, Ross JS, Henk HJ, Borgundvaag B, Shah ND, Bellolio MF. | Ann Emerg Med. 2018 Mar;71(3):326-336.e19
DOI: https://doi.org/10.1016/j.annemergmed.2017.08.042  | Télécharger l'article au format  
Keywords: Aucun

Pain management and sedation/original research

Introduction : We explore the emergency department (ED) contribution to prescription opioid use for opioid-naive patients by comparing the guideline concordance of ED prescriptions with those attributed to other settings and the risk of patients' continuing long-term opioid use.

Méthode : We used analysis of administrative claims data (OptumLabs Data Warehouse 2009 to 2015) of opioid-naive privately insured and Medicare Advantage (aged and disabled) beneficiaries to compare characteristics of opioid prescriptions attributed to the ED with those attributed to other settings. Concordance with Centers for Disease Control and Prevention (CDC) guidelines and rate of progression to long-term opioid use are reported.

Résultats : We identified 5.2 million opioid prescription fills that met inclusion criteria. Opioid prescriptions from the ED were more likely to adhere to CDC guidelines for dose, days' supply, and formulation than those attributed to non-ED settings. Disabled Medicare beneficiaries were the most likely to progress to long-term use, with 13.4% of their fills resulting in long-term use compared with 6.2% of aged Medicare and 1.8% of commercial beneficiaries' fills. Compared with patients in non-ED settings, commercial beneficiaries receiving opioid prescriptions in the ED were 46% less likely, aged Medicare patients 56% less likely, and disabled Medicare patients 58% less likely to progress to long-term opioid use.

Conclusion : Compared with non-ED settings, opioid prescriptions provided to opioid-naive patients in the ED were more likely to align with CDC recommendations. They were shorter, written for lower daily doses, and less likely to be for long-acting formulations. Prescriptions from the ED are associated with a lower risk of progression to long-term use.

Conclusion (proposition de traduction) : Par rapport aux services de consultations on urgentes, les ordonnances d'opioïdes remises aux patients n'ayant jamais reçu d'opioïdes dans le service des urgences étaient plus susceptibles de suivre les recommandations des « Centers for Disease Control and Prevention ». Les prescriptions étaient plus courtes, prescrites pour des doses quotidiennes plus faibles, et moins susceptibles d'être des formulations à action prolongée.
Les prescriptions du service des urgences sont associées à un risque moindre de progression vers une utilisation à long terme.

Acetaminophen or Nonsteroidal Anti-Inflammatory Drugs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, Randomized, Clinical Trial.
Ridderikhof ML, Lirk P, Goddijn H, Vandewalle E, Schinkel E, Van Dieren S, Kemper EM, Hollmann MW, Goslings JC. | Ann Emerg Med. 2018 Mar;71(3):357-368.e8
DOI: https://doi.org/10.1016/j.annemergmed.2017.08.041
Keywords: Aucun

Pain management and sedation/original research

Introduction : We determine whether pain treatment with acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the combination of both in minor musculoskeletal trauma.

Méthode : The Paracetamol or NSAIDs in Acute Musculoskeletal Trauma Study was a double-blind, randomized, clinical trial conducted in 2 general practices and 2 emergency departments in the Netherlands. A total of 547 adults, aged 18 years and older, with acute blunt minor musculoskeletal extremity trauma were randomly assigned in a 1:1:1 ratio to acetaminophen 4,000 mg/day, diclofenac 150 mg/day, or acetaminophen 4,000 mg/day+diclofenac 150 mg/day during 3 consecutive days. Patients, health care staff, and outcome assessors were blinded for treatment allocation. Follow-up for each patient was 30 days. Primary outcome measures were between-group differences in mean numeric rating scale (NRS) pain scores in rest and with movement at 90 minutes after initial drug administration compared with baseline pain scores with a predefined noninferiority margin of 0.75 NRS points. Secondary outcomes included NRS pain scores during 3 consecutive days and need for additional analgesia.

Résultats : One hundred eighty-two patients were treated with acetaminophen, 183 with diclofenac, and 182 with combination treatment. Intention-to-treat analysis revealed mean NRS reduction in rest -1.23 (95% confidence interval [CI] -1.50 to -0.95) and -1.72 (95% CI -2.01 to -1.44) with movement, both for acetaminophen at 90 minutes compared with baseline. Pairwise comparison in rest with diclofenac showed a difference of -0.027 (97.5% CI -0.45 to 0.39) and -0.052 (97.5% CI -0.46 to 0.36) for combination treatment. With movement, these numbers were -0.20 (97.5% CI -0.64 to 0.23) and -0.39 (97.5% CI -0.80 to 0.018), respectively. All differences were well below the predefined noninferiority margin.

Conclusion : Pain treatment with acetaminophen was not inferior to that with diclofenac or the combination of acetaminophen and diclofenac in acute minor musculoskeletal extremity trauma, both in rest and with movement.

Conclusion (proposition de traduction) : Le traitement de la douleur par le paracétamol n'était pas inférieur à celui par diclofénac ou de la combinaison du paracétamol et du diclofénac dans les traumatismes aigus mineures des extrémités, tant au repos que pendant le mouvement.

A Comparison of Headache Treatment in the Emergency Department: Prochlorperazine Versus Ketamine.
Zitek T, Gates M, Pitotti C, Bartlett A, Patel J, Rahbar A, Forred W, Sontgerath JS, Clark JM. | Ann Emerg Med. 2018 Mar;71(3):369-377.e1
DOI: https://doi.org/10.1016/j.annemergmed.2017.08.063
Keywords: Aucun

Pain management and sedation/original research

Introduction : Intravenous subdissociative-dose ketamine has been shown to be effective for pain management, but has not been specifically studied for headaches in the emergency department (ED). For this reason, we designed a study to compare standard treatment (prochlorperazine) with ketamine in patients with benign headaches in the ED.

Méthode : This study was a multicenter, double-blind, randomized, controlled trial with a convenience sample of patients presenting to the ED with benign headaches. Patients were randomized to receive either prochlorperazine and diphenhydramine or ketamine and ondansetron. Patients' headache severity was measured on a 100-mm visual analog scale (VAS) at 0, 15, 30, 45, and 60 minutes. Nausea, vomiting, anxiety, and the need for rescue medications were also tracked. Patients were contacted at 24 to 48 hours posttreatment to rate their satisfaction and to determine whether they were still experiencing a headache.

Résultats : There were a total of 54 subjects enrolled. Two patients in the ketamine group and one in the prochlorperazine group withdrew because of adverse effects of the medications. In regard to the primary outcome, at 60 minutes, the prochlorperazine group had a mean improvement in VAS pain scores of 63.5 mm compared with 43.5 mm in the ketamine group, corresponding to a between-groups difference of 20.0 mm (95% confidence interval [CI] 2.8 to 37.2 mm) and a P value of .026. At 45 minutes, the prochlorperazine group had a mean improvement in pain scores of 56.1 mm compared with 38.0 mm in the ketamine group, a difference of 18.1 mm (95% CI 1.0 to 35.2 mm). At 24- to 48-hour follow-up, the mean satisfaction score was 8.3 of 10 for prochlorperazine and 4.9 of 10 for ketamine, a difference of 3.4 (95% CI 1.2 to 5.6). There was not a statistically significant difference in the percentage of patients who had a headache at follow-up or in other secondary outcomes.

Conclusion : Prochlorperazine appears to be superior to ketamine for the treatment of benign headaches in the ED.

Conclusion (proposition de traduction) : La prochlorpérazine semble être supérieure à la kétamine pour le traitement des céphalées bénignes aux urgences.

Commentaire : Le Stemetil® (prochlorpérazine) est un médicament mis à disposition dans le milieu hospitalier sous forme de comprimé à 25 mg (rétrocédable par les pharmacies hospitalières par prolongation des conditions d'inscription).

How Effective Is a Regional Nerve Block for Treating Pain Associated With Hip Fractures?.
Gottlieb M, Chien N, Seagraves T. | Ann Emerg Med. 2018 Mar;71(3):378-380
DOI: https://doi.org/10.1016/j.annemergmed.2017.09.032
Keywords: Aucun

Systematic review snapshot

Introduction : Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature were searched from inception to August 2016 without language or publication status restrictions. Several trial registries were also searched to identify studies in progress. Additionally, conference proceedings of anesthesiology societies and abstracts from the American Society of Anesthesiologists’ Web site were screened from 2012 to 2014.

Méthode : The search strategy identified 1,116 trials, of which 31 (1,760 total participants) met the inclusion criteria for this review. The trials took place in 20 countries, with publication dates extending from 1980 to 2016. The type of peripheral nerve block performed varied greatly in the studies, including type of nerve block (eg, femoral nerve block, fascia iliaca compartment block), duration of block (eg, singleshot block, continuous block), technique (eg, nerve stimulator, ultrasonographic guidance, landmark technique), and timing of nerve block (eg, preoperatively, intraoperatively, postoperatively).

Résultats : When compared with systemic analgesia, nerve block participants had a standardized mean reduction in pain level on movement at 30 minutes of –1.41, which equates to a reduction of –3.4 on a pain scale of 0 to 10. There was also a lower incidence of pneumonia (10.9% versus 26.9%), shorter time to first mobilization, lower cost for analgesic regimen, decreased opioid consumption, and increased patient satisfaction. There were no differences in the remaining outcomes, and no major complications were reported in the 31 trials assessing peripheral nerve blockade. Most of the studies were at overall low or moderate risk of bias.

Conclusion : Regional nerve blockade reduces pain on movement, risk of pneumonia, and time to first mobilization among patients with hip fractures with no major complications.

Conclusion (proposition de traduction) : Le bloc nerveux réduit la douleur liée aux mouvements, le risque de pneumopathie et le délai avant la première mobilisation chez les patients souffrant de fractures de la hanche sans complications majeures.

Preoxygenation With Flush Rate Oxygen: Comparing the Nonrebreather Mask With the Bag-Valve Mask.
Driver BE, Klein LR, Carlson K, Harrington J, Reardon RF, Prekker ME. | Ann Emerg Med. 2018 Mar;71(3):381-386
DOI: https://doi.org/10.1016/j.annemergmed.2017.09.017
Keywords: Aucun

Airway/original research

Introduction : Nonrebreather masks and bag-valve masks are used for preoxygenation before emergency intubation. Flush rate oxygen delivered with a nonrebreather mask is noninferior to bag-valve mask oxygen at 15 L/min. We seek to compare the nonrebreather mask with flush rate oxygen to a bag-valve mask with flush rate oxygen (with and without inspiratory assistance) and determine whether the efficacy of bag-valve mask with flush rate oxygen is compromised by a simulated mask leak.

Méthode : We conducted 2 prospective studies in healthy, adult volunteers. All devices in both studies used flush rate oxygen, achieved by rotating the flowmeter dial counterclockwise until it could not be rotated farther, which delivered oxygen at 40 to 60 L/min. Study 1 compared preoxygenation with nonrebreather mask to bag-valve mask (modified with a one-way exhalation port) with and without a simulated mask leak. Study 2 compared nonrebreather mask to bag-valve mask with inspiratory assistance. The primary outcome was FeO2. For each comparison, we prespecified a noninferiority margin of FeO2 for the nonrebreather mask (compared with the bag-valve mask, bag-valve mask with mask leak, and bag-valve mask with assistance) of 10%.

Résultats : Thirty subjects were enrolled in study 1 and 27 subjects were enrolled in study 2. For study 1, mean FeO2 values for nonrebreather mask, bag-valve mask, and bag-valve mask with leak were 81% (95% confidence interval [CI] 78% to 83%), 76% (95% CI 71% to 81%), and 30% (95% CI 26% to 35%), respectively. FeO2 for the nonrebreather mask was noninferior to the bag-valve mask at flush rate (difference 5%; 95% CI -1% to 10%). FeO2 was higher for the nonrebreather mask compared with the bag-valve mask with a simulated mask leak (difference 51%; 95% CI 46% to 55%). For study 2, mean FeO2 values for nonrebreather mask and bag-valve mask with assistance were 83% (95% CI 80% to 86%) and 77% (95% CI 73% to 80%), respectively. FeO2 for the nonrebreather mask was noninferior to the bag-valve mask with assistance at flush rate (difference 6%; 95% CI 3% to 10%).

Conclusion : With flush rate oxygen, the nonrebreather mask is noninferior to the bag-valve mask, with and without inspiratory assistance. Bag-valve mask performed poorly with a mask leak, even with flush rate oxygen. Flush rate oxygen with a nonrebreather mask is a reasonable default preoxygenation method in spontaneously breathing patients with no underlying respiratory pathology.

Conclusion (proposition de traduction) : Avec l'oxygène à débit de rinçage, le masque facial simple est non inférieur au masque à haute concentration, avec et sans assistance inspiratoire. Le masque à haute concentration fonctionnait mal avec une fuite au niveau du masque, même avec un débit d'oxygène insuffisant. L'oxygénothérapie avec un masque facial simple est une méthode de préoxygénation par défaut chez les patients respirant spontanément sans pathologie respiratoire sous-jacente.

Commentaire : La bonne utilisation du masque facial à haute concentration est nécessaire pour son utilisation. La formation des paramédicaux semble utile au vue de cette étude…

The Effect of Successful Intubation on Patient Outcomes After Out-of-Hospital Cardiac Arrest in Taipei.
Chiang WC, Hsieh MJ, Chu HL, Chen AY, Wen SY, Yang WS, Chien YC, Wang YC, Lee BC, Wang HC, Huang EP, Yang CW, Sun JT, Chong KM, Lin HY, Hsu SH, Chen SY, Ma MH. | Ann Emerg Med. 2018 Mar;71(3):387-396.e2
DOI: https://doi.org/10.1016/j.annemergmed.2017.08.008
Keywords: Aucun

Airway/original research

Introduction : The effect of out-of-hospital intubation in patients with out-of-hospital cardiac arrest remains controversial. The Taipei City paramedics are the earliest authorized to perform out-of-hospital intubation among Asian areas. This study evaluates the association between successful intubation and out-of-hospital cardiac arrest survival in Taipei.

Méthode : We analyzed 6 years of Utstein-based registry data from nontrauma adult patients with out-of-hospital cardiac arrest who underwent out-of-hospital airway management including intubation, laryngeal mask airway, or bag-valve-mask ventilation. The primary analysis was intubation success on patient outcomes. The primary outcome was survival to discharge and the secondary outcomes included sustained return of spontaneous circulation and favorable neurologic survival. Sensitivity analysis was performed with intubation attempts rather than intubation success. Subgroup analysis of advanced life support-serviced districts was also performed.

Résultats : A total of 10,853 cases from 2008 to 2013 were analyzed. Among out-of-hospital cardiac arrest patients receiving airway management, successful intubation, laryngeal mask airway, and bag-valve-mask ventilation was reported in 1,541, 3,099, and 6,213 cases, respectively. Compared with bag-valve-mask device use, successful out-of-hospital intubation was associated with improved chances of sustained return of spontaneous circulation (adjusted odds ratio [aOR] 1.91; 95% confidence interval [CI] 1.66 to 2.19), survival to discharge (aOR 1.98; 95% CI 1.57 to 2.49), and favorable neurologic outcome (aOR 1.44; 95% CI 1.03 to 2.03). The results were comparable in sensitivity and subgroup analyses.

Conclusion : In nontrauma adult out-of-hospital cardiac arrest in Taipei, successful out-of-hospital intubation was associated with improved odds of sustained return of spontaneous circulation, survival to discharge, and favorable neurologic outcome.

Conclusion (proposition de traduction) : Lors d'un arrêt cardiaque non traumatique extra-hospitalier à Taipei, une intubation réussie en dehors de l'hôpital était associée à une probabilité accrue de retour soutenu à une circulation spontanée, à la survie à la sortie et à un résultat neurologique favorable.

Commentaire : Confirme l'attitude française qui préconise l'intubation des patients en ACR par les SMUR.

Rocuronium Should Be the Default Paralytic in Rapid Sequence Intubation.
Swaminathan AK, Mallemat H. | Ann Emerg Med. 2018 Mar;71(3):397-398
DOI: https://doi.org/10.1016/j.annemergmed.2017.04.039
Keywords: Aucun

Clinical controversies

Editorial : Les cliniciens ont actuellement deux agents facilement disponibles, le rocuronium et la succinylcholine, qui sont capables d'induire la paralysie musculaire nécessaire à l'intubation rapide. Bien que l'un ou l'autre agent puisse être avantageux dans certaines situations, le choix d'un agent par défaut pour la plupart des intubations est moins clair et plus controversé. Dans cet article de Controverses cliniques, les défenseurs pro et con présentent les preuves disponibles et les arguments relatifs à l'utilisation de ces agents et discutent des points de vue opposés qui doivent être pris en compte dans le choix d'un paralytique par défaut.

Conclusion (proposition de traduction) : Les cliniciens ont actuellement deux agents facilement disponibles, le rocuronium et la succinylcholine, qui sont capables d'induire la paralysie musculaire nécessaire à l'intubation en séquence rapide. Bien que l'un ou l'autre agent puisse être avantageux dans certaines situations, le choix d'un agent par défaut pour la plupart des intubations est moins clair et plus controversé. Dans cet article de Controverses cliniques, les défenseurs pro et contre présentent les preuves disponibles et les arguments relatifs à l'utilisation de ces agents et discutent des points de vue opposés qui doivent être pris en compte dans le choix d'un paralytique par défaut.

Rocuronium Versus Succinylcholine Revisited: Succinylcholine Remains the Best Choice.
Shoenberger JM, Mallon WK. | Ann Emerg Med. 2018 Mar;71(3):398-399
DOI: https://doi.org/10.1016/j.annemergmed.2017.07.478
Keywords: Aucun

Clinical controversies

Editorial : Les cliniciens ont actuellement deux agents facilement disponibles, le rocuronium et la succinylcholine, qui sont capables d'induire la paralysie musculaire nécessaire à l'intubation rapide. Bien que l'un ou l'autre agent puisse être avantageux dans certaines situations, le choix d'un agent par défaut pour la plupart des intubations est moins clair et plus controversé. Dans cet article de Controverses cliniques, les défenseurs pro et con présentent les preuves disponibles et les arguments relatifs à l'utilisation de ces agents et discutent des points de vue opposés qui doivent être pris en compte dans le choix d'un paralytique par défaut.

Conclusion (proposition de traduction) : Les cliniciens ont actuellement deux agents facilement disponibles, le rocuronium et la succinylcholine, qui sont capables d'induire la paralysie musculaire nécessaire à l'intubation en séquence rapide. Bien que l'un ou l'autre agent puisse être avantageux dans certaines situations, le choix d'un agent par défaut pour la plupart des intubations est moins clair et plus controversé. Dans cet article de Controverses cliniques, les défenseurs pro et contre présentent les preuves disponibles et les arguments relatifs à l'utilisation de ces agents et discutent des points de vue opposés qui doivent être pris en compte dans le choix d'un paralytique par défaut.

Does the Use of Video Laryngoscopy Improve Intubation Outcomes?.
April MD, Long B. | Ann Emerg Med. 2018 Mar;71(3):e9-e11
DOI: https://doi.org/10.1016/j.annemergmed.2017.06.038
Keywords: Aucun

Airway/systematic review snapshot

Editorial : In adult patients, video laryngoscopy improves the glottic view but does not improve first-attempt success. In patients with anticipated difficult airways, video laryngoscopy may reduce the risk of failed intubation.

Conclusion (proposition de traduction) : Chez les patients adultes, l'utilisation du vidéo-laryngoscope améliore la vision de la glotte mais n'améliore pas le taux de réussite de la première tentative d'intubation.
Chez les patients ayant une prédiction d'intubation difficile, le vidéo-laryngoscope peut réduire le risque d'échec de l'intubation.

Managing Patients With Nontraumatic, Severe, Rapid-Onset Headache.
Edlow JA | Ann Emerg Med. 2018 Mar;71(3):400-408
DOI: https://doi.org/10.1016/j.annemergmed.2017.04.044
Keywords: Aucun

Neurology/expert clinical management

Editorial : Severe rapid-onset headache, sometimes called thunderclap headache, is a relatively common emergency department (ED) chief complaint. Although these headaches have been defined as “peaking within one minute,”1,2 some have questioned this rigid time criterion.3 In one study of subarachnoid hemorrhage diagnosis, the interobserver agreement in the ED for “thunderclap” onset was only moderate (κ=0.49), and 6 (of 132) subarachnoid hemorrhage patients reported time to peak intensity of 1 hour.4 For these reasons, I do not strictly use “sudden onset” in practice, but these patients generally recall exactly what they were doing at headache onset.

Conclusion : Each strategy has clear advantages and disadvantages that incorporate physician and patient biases, which, in the spirit of shared decisionmaking, the physician should discuss with patients; some may wish to avoid radiation exposure, whereas others may adamantly refuse lumbar puncture. Regardless of the strategy chosen, it is important to consider the full range of potentially serious causes of severe rapid-onset headache, not just subarachnoid hemorrhage.

Conclusion (proposition de traduction) : Chaque stratégie comporte des avantages et des inconvénients clairs qui tiennent compte des préjugés des médecins et des patients, ce qui, dans l'esprit de la prise de décision partagée, devrait être discuté par le médecin avec les patients ; certains peuvent souhaiter éviter l'exposition aux radiations, tandis que d'autres peuvent refuser catégoriquement la ponction lombaire.
Quelle que soit la stratégie choisie, il est important de prendre en compte l'ensemble des causes potentiellement graves de céphalée sévère de survenue rapide, et pas seulement l'hémorragie sous-arachnoïdienne.

Managing Patients With Transient Ischemic Attack.
Edlow JA | Ann Emerg Med. 2018 Mar;71(3):409-415
DOI: https://doi.org/10.1016/j.annemergmed.2017.06.026
Keywords: Aucun

Neurology/expert clinical management

Editorial : Approximately 300,000 patients are treated annually in US emergency departments (EDs) for cerebral transient ischemic attack. Their management is variable. Created in 1975, the historical definition—focal neurologic symptoms with a vascular cause, lasting less than 24 hours—no longer makes sense in a world of magnetic resonance imaging (MRI), fibrinolytic treatment for ischemic stroke, and a better understanding of the ultraearly stroke risk after transient ischemic attack. The new definition of transient ischemic attack is “a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction.” The last 2 decades have witnessed an explosion of important research about transient ischemic attack. Most studies on transient ischemic attack use the historical definition, and many combine patients with transient ischemic attack and minor ischemic stroke (usually defined as a stroke that leaves a patient without a significant, disabling deficit) because the clinical approach to diagnosis and treatment in both groups is identical.

Conclusion : The reality is that emergency physicians must use whatever system of care is available to them. Whatever that is, it is important to recognize that how fast the evaluation occurs is much more important than where it occurs. Rapid use of antiplatelet treatment and other measures discussed above will prevent disabling and fatal strokes in many of these patients. Patients discharged from the emergency department or emergency department -based observation unit should receive standardized instructions about neurologic symptoms for which to immediately return, information about lifestyle changes, and information about various medical interventions, along with a tight follow-up ideally with a stroke neurologist, with the recognition that this is not possible in some settings. Emergency physicians should collaborate with physicians from other stakeholder specialties to create the most streamlined infrastructure that their local environment will support to evaluate patients with transient ischemic attack.

Conclusion (proposition de traduction) : Les urgentistes doivent utiliser n'importe quel système de soins à leur disposition. Il est important de reconnaître que la rapidité d'exécution de l'évaluation est beaucoup plus importante que celle où elle se produit.
L'utilisation rapide du traitement antiplaquettaire et d'autres mesures discutées ci-dessus préviendra les AVC invalidants et fatals chez plusieurs de ces patients. Les patients sortis du service des urgences ou du service d'urgence doivent recevoir des instructions standardisées sur les symptômes neurologiques pour lesquels ils doivent revenir immédiatement, des informations sur les changements de style de vie et des informations sur diverses interventions médicales, ainsi qu'un suivi serré idéalement avec un neurologue mais il faut savoir que cela n'est pas possible dans certains contextes. Les médecins urgentistes devraient collaborer avec les intervenants d'autres spécialités pour créer l'infrastructure la plus rationalisée que leur environnement local soutiendra pour évaluer les patients atteints d'un accident vasculaire ischémique transitoire.

Do Intravenous Benzodiazepines or Benzodiazepines by an Alternative Route (Nonintravenous) Abort Seizures Faster?.
Long B, April MD. | Ann Emerg Med. 2018 Mar;71(3):419-421
DOI: https://doi.org/10.1016/j.annemergmed.2017.06.012
Keywords: Aucun

Neurology/systematic review snapshot

Méthode : The authors included 11 studies, with 10 randomized controlled trials and 1 observational longitudinal study for analysis, with 1,633 patients. Ten of the 11 articles were predominantly pediatric, although a single study accounting for more than half the patients analyzed in the meta-analysis (893 patients) comprised both children and adults with mean age 43 years among patients receiving benzodiazepines by alternative routes and44 years in the intravenous group.

Résultats : Comparison of failure, defined by failure to stop seizure, favored benzodiazepines administered by alternative routes (odds ratio 0.72; 95% CI 0.56 to 0.92). Pediatric subgroup analysis demonstrated no difference in efficacy between benzodiazepines administered by alternative routes versus intravenous benzodiazepines (odds ratio 1.16; 95% CI 0.74 to 1.81) with removal of this study. Intravenous benzodiazepines have a shorter interval between drug administration and seizure abortion (mean difference 0.74 minutes; 95% CI 0.52 to 0.95 minutes). However, this was not found when the time to seizure termination from decision to treat was assessed, which factors in delays to treatment because of venous access. When these delays were factored in, benzodiazepines administered by alternative routes achieved faster net effect (mean difference –3.41 minutes; 95% CI –5.13 to –1.69 minutes).3-5 The authors found no difference between the 2 groups in regard to incidence of respiratory depression.

Conclusion : Benzodiazepines by an alternative route abort seizures faster and possess superior efficacy compared with intravenous benzodiazepines in patients without intravenous access.

Conclusion (proposition de traduction) : Les benzodiazépines par une voie alternative arrêtent les crises plus rapidement et possèdent une efficacité supérieure par rapport aux benzodiazépines par voie intraveineuse chez les patients sans accès veineuse périphérique.

Commentaire : La voie alternative dont il est question ici, est la voie intra rectale, notamment chez l'enfant.

Potentially modifiable respiratory variables contributing to outcome in ICU patients without ARDS: a secondary analysis of PRoVENT.
Simonis FD, and al.; PRoVENT investigators; PROVE Network investigators.. | Ann Intensive Care. 2018 Mar 21;8(1):39
DOI: https://doi.org/10.1186/s13613-018-0385-7  | Télécharger l'article au format  
Keywords: Mechanical ventilation; Mortality; Outcome; Ventilator settings

Research

Introduction : The majority of critically ill patients do not suffer from acute respiratory distress syndrome (ARDS). To improve the treatment of these patients, we aimed to identify potentially modifiable factors associated with outcome of these patients.

Méthode : The PRoVENT was an international, multicenter, prospective cohort study of consecutive patients under invasive mechanical ventilatory support. A predefined secondary analysis was to examine factors associated with mortality. The primary endpoint was all-cause in-hospital mortality.

Résultats : 935 Patients were included. In-hospital mortality was 21%. Compared to patients who died, patients who survived had a lower risk of ARDS according to the 'Lung Injury Prediction Score' and received lower maximum airway pressure (Pmax), driving pressure (ΔP), positive end-expiratory pressure, and FiO2 levels. Tidal volume size was similar between the groups. Higher Pmax was a potentially modifiable ventilatory variable associated with in-hospital mortality in multivariable analyses. ΔP was not independently associated with in-hospital mortality, but reliable values for ΔP were available for 343 patients only. Non-modifiable factors associated with in-hospital mortality were older age, presence of immunosuppression, higher non-pulmonary sequential organ failure assessment scores, lower pulse oximetry readings, higher heart rates, and functional dependence.

Conclusion : Higher Pmax was independently associated with higher in-hospital mortality in mechanically ventilated critically ill patients under mechanical ventilatory support for reasons other than ARDS.

Conclusion (proposition de traduction) : Une Pmax plus élevée était indépendamment associée à une mortalité hospitalière plus élevée chez les patients de soins intensifs sous ventilation mécanique sous assistance ventilatoire mécanique pour d'autres motifs qu'un SDRA.

Predictors of response to fixed-dose vasopressin in adult patients with septic shock.
Sacha GL, Lam SW, Duggal A, Torbic H, Bass SN, Welch SC, Butler RS, Bauer SR. | Ann Intensive Care. 2018 Mar 6;8(1):35
DOI: https://doi.org/10.1186/s13613-018-0379-5  | Télécharger l'article au format  
Keywords: Catecholamines; Norepinephrine; Sepsis; Septic shock; Vasopressin; Vasopressors

Research

Introduction : Vasopressin is often utilized for hemodynamic support in patients with septic shock. However, the most appropriate patient to initiate therapy in is unknown. This study was conducted to determine factors associated with hemodynamic response to fixed-dose vasopressin in patients with septic shock.

Méthode : Single-center, retrospective cohort of patients receiving fixed-dose vasopressin for septic shock for at least 6 h with concomitant catecholamines in the medical, surgical, or neurosciences intensive care unit (ICU) at a tertiary care center. Patients were classified as responders or non-responders to fixed-dose vasopressin. Response was defined as a decrease in catecholamine dose requirements and achievement of mean arterial pressure ≥ 65 mmHg at 6 h after initiation of vasopressin.

Résultats : A total of 938 patients were included: 426 responders (45%), 512 non-responders (55%). Responders had lower rates of in-hospital (57 vs. 72%; P < 0.001) and ICU mortality (50 vs. 68%; P < 0.001), and increased ICU-free days at day 14 and hospital-free days at day 28 (2.3 ± 3.8 vs. 1.6 ± 3.3; P < 0.001 and 4.2 ± 7.2 vs. 2.8 ± 6.0; P < 0.001, respectively). On multivariable analysis, non-medical ICU location was associated with increased response odds (OR 1.70; P = 0.0049) and lactate at vasopressin initiation was associated with decreased response odds (OR 0.93; P = 0.0003). Factors not associated with response included APACHE III score, SOFA score, corticosteroid use, and catecholamine dose.

Conclusion : In this evaluation, 45% responded to the addition of vasopressin with improved outcomes compared to non-responders. The only factors found to be associated with vasopressin response were ICU location and lactate concentration.

Conclusion (proposition de traduction) : Dans cette évaluation, 45 % des patients ont répondu à l'introduction de vasopressine avec des résultats meilleurs par rapport aux non-répondeurs.
Les seuls facteurs associés à la réponse à la vasopressine étaient l'hospitalisation en USI et le taux de lactate.

Outcome of elderly emergency department patients hospitalised on weekends - a retrospective cohort study.
Brouns SHA, Wachelder JJ, Jonkers FS, Lambooij SL, Dieleman JP, Haak HR. | BMC Emerg Med. 2018 Mar 7;18(1):9
DOI: https://doi.org/10.1186/s12873-018-0160-y  | Télécharger l'article au format  
Keywords: Aged; Emergency service; Outcome and process assessment (health care); hospital

Research Article

Introduction : Studies investigating different medical conditions and settings have demonstrated mixed results regarding the weekend effect. However, data on the outcome of elderly patients hospitalised on weekends is scarce. The objective was to compare in-hospital and two-day mortality rates between elderly emergency department (ED) patients (≥65 years) admitted on weekends versus weekdays.

Méthode : A retrospective cohort study of emergency department visits of internal medicine patients ≥65 years presenting to the emergency department between 01 and 09-2010 and 31-08-2012 was conducted. The weekend was defined as the period from midnight on Friday to midnight on Sunday.

Résultats : Data on 3697 emergency department visits by elderly internal medicine patients (mean age 78.6 years old) were included. In total, 2743 emergency department visits (74.2%) resulted in hospitalisation, of which 22.9% occurred on weekends. Comorbidity and urgency levels were higher in patients admitted on weekends. In-hospital mortality was 11.4% for patients admitted on weekends compared with 8.9% on weekdays (OR 1.3, 95%CI 0.99-1.8). Two-day mortality was 3.2% in patients hospitalised on weekends versus 1.9% on weekdays (OR 1.7, 95%CI 0.99-2.9). Multivariable adjustment for age, comorbidity and triage level demonstrated comparable in-hospital and two-day mortality for weekend and week admission (ORadj 1.2, 95%CI 0.9-1.7 and ORadj 1.5, 95%CI 0.8-2.6, resp.).

Conclusion : A small weekend effect was observed in elderly internal medicine patients, which was not statistically significant. This effect was partly explained by a higher comorbidity and urgency level in elderly patients hospitalised on weekends than during weekdays. Emergency care for the elderly is not compromised by adjusted logistics during the weekend.

Conclusion (proposition de traduction) : Un petit effet « week-end » a été observé chez les patients âgés en médecine interne mais qui n'était pas statistiquement significatif.
Cet effet s'explique en partie par une comorbidité et un niveau d'urgence plus élevés chez les patients âgés hospitalisés les fins de semaine plutôt que les jours de semaine. LLes soins d'urgence pour les personnes âgées ne sont pas compromis par la logistique adaptée pendant le week-end.

Endovascular treatment for acute ischaemic stroke in routine clinical practice: prospective, observational cohort study (MR CLEAN Registry).
Jansen IGH, Mulder MJHL, Goldhoorn RB; MR CLEAN Registry investigators. | BMJ. 2018 Mar 9;360:k949
DOI: https://doi.org/10.1136/bmj.k949
Keywords: Aucun

Research

Introduction : To determine outcomes and safety of endovascular treatment for acute ischaemic stroke, due to proximal intracranial vessel occlusion in the anterior circulation, in routine clinical practice.
DESIGN: Ongoing, prospective, observational cohort study.
SETTING: 16 centres that perform endovascular treatment in the Netherlands.

Méthode : 1488 patients included in the Multicentre Randomised Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands (MR CLEAN) Registry who had received endovascular treatment, including stent retriever thrombectomy, aspiration, and all alternative methods for acute ischaemic stroke within 6.5 hours from onset of symptoms between March 2014 and June 2016.
MAIN OUTCOME MEASURES: The primary outcome was the modified Rankin Scale (mRS) score, ranging from 0 (no symptoms) to 6 (death) at 90 days after the onset of symptoms. Secondary outcomes were excellent functional outcome (mRS score 0-1), good functional outcome (mRS score 0-2), and favourable functional outcome (mRS score 0-3) at 90 days; score on the extended thrombolysis in cerebral infarction scale at the end of the intervention procedure; National Institutes of Health Stroke Scale score 24-48 hours after intervention; and complications that occurred during intervention, hospital admission, or three months' follow up period. Outcomes and safety variables in the MR CLEAN Registry were compared with the MR CLEAN trial intervention and control arms.

Résultats : A statistically significant shift was observed towards better functional outcome in patients in the MR CLEAN Registry compared with the MR CLEAN trial intervention arm (adjusted common odds ratio 1.30, 95% confidence interval 1.02 to 1.67) and the MR CLEAN trial control arm (1.85, 1.46 to 2.34). The reperfusion rate, with successful reperfusion defined as a score of 2B-3 on the extended thrombolysis in cerebral infarction score, was 58.7%, the same as for patients in the MR CLEAN trial. Duration from onset of stroke to start of endovascular treatment and from onset of stroke to successful reperfusion or last contrast bolus was one hour shorter for patients in the MR CLEAN Registry. Symptomatic intracranial haemorrhage occurred in 5.8% of patients in the MR CLEAN Registry compared with 7.7% in the MR CLEAN trial intervention arm and 6.4% in the MR CLEAN trial control arm.

Conclusion : In routine clinical practice, endovascular treatment for patients with acute ischaemic stroke is at least as effective and safe as in the setting of a randomised controlled trial.

Conclusion (proposition de traduction) : Dans la pratique clinique de routine, le traitement endovasculaire des patients présentant un AVC ischémique aigu est au moins aussi efficace et sûr que dans le cadre d'un essai contrôlé randomisé.

Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study.
Pasternak B, Inghammar M, Svanström H. | BMJ. 2018 Mar 8;360:k678
DOI: https://doi.org/10.1136/bmj.k678
Keywords: Aucun

Research

Introduction : To investigate whether oral fluoroquinolone use is associated with an increased risk of aortic aneurysm or dissection.
DESIGN: Nationwide historical cohort study using linked register data on patient characteristics, filled prescriptions, and cases of aortic aneurysm or dissection.
SETTING: Sweden, July 2006 to December 2013.

Méthode : 360 088 treatment episodes of fluoroquinolone use (78%ciprofloxacin) and propensity score matched comparator episodes of amoxicillin use (n=360 088).
MAIN OUTCOME MEASURES: Cox regression was used to estimate hazard ratios for a first diagnosis of aortic aneurysm or dissection, defined as admission to hospital or emergency department for, or death due to, aortic aneurysm or dissection, within 60 days from start of treatment.

Résultats : Within the 60 day risk period, the rate of aortic aneurysm or dissection was 1.2 cases per 1000 person years among fluoroquinolone users and 0.7 cases per 1000 person years among amoxicillin users. Fluoroquinolone use was associated with an increased risk of aortic aneurysm or dissection (hazard ratio 1.66 (95% confidence interval 1.12 to 2.46)), with an estimated absolute difference of 82 (95% confidence interval 15 to 181) cases of aortic aneurysm or dissection by 60 days per 1 million treatment episodes. In a secondary analysis, the hazard ratio for the association with fluoroquinolone use was 1.90 (1.22 to 2.96) for aortic aneurysm and 0.93 (0.38 to 2.29) for aortic dissection.

Conclusion : In a propensity score matched cohort, fluoroquinolone use was associated with an increased risk of aortic aneurysm or dissection. This association appeared to be largely driven by aortic aneurysm.

Conclusion (proposition de traduction) : Dans une cohorte appariée avec score de propension, l'utilisation de fluoroquinolone était associée à un risque accru d'anévrisme ou de dissection aortique. Cette association semble concerner majoritairement l'anévrisme aortique.

Commentaire : On savait que les fluoroquinolones étaient associés à des risques de rupture du tendon d'Achille ou d'autres tendinopathies et de décollement de la rétine. Cette étude confirme que les fluoroquinolones doublent également le risque de survenue d'une dissection aortique ou d'un anévrisme aortique. Ce sont des pathologies liées au collagène. Or, des maladies génétiques liées à un défaut du collagène comme les syndromes de Marfan et d'Ehlers-Danlos augmentent le risque de dissection ou anévrisme aortique.
En 2015, Lee CC and al. Risk of Aortic Dissection and Aortic Aneurysm in Patients Taking Oral Fluoroquinolone . JAMA Intern Med. 2015 Nov;175(11):1839-47, a montré que la prise d'une fluoroquinolone dans les 60 jours était associée à une multiplication par 2,4 du risque de dissection aortique ou d'anévrisme aortique. Et le fait d'en avoir pris entre 60 jours et un an avant augmentait encore le risque de 48 %. Le risque était plus important chez les femmes et chez les personnes de 70 ans et plus.
Enfin, concernant les résultats de cette étude, voir l'éditorial : Fluoroquinolones and the aorta   de Juurlink DN. dans BMJ. 2018 Mar 8;360:k988.

Compliance of tranexamic acid administration to trauma patients at a level-one trauma centre.
Ghawnni A, Coates A, Owen J. | CJEM. 2018 Mar;20(2):216-221
DOI: https://doi.org/10.1017/cem.2018.22
Keywords: TXA; Trauma; bleeding; compliance; emergency; massive hemorrhage; resuscitation; tranexamic acid; transfusion

Original Research

Introduction : Current practice for the treatment of traumatic hemorrhage includes fluid resuscitation and the administration of blood products. The administration of tranexamic acid (TXA) within 8 hours of injury has been shown to significantly reduce mortality in a large, prospective, randomized controlled trial. As a result, TXA is widely used in trauma centres to manage trauma patients with major bleeding. The primary aim of this study was to assess the compliance of TXA administration at a level-one trauma centre in Hamilton, Ontario, Canada.

Méthode : We conducted a retrospective medical record review of consecutive adult trauma patients received at the Hamilton General Hospital between January 1, 2012 and December 31, 2014. Compliance with TXA administration was based on the inclusion criteria of the CRASH-2 trial.

Résultats : Five hundred and thirty-four of 2,475 trauma patients met the inclusion criteria for TXA administration. Twenty-one patients who received TXA at peripheral hospital prior to their arrival at the level-one trauma centre were excluded from the analysis, and 18 patients were excluded due to missing data. One hundred and thirty-four patients received TXA, representing a compliance rate of 27%. Mean time from arrival to TXA administration was 47 minutes. Compliance increased for those who required massive transfusion and as the number of criteria for TXA administration increased.

Conclusion : Compliance with TXA administration to trauma patients with suspected major bleeding was low. Quality improvement strategies aimed at increasing appropriate use of TXA are warranted.

Conclusion (proposition de traduction) : L'observance de l'administration d'acide tramexanique chez les patients traumatisés suspecté de présenter un saignement majeur était faible. Des stratégies d'amélioration de la qualité visant à accroître l'utilisation appropriée du d'acide tramexanique sont névessaires.

Rates and predictive factors of return to the emergency department following an initial release by the emergency department for acute heart failure.
Claret PG, Calder LA, Stiell IG, Yan JW, Clement CM, Borgundvaag B, Forster AJ, Perry JJ, Rowe BH. | CJEM. 2018 Mar;20(2):222-229
DOI: https://doi.org/10.1017/cem.2017.14
Keywords: cohort studies; emergency service; heart failure; multivariate analysis; risk assessment

Original Research

Introduction : Following release by emergency department (ED) for acute heart failure (AHF), returns to ED represent important adverse health outcomes. The objective of this study was to document relapse events and factors associated with return to ED in the 14-day period following release by ED for patients with AHF.

Méthode : The primary outcome was the number of return to ED for patients who were release by ED after the initial visit, for any related medical problem within 14 days of this initial ED visit.

Résultats : Return visits to the EDs occurred in 166 (20%) patients. Of all patients who returned to ED within the 14-day period, 77 (47%) were secondarily admitted to the hospital. The following factors were associated with return visits to ED: past medical history of percutaneous coronary intervention or coronary artery bypass graft (aOR=1.51; 95% CIs [1.01-2.24]), current use of antiarrhythmics medications (1.96 [1.05-3.55]), heart rate above 80 /min (1.89 [1.28-2.80]), systolic blood pressure below 140 mm Hg (1.67[1.14-2.47]), oxygen saturation (SaO2) above 96% (1.58 [1.08-2.31]), troponin above the upper reference limit of normal (1.68 [1.15-2.45]), and chest X-ray with pleural effusion (1.52 [1.04-2.23]).

Conclusion : Many heart failure patients (i.e. 1 in 5 patients) are released from the ED and then suffer return to ED. Patients with multiple medical comorbidities, and those with abnormal initial vital signs are at increased risk for return to ED and should be identified.

Conclusion (proposition de traduction) : De nombreux patients souffrant d'insuffisance cardiaque (c'est-à-dire 1 patient sur 5) sont sortant du service des urgences et nécessitent ensuite un retour aux urgences. Les patients présentant de multiples comorbidités médicales et ceux présentant des signes vitaux initiaux anormaux courent un risque accru de retour aux urgences et doivent être identifiés.

Self-awareness of computed tomography ordering in the emergency department.
Kadhim-Saleh A, Worrall JC, Taljaard M, Gatien M, Perry JJ. | CJEM. 2018 Mar;20(2):275-283
DOI: https://doi.org/10.1017/cem.2017.45
Keywords: computed tomography; cost-effectiveness; emergency department; practice variation; radiation; self-awareness

Original Research

Introduction : Physician variation in the use of computed tomography (CT) is concerning due to the risks of ionizing radiation, cost, and downstream effects of unnecessary testing. The objectives of this study were to describe variation in CT-ordering rates among emergency physicians (EPs), to measure correlation between perceived and actual CT-ordering rates, to assess attitudes that influence decisions to order imaging tests, and to identify EP attitudes associated with higher CT utilization.

Méthode : This study was a retrospective review of imaging and administrative billing records at two emergency department sites of a tertiary care adult teaching hospital. The study also included a cross-sectional survey of EPs at this hospital. We asked physicians about their perceived ordering behaviour, and what factors influenced their decision to order a CT. We examined correlations between perceived and actual CT-ordering rates. We adjusted ordering rates for shift distribution using a logistic regression model and identified outlier physicians whose ordering rate was significantly lower or higher than expected. We used multivariable regression analysis to determine which survey responses predicted higher CT utilization.

Résultats : During the study period, 59 EPs saw 45,854 patients, and ordered 6,609 CTs - a mean ordering rate of 14.4% (standard deviation (SD)=4.3%). The ordering rate for individual physicians ranged from 5.9% to 25.9%. Of the 59 EPs, 13 EPs were low-ordering outliers; 12 were high-ordering outliers. Forty-five EPs (76.3%) completed the survey. Mean perceived ordering rate was 12.6%, and was weakly correlated with actual ordering (r=0.19, p=0.21). 42 EPs (93.3%) believed they ordered "about the same" or "fewer" CTs than their peers. Of the 17 EPs in the two highest ordering quintiles, only 3 (18%) knew they were high orderers. In the multivariable analysis, higher ordering was associated with increasing strength of response to the following predictors: medico-legal risk (relative risk [RR]=1.18, 95% CI: 1.03-1.21), risk of contrast (RR=1.14, 95% CI: 1.07-1.22), what colleagues would do (RR=1.09, 95% CI: 0.99-1.19), risk of missing a diagnosis (RR=1.08, 95% CI: 0.98-1.21), and patient wishes (RR=1.07, 95% CI: 0.97-1.17).

Conclusion : There is large variation in CT ordering among EPs. Physicians' self-reported ordering rate correlates poorly with actual ordering. High CT orderers were rarely aware that they ordered more than their colleagues. Higher rates of ordering were observed among physicians who reported increased concern with 1) risk of missing a diagnosis, 2) medico-legal risk, 3) risk of contrast, 4) patient wishes, and 5) what colleagues would do.

Conclusion (proposition de traduction) : Il y a une grande variation dans la prescription de tomodensitométries parmi les médecins d'urgence. Le taux de prescription autodéclaré des médecins est faiblement corrélé avec l'importance de la prescription réelle. Les prescripteurs importants de tomodensitométrie étaient rarement conscients qu'ils prescrivaient plus que leurs collègues.
Des taux de prescriptions plus importantes ont été observés chez les médecins qui ont exprimé des préoccupations accrues avec 1) le risque de rater un diagnostic, 2) le risque médico-légal, 3) le risque de contraste, 4) les demandes du patient et 5) ce que les collègues feraient.

The Use of M-Mode Ultrasonography to Differentiate the Causes of B Lines.
Singh AK, Mayo PH, Koenig S, Talwar A, Narasimhan M. | Chest. 2018 Mar;153(3):689-696
DOI: https://doi.org/10.1016/j.chest.2017.10.019
Keywords: M-mode ultrasonography; lung ultrasonography; pulmonary edema

Original research article

Introduction : The presence of B lines on lung ultrasonography is a characteristic feature of both cardiogenic pulmonary edema (CPE) and noncardiogenic alveolar interstitial syndrome (NCAIS), so their presence does not allow the clinician to differentiate between the two entities. Our study used M-mode ultrasonography of the pleura to differentiate CPE from NCAIS.

Méthode : A total of 43 subjects were enrolled in the study, and based on history, physical examination, and chart review, the patients were divided into three groups: an NCAIS group, a CPE group, and a control group. Three distinct pleural line morphologic categories were identified: a continuous pleural line, a fragmented pleural line, and a sinusoidal pleural line. In addition, two separate subpleural patterns were independently identified by the investigators: a horizontal pattern and a vertical pattern. These pleural and subpleural patterns were correlated with subject diagnoses.

Résultats : A fragmented pleural line and a vertical subpleural pattern on M-mode ultrasonography is associated with patients who have NCAIS. Most patients with CPE have a continuous pleural line and a vertical subpleural pattern on M-mode ultrasonography. A sinusoidal pleural line on M-mode ultrasonography is suggestive of the presence of a pleural effusion.

Conclusion : Our results indicate that M-mode ultrasonography is useful to distinguish CPE from NCAIS based on the pleural and the subpleural morphologic features.

Conclusion (proposition de traduction) : Nos résultats indiquent que l'échographie en mode M est utile pour distinguer l'œdème pulmonaire cardiogène du syndrome interstitiel alvéolaire non cardiogène basé sur les caractéristiques morphologiques pleurales et sous-pleurales.

A Comparison of the Quick-SOFA and Systemic Inflammatory Response Syndrome Criteria for the Diagnosis of Sepsis and Prediction of Mortality: A Systematic Review and Meta-Analysis.
Serafim R, Gomes JA, Salluh J, Póvoa P. | Chest. 2018 Mar;153(3):646-655
DOI: https://doi.org/10.1016/j.chest.2017.12.015
Keywords: SIRS criteria; prediction of mortality; qSOFA; sepsis diagnosis

Original research article

Introduction : Several studies were published to validate the quick Sepsis-related Organ Failure Assessment (qSOFA), namely in comparison with the systemic inflammatory response syndrome (SIRS) criteria. We performed a systematic review and meta-analysis with the aim of comparing the qSOFA and SIRS in patients outside the ICU.

Méthode : We searched MEDLINE, CINAHL, and the Web of Science database from February 23, 2016 until June 30, 2017 to identify full-text English-language studies published after the Sepsis-3 publication comparing the qSOFA and SIRS and their sensitivity or specificity in diagnosing sepsis, as well as hospital and ICU length of stay and hospital mortality. Data extraction from the selected studies followed the recommendations of the Meta-analyses of Observational Studies in Epidemiology group and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Résultats : From 4,022 citations, 10 studies met the inclusion criteria. Pooling all the studies, a total of 229,480 patients were evaluated. The meta-analysis of sensitivity for the diagnosis of sepsis comparing the qSOFA and SIRS was in favor of SIRS (risk ratio [RR], 1.32; 95% CI, 0.40-2.24; P < .0001; I2 = 100%). One study described the specificity for the diagnosis of infection comparing SIRS (84.4%; 95% CI, 76.2-90.6) with the qSOFA (97.3%; 95% CI < 92.1-99.4); the qSOFA demonstrated better specificity. The meta-analysis of the area under the receiver operating characteristic curve of six studies comparing the qSOFA and SIRS favored the qSOFA (RR, 0.03; 95% CI, 0.01-0.05; P = .002; I2 = 48%) as a predictor of inhospital mortality.

Conclusion : The SIRS was significantly superior to the qSOFA for sepsis diagnosis, and the qSOFA was slightly better than the SIRS in predicting hospital mortality. The association of both criteria could provide a better model to initiate or escalate therapy in patients with sepsis.

Conclusion (proposition de traduction) : Le SIRS était significativement supérieur au qSOFA pour le diagnostic de septicémie, et le qSOFA était légèrement meilleur que le SIRS pour prédire la mortalité hospitalière. L'association des deux critères pourrait fournir un meilleur modèle pour amorcer ou intensifier le traitement chez les patients atteints de septicémie.

Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease.
Walters JA, Tan DJ, White CJ, Wood-Baker R. | Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897
DOI: https://doi.org/10.1002/14651858.CD006897.pub4
Keywords: Aucun

Review

Introduction : Current guidelines recommend that patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) should be treated with systemic corticosteroid for seven to 14 days. Intermittent systemic corticosteroid use is cumulatively associated with adverse effects such as osteoporosis, hyperglycaemia and muscle weakness. Shorter treatment could reduce adverse effects.
OBJECTIVES: To compare the efficacy of short-duration (seven or fewer days) and conventional longer-duration (longer than seven days) systemic corticosteroid treatment of adults with acute exacerbations of COPD.

Méthode : Searches were carried out using the Cochrane Airways Group Specialised Register of Trials, MEDLINE and CENTRAL (Cochrane Central Register of Controlled Trials) and ongoing trials registers up to March 2017.
SELECTION CRITERIA: Randomised controlled trials comparing different durations of systemic corticosteroid defined as short (i.e. seven or fewer days) or longer (i.e. longer than seven days). Other interventions-bronchodilators and antibiotics-were standardised. Studies with participants requiring assisted ventilation were excluded.
DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as expected by The Cochrane Collaboration.

Résultats : Eight studies with 582 participants met the inclusion criteria, of which five studies conducted in hospitals with 519 participants (range 28 to 296) contributed to the meta-analysis. Mean ages of study participants were 65 to 73 years, the proportion of male participants varied (58% to 84%) and COPD was classified as severe or very severe. Corticosteroid treatment was given at equivalent daily doses for three to seven days for short-duration treatment and for 10 to 15 days for longer-duration treatment. Five studies administered oral prednisolone (30 mg in four, tapered in one), and two studies provided intravenous corticosteroid treatment. Studies contributing to the meta-analysis were at low risk of selection, performance, detection and attrition bias. In four studies we did not find a difference in risk of treatment failure between short-duration and longer-duration systemic corticosteroid treatment (n = 457; odds ratio (OR) 0.72, 95% confidence interval (CI) 0.36 to 1.46)), which was equivalent to 22 fewer per 1000 for short-duration treatment (95% CI 51 fewer to 34 more). No difference in risk of relapse (a new event) was observed between short-duration and longer-duration systemic corticosteroid treatment (n = 457; OR 1.04, 95% CI 0.70 to 1.56), which was equivalent to nine fewer per 1000 for short-duration treatment (95% CI 68 fewer to 100 more). Time to the next COPD exacerbation did not differ in one large study that was powered to detect non-inferiority and compared five days versus 14 days of systemic corticosteroid treatment (n = 311; hazard ratio 0.95, 95% CI 0.66 to 1.37). In five studies no difference in the likelihood of an adverse event was found between short-duration and longer-duration systemic corticosteroid treatment (n = 503; OR 0.89, 95% CI 0.46 to 1.69, or nine fewer per 1000 (95% CI 44 fewer to 51 more)). Length of hospital stay (n = 421; mean difference (MD) -0.61 days, 95% CI -1.51 to 0.28) and lung function at the end of treatment (n = 185; MD FEV1 -0.04 L; 95% CI -0.19 to 0.10) did not differ between short-duration and longer-duration treatment.

Conclusion : Information from a new large study has increased our confidence that five days of oral corticosteroids is likely to be sufficient for treatment of adults with acute exacerbations of COPD, and this review suggests that the likelihood is low that shorter courses of systemic corticosteroids (of around five days) lead to worse outcomes than are seen with longer (10 to 14 days) courses. We graded most available evidence as moderate in quality because of imprecision; further research may have an important impact on our confidence in the estimates of effect or may change the estimates. The studies in this review did not include people with mild or moderate COPD; further studies comparing short-duration systemic corticosteroid versus conventional longer-duration systemic corticosteroid for treatment of adults with acute exacerbations of COPD are required.

Conclusion (proposition de traduction) : Les informations issues d'une nouvelle étude de grande échelle ont augmenté notre degré de confiance dans le fait que cinq jours de corticoïdes oraux sont susceptibles d'être suffisants pour le traitement des adultes souffrant d'exacerbations aiguës de BPCO, et cette revue suggère que la probabilité est faible que des traitements plus courts de corticoïdes systémiques (d'environ cinq jours) conduisent à de plus mauvais résultats que ceux observés avec des traitements plus longs (de 10 à 14 jours). Nous avons classé la plupart des preuves disponibles comme étant de qualité modérée en raison de l'imprécision ; des recherches supplémentaires pourraient avoir un impact important sur notre degré de confiance dans les estimations de l'effet ou pourraient modifier les estimations. Les études incluses dans cette revue n'incluaient pas de personnes atteintes de BPCO légère ou modérée ; des études supplémentaires comparant la corticothérapie systémique de courte durée par rapport à la corticothérapie systémique conventionnelle de plus longue durée pour le traitement des adultes souffrant d'exacerbations aiguës de la BPCO sont nécessaires.

A Systematic Review of the High-flow Nasal Cannula for Adult Patients.
Helviz Y, Einav S. | Crit Care. 2018 Mar 20;22(1):71
DOI: https://doi.org/10.1186/s13054-018-1990-4  | Télécharger l'article au format  
Keywords: Aucun

Review

Editorial : Over the last 10 years, HFNCs have had widespread uptake in the adult population. The idea that one may provide NIV with little discomfort to the patient is conceptually attractive. However, there is still much de- bate regarding the role of the HFNC in the management of critically ill patients and only recently has some better quality research emerged on the topic. This review covers the potential beneficial and deleterious effects of the HFNC and the latest evidence regarding its use in some of the more common clinical settings.

Conclusion : The HFNC seems more effective than conventional oxygen therapy and non-inferior to NIV in most studies. The quality of data on the HFNC is slightly better re- garding patients post-extubation, but there is need for more studies even in this clinical setting to generate a clearer signal. The HFNC seems to hold promise for ap- neic oxygenation during airway instrumentation but the studies performed on this topic have largely been under- powered. With regards to provision of HFNC therapy to immune compromised patients and those requiring palliative care, the retrospective nature of the studies performed thus far precludes determination of any causative association between patient management and outcome. However, there may be ethical considerations for providing this treatment in some cases.

Conclusion (proposition de traduction) : La HFNC semble plus efficace que l'oxygénothérapie conventionnelle et non inférieure à la VNI dans la plupart des études. La qualité des données sur le HFNC est légèrement meilleure en ce qui concerne les patients après l'extubation, mais il y a besoin de plus d'études même dans ce contexte clinique pour générer un signal plus clair. La HFNC semble prometteuse pour l'oxygénation avant l'intubation lors de l'instrumentation des voies aériennes, mais les études réalisées sur ce sujet ont été largement sous-alimentées. En ce qui concerne l'administration de l'HFNC aux patients immunocompromis et à ceux nécessitant des soins palliatifs, la nature rétrospective des études réalisées jusqu'à maintenant exclut la détermination de toute association causale entre la prise en charge du patient et le résultat. Cependant, il peut y avoir des considérations éthiques pour fournir ce traitement dans certains cas.

The efficacy and safety of pre-hospital cooling after out-of-hospital cardiac arrest: a systematic review and meta-analysis.
Lindsay PJ, Buell D, Scales DC. | Crit Care. 2018 Mar 13;22(1):66
DOI: https://doi.org/10.1186/s13054-018-1984-2  | Télécharger l'article au format  
Keywords: Cooling; Out-of-hospital cardiac arrest; Pre-hospital; Therapeutic hypothermia

Research

Introduction : Mild therapeutic hypothermia (TH), or targeted temperature management, improves survival and neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA). International guidelines strongly support initiating TH for all eligible individuals presenting with OHCA; however, the timing of cooling initiation remains uncertain. This systematic review and meta-analysis was conducted with all available randomised controlled trials (RCTs) included to explore the efficacy and safety of initiating pre-hospital TH in patients with OHCA.

Méthode : The MEDLINE and Cochrane databases were searched from inception to October 2017. Inclusion criteria for full-text review included RCTs comparing pre-hospital TH with no pre-hospital TH after cardiac arrest, patients > 14 years of age with documented cardiac arrest from any rhythm, and outcome data that included survival to hospital discharge and temperature at hospital arrival. Results of retrieved studies were compared through meta-analysis using random effects modelling.

Résultats : A total of 10 trials comprising 4220 patients were included. There were no significant differences between the two arms for the primary outcome of neurological recovery (risk ratio [RR] 1.04, 95% CI 0.93-1.15) or the secondary outcome of survival to hospital discharge (RR 1.01, 95% CI 0.92-1.11). However, there was a significantly lower temperature at hospital arrival in patients receiving pre-hospital TH (mean difference - 0.83, 95% CI - 1.03 to - 0.63). Pre-hospital TH significantly increased the risk of re-arrest (RR 1.19, 95% CI 1.00 to 1.41). No survival differences were observed among subgroups of patients who received intra-arrest TH vs post-arrest TH or who had shockable vs non-shockable rhythms.

Conclusion : Pre-hospital TH after OHCA effectively decreases body temperature at the time of hospital arrival. However, it does not improve rates of survival with good neurological outcome or overall survival and is associated with increased rates of re-arrest.

Conclusion (proposition de traduction) : Le refroidissement pré-hospitalier après arrêt cardiaque extrahospitalier diminue efficacement la température corporelle au moment de l'arrivée à l'hôpital.
Cependant, elle n'améliore pas les taux de survie avec de bons résultats neurologiques ou de survie globale et est associée à des taux accrus de nouvel arrêt cardiaque.

Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis.
Smit JM, Raadsen R, Blans MJ, Petjak M, Van de Ven PM, Tuinman PR. | Crit Care. 2018 Mar 13;22(1):65
DOI: https://doi.org/10.1186/s13054-018-1989-x  | Télécharger l'article au format  
Keywords: CVC malposition; Central venous catheter; Chest x-ray; Iatrogenic complications; Meta-analysis; Pneumothorax; Ultrasound

review

Introduction : Insertion of a central venous catheter (CVC) is common practice in critical care medicine. Complications arising from CVC placement are mostly due to a pneumothorax or malposition. Correct position is currently confirmed by chest x-ray, while ultrasonography might be a more suitable option. We performed a meta-analysis of the available studies with the primary aim of synthesizing information regarding detection of CVC-related complications and misplacement using ultrasound (US).

Méthode : This is a systematic review and meta-analysis registered at PROSPERO (CRD42016050698). PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Articles which reported the diagnostic accuracy of US in detecting the position of CVCs and the mechanical complications associated with insertion were included. Primary outcomes were specificity and sensitivity of US. Secondary outcomes included prevalence of malposition and pneumothorax, feasibility of US examination, and time to perform and interpret both US and chest x-ray. A qualitative assessment was performed using the QUADAS-2 tool.

Résultats : We included 25 studies with a total of 2548 patients and 2602 CVC placements. Analysis yielded a pooled specificity of 98.9 (95% confidence interval (CI): 97.8-99.5) and sensitivity of 68.2 (95% CI: 54.4-79.4). US examination was feasible in 96.8% of the cases. The prevalence of CVC malposition and pneumothorax was 6.8% and 1.1%, respectively. The mean time for US performance was 2.83 min (95% CI: 2.77-2.89 min) min, while chest x-ray performance took 34.7 min (95% CI: 32.6-36.7 min). US was feasible in 97%. Further analyses were performed by defining subgroups based on the different utilized US protocols and on intra-atrial and extra-atrial misplacement. Vascular US combined with transthoracic echocardiography was most accurate.

Conclusion : US is an accurate and feasible diagnostic modality to detect CVC malposition and iatrogenic pneumothorax. Advantages of US over chest x-ray are that it can be performed faster and does not subject patients to radiation. Vascular US combined with transthoracic echocardiography is advised. However, the results need to be interpreted with caution since included studies were often underpowered and had methodological limitations. A large multicenter study investigating optimal US protocol, among other things, is needed.

Conclusion (proposition de traduction) : L'échographie est une modalité diagnostique précise et faisable pour détecter la malposition d'un KTC et un pneumothorax iatrogène. Les avantages de l'échographie par rapport à la radiographie pulmonaire sont qu'elle peut être effectuée plus rapidement et qu'elle ne soumet pas les patients à l'exposition aux rayonnements ionisants. L'échocardiographie vasculaire combinée à l'échocardiographie transthoracique est conseillée. Toutefois, les résultats doivent être interprétés avec prudence, car les études retenues étaient souvent en sous-effectifs et présentaient des limites méthodologiques. Une vaste étude multicentrique sur le protocole d'échographie optimal, entre autres choses, serait nécessaire.

Neuromuscular blockade is associated with the attenuation of biomarkers of epithelial and endothelial injury in patients with moderate-to-severe acute respiratory distress syndrome.
Sottile PD, Albers D, Moss MM. | Crit Care. 2018 Mar 10;22(1):63
DOI: https://doi.org/10.1186/s13054-018-1974-4  | Télécharger l'article au format  
Keywords: Adult; Biomarkers; Mechanical; Neuromuscular blockade; Respiratory distress syndrome; Ventilator-induced lung injury; Ventilators

Research

Introduction : Neuromuscular blockade (NMB) is a therapy for acute respiratory distress syndrome (ARDS). However, the mechanism by which NMB may improve outcome for ARDS patients remains unclear. We sought to determine whether NMB attenuates biomarkers of epithelial and endothelial lung injury and systemic inflammation in ARDS patients, and whether the association is dependent on tidal volume size and the initial degree of hypoxemia.

Méthode : We performed a secondary analysis of patients enrolled in the ARDS network low tidal volume ventilation (ARMA) study. Our primary predictor variable was the number of days receiving NMB between study enrollment and day 3. Our primary outcome variables were the change in concentration of biomarkers of epithelial injury (serum surfactant protein-D (SP-D)), endothelial injury (von Willebrand factor (VWF)), and systemic inflammation (interleukin (IL)-8). Multivariable regression analysis was used to compare the change in biomarker concentration controlling for multiple covariates. Patients were stratified by treatment arm (12 versus 6 cm3/kg) and by an initial arterial oxygen tension (PaO2) to fractional inspired oxygen (FiO2) (P/F) ratio of 120.

Résultats : A total of 446 (49%) patients had complete SP-D, VWF, and IL-8 measurements on study enrollment and day 3. After adjusting for baseline differences, each day of NMB was associated with a decrease in SP-D (-23.7 ng/ml/day, p = 0.029), VWF (-33.5% of control/day, p = 0.015), and IL-8 (-362.6 pg/ml/day, p = 0.030) in patients with an initial P/F less than or equal to 120 and receiving low tidal volume ventilation. However, patients with a P/F ratio of greater than 120 or receiving high tidal volume ventilation had either no change or an increase in SP-D, WVF, or IL-8 concentrations.

Conclusion : NBM is associated with decreased biomarkers of epithelial and endothelial lung injury and systemic inflammation in ARDS patients receiving low tidal volume ventilation and those with a P/F ratio less than or equal to 120.

Conclusion (proposition de traduction) : La curarisation est associé à une diminution des biomarqueurs, des lésions pulmonaires épithéliales et endothéliales et de l'inflammation systémique chez les patients atteints du syndrome de détresse respiratoire aiguë recevant une ventilation à faible volume courant et ceux dont le rapport (PaO2/FiO2) de la pression artérielle de l'oxygène et de la fraction inspirée en oxygène est inférieur ou égal à 120.

Practice Patterns and Outcomes Associated With Early Sedation Depth in Mechanically Ventilated Patients: A Systematic Review and Meta-Analysis.
Stephens RJ, Dettmer MR, Roberts BW, Ablordeppey E, Fowler SA, Kollef MH, Fuller BM. | Crit Care Med. 2018 Mar;46(3):471-479
DOI: https://doi.org/10.1097/CCM.0000000000002885
Keywords: Aucun

Review Article

Introduction : Emerging data suggest that early deep sedation may negatively impact clinical outcomes. This systematic review and meta-analysis defines and quantifies the impact of deep sedation within 48 hours of initiation of mechanical ventilation, as described in the world's literature. The primary outcome was mortality. Secondary outcomes included hospital and ICU lengths of stay, mechanical ventilation duration, and delirium and tracheostomy frequency.

Méthode : Data Sources: The following data sources were searched: MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews and Effects, Cochrane Database of Systematic Reviews databases, ClinicalTrials.gov, conference proceedings, and reference lists.
Study Selection: Randomized controlled trials and nonrandomized studies were included.
Data Extraction: Two reviewers independently screened abstracts of identified studies for eligibility.

Résultats : Nine studies (n = 4,521 patients) published between 2012 and 2017 were included. A random effects meta-analytic model revealed that early light sedation was associated with lower mortality (9.2%) versus deep sedation (27.6%) (odds ratio, 0.34 [0.21-0.54]). Light sedation was associated with fewer mechanical ventilation (mean difference, -2.1; 95% CI, -3.6 to -0.5) and ICU days (mean difference, -3.0 (95% CI, -5.4 to -0.6). Delirium frequency was 28.7% in the light sedation group and 48.5% in the deep sedation group, odds ratio, 0.50 (0.22-1.16).

Conclusion : Deep sedation in mechanically ventilated patients, as evaluated in a small number of qualifying heterogeneous randomized controlled trials and observational studies, was associated with increased mortality and lengths of stay. Interventions targeting early sedation depth assessment, starting in the emergency department and subsequent ICU admission, deserve further investigation and could improve outcome.

Conclusion (proposition de traduction) : La sédation profonde chez les patients ventilés mécaniquement, telle qu'évaluée dans un petit nombre d'essais comparatifs hétérogènes randomisés et d'études observationnelle, a été associée à une augmentation de la mortalité et de la durée du séjour. Les interventions visant l'évaluation précoce de la profondeur de la sédation, en commençant aux urgences et à l'admission en filière à l'USI, méritent un examen plus approfondi et pourraient améliorer les résultats.

Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility.
Kyle T, Greaves I, Beynon A, Whittaker V, Brewer M, Smith J. | Emerg Med J. 2018 Mar;35(3):176-179
DOI: https://doi.org/10.1136/emermed-2017-206717
Keywords: major trauma management; military; prehospital care

Original research

Introduction : Hypocalcaemia is a common metabolic derangement in critically ill patients. Blood transfusion can also contribute to depleted calcium levels. The aims of this study were to identify the incidence of hypocalcaemia in military trauma patients receiving blood products en route to a deployed hospital facility and to determine if intravenous calcium, given during the prehospital phase, has an effect on admission calcium levels.

Méthode : This was a retrospective review of patients transported by the UK Medical Emergency Response Team in Afghanistan between January 2010 and December 2014 who were treated with blood products in the prehospital setting. Total units of blood products administered, basic demographics, Injury Severity Score and trauma type were collected. Ionised serum calcium levels on admission to hospital were compared between those who received blood products without prehospital intravenous calcium supplemental therapy (non-treatment) and patients who were treated with 10 mL of intravenous calcium chloride (10%) concurrently with blood products (treatment).

Résultats : The study included 297 patients; 237 did not receive calcium and 60 did. The incidence of hypocalcaemia in the non-treatment group was 70.0% (n=166) compared with 28.3% (n=17) in the treatment group. Serum calcium levels were significantly different between the groups (1.03 mmol/L vs 1.25 mmol/L, difference 0.22 mmol/L, 95% CI 0.15 to 0.27). In the non-treatment group, 26.6% (n=63) had calcium levels within the normal range compared with 41.7% (n=25) in those who received calcium. There was a dose response of calcium level to blood products with a significant decrease in calcium levels as the volume of blood products increased.

Conclusion : Trauma patients who received blood products were at high risk of hypocalcaemia. Aggressive management of these patients with intravenous calcium during transfusion may be required.

Conclusion (proposition de traduction) : Les patients traumatisés ayant été transfusé avec des produits sanguins présentaient un risque élevé d'hypocalcémie. Une prise en charge agressive de ces patients par des injections intraveineuses de calcium pendant la transfusion peut être nécessaire.

Understanding cardiac troponin part 2: early rule out of acute coronary syndrome.
Carlton E, Body R. | Emerg Med J. 2018 Mar;35(3):192-197
DOI: https://doi.org/10.1136/emermed-2017-207161
Keywords: acute coronary syndrome; acute myocardial infarct

Review

Editorial : Chest pain of suspected cardiac origin is a very common emergency department presentation. Over the past decade, there has been an exponential growth in strategies that promote blood sampling at earlier and earlier time points after presentation to facilitate the rule out of acute coronary syndrome.In part 2 of this series, we examine key concepts from the recent literature with the aim of improving clinicians' understanding of the rule-out strategies available to them and provide a structured overview of strategies that facilitate discharge with blood testing over <3 hours.

Conclusion (proposition de traduction) : La douleur thoracique évocatrice d'une origine cardiaque est une présentation très courante au service des urgences. Au cours de la dernière décennie, il y a eu une croissance exponentielle de stratégies qui testaient l'évaluation sanguine précoce et le plus rapidement après l’admission pour faciliter l'exclusion du syndrome coronarien aigu. Dans la deuxième partie de cette revue, nous examinons les concepts clés issus de la littérature récente dans le but d'améliorer la compréhension des stratégies d'exclusion pour les cliniciens et de fournir une vue d'ensemble structurée des stratégies qui facilitent la sortie avec des tests sanguins en moins de 3 heures.

Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial.
Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, Vangaveti VN, Ray R. | Emerg Med J. 2018 Mar;35(3):179-184
DOI: https://doi.org/10.1136/emermed-2017-206787
Keywords: analgesia/pain control; pain management

Original article

Introduction : To determine if intravenous paracetamol was superior to oral paracetamol as an adjunct to opioids in the management of moderate to severe pain in the ED setting

Méthode : A prospective, randomised, double-blind, double-dummy, controlled trial was conducted at a single academic tertiary care ED. Adult patients with moderate to severe pain were randomly assigned to receive either the intravenous paracetamol or oral paracetamol. The primary outcome was Visual Analogue Scale (VAS) pain reduction at 30 min. A clinically significant change in pain was defined as 13 mm.

Résultats : 87 participants were included in the final analysis, with a median age of 43.5 years and 59.8% were female. Overall mean baseline VAS pain score was 67.9 mm (±16.0). Both formulations achieved a clinically significant mean pain score reduction at 30 min, with no significant difference between the groups with 16.0 mm (SD 19.1 mm) in the intravenous group and 14.6 mm (SD 26.4) in the oral group; difference -1.4 mm (95% CI -11.6 to 8.8, P=0.79). Secondary outcomes, including postintervention intravenous opioid administration, patient satisfaction, side effects and length of stay, did not differ between groups.

Conclusion : Overall, there was a small but clinically significant decrease in pain in each group. No superiority was demonstrated in this trial with intravenous paracetamol compared with oral paracetamol in terms of efficacy of analgesia and no difference in length of stay, patient satisfaction, need for rescue analgesia or side effects.

Conclusion (proposition de traduction) : Dans l'ensemble, il y a eu une diminution faible mais cliniquement significative de la douleur dans chaque groupe. Aucune supériorité n'a été démontrée dans cette étude avec le paracétamol par voie intraveineuse comparé au paracétamol oral en termes d'efficacité de l'analgésie et aucune différence de durée de séjour, de satisfaction du patient, de besoin d'analgésie de secours ou d'effets secondaires.

2018 ESC Guidelines for the diagnosis and management of syncope.
Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG; ESC Scientific Document Group. | Eur Heart J. 2018 Mar 19
DOI: https://doi.org/10.1093/eurheartj/ehy037
Keywords: Aucun

ESC guidelines

Editorial : The first ESC Guidelines for the management of syncope were published in 2001, with subsequent versions in 2004 and 2009. In March 2015, the ESC CPG considered that there were enough new data to justify the production of new Guidelines. The most important aspect characterizing this document is the composition of the Task Force, which is truly multidisciplinary. Cardiologists form a minority of the panel; experts in emergency medicine, internal medicine and physiology, neurology and autonomic diseases, geriatric medicine, and nursing cover all aspects of management of the various forms of syncope and transient loss of consciousness (TLOC).

Conclusion : The ESC Task Force has selected 19 simple rules   to guide the diagnosis and management of syncope patients with TLOC according to the 2018 ESC Guidelines on syncope.
Diagnosis: initial evaluation (1 to 8).
Diagnosis: subsequent investigations (9 to 13).
Treatment (14 to 19).

Conclusion (proposition de traduction) : Recommandations

Ceftriaxone promotes the emergence of AmpC-overproducing Enterobacteriaceae in gut microbiota from hospitalized patients.
de Lastours V, Goulenok T, Guérin F, Jacquier H, Eyma C, Chau F, Cattoir V, Fantin B. | Eur J Clin Microbiol Infect Dis. 2018 Mar;37(3):417-421
DOI: https://doi.org/10.1007/s10096-018-3186-x
Keywords: Aucun

Original Article

Editorial : Epidemiological data suggest that ceftriaxone may promote the emergence of commensal AmpC-overproducing Enterobacteriaceae because of a high biliary excretion. We tested this hypothesis in hospitalized patients either treated by ceftriaxone alone or receiving no antibiotics. Hospitalized patients with no previous antibiotics or hospitalization in the last 3 months, treated only with ceftriaxone, were prospectively included. For each ceftriaxone-treated patient, a control patient receiving no antibiotics was included. Clinical data and stools were collected at T0 (before antibiotics) and T1 (at the end of ceftriaxone treatment or at discharge) and T2 (3-6 months after T1) for the ceftriaxone-treated patients and at T0 and T1 for control patients. Third-generation cephalosporin-resistant Enterobacteriaceae were detected, identified by matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF), and characterized genetically. Clonal relatedness was evaluated by random amplified polymorphic DNA-polymerase chain reaction (RAPD-PCR). Fifteen ceftriaxone and 22 control patients were included. Patients' characteristics did not differ. At T0, 2/15 ceftriaxone-treated versus 1/22 control patients carried third-generation cephalosporin-resistant Enterobacteriaceae (p = 0.6). At T1, 4/15 (27%) ceftriaxone-treated patients carried AmpC producers versus 0/22 control patients (p = 0.02). Additionally, two and three subjects carried extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in the ceftriaxone and control groups, respectively (p = 1). At T2, three ceftriaxone-treated patients still carried AmpC-producing Enterobacteriaceae with the same RAPD profile as at T1. In hospitalized subjects with no other selective pressure, treatment by ceftriaxone alone promotes the gut colonization by AmpC-overproducing Enterobacteriaceae in over a quarter of patients, with a persistent carriage after the end of antibiotic exposure. The ecological impact of ceftriaxone should not be underestimated.

Conclusion : Because cefotaxime, another TGC, has much lower biliary excretion than ceftriaxone, it would be interesting to deter- mine whether the impact of cefotaxime is different on the gut microbiota in terms of emergence of bacterial resistance. This specific issue is currently under investigation in our cen- ter thanks to a randomized prospective study in healthy vol- unteers, which aims to compare the effects of a treatment by ceftriaxone versus cefotaxime on the emergence of resistant Enterobacteriaceae in the gut, as well as the broader impact on the gut microbiota.

Conclusion (proposition de traduction) : Puisque le céfotaxime, une autre céphalosporine de troisième génération, a une excrétion biliaire beaucoup plus faible que la ceftriaxone, il serait intéressant de déterminer si l'impact du céfotaxime est différent sur le microbiote intestinal en termes d'émergence de résistance bactérienne.
Ce dossier spécifique est actuellement investigué dans notre centre grâce à une étude prospective randomisée chez des volontaires sains, qui vise à comparer les effets d'un traitement par ceftriaxone versus céfotaxime sur l'émergence d'Enterobacteriaceae résistantes dans l'intestin, ainsi que l'impact plus large sur le microbiote intestinal.

Early decrease of oxidative stress by non-invasive ventilation in patients with acute respiratory failure.
Garramone A, Cangemi R, Bresciani E, Carnevale R, Bartimoccia S, Fante E, Corinti M, Brunori M, Violi F, Bertazzoni G, Pignatelli P. | Intern Emerg Med. 2018 Mar;13(2):183-190
DOI: https://doi.org/10.1007/s11739-017-1750-5
Keywords: Acute respiratory failure; NADPH-oxidase; Non-invasive ventilation; Oxidative stress

Original article

Introduction : Oxidative stress plays an important role in chronic respiratory diseases where the use of non-invasive ventilation seems to reduce the oxidative damage. Data on acute respiratory failure are still lacking.

Méthode : The aim of the study is to investigate the interplay between oxidative stress and acute respiratory failure, and the role of non-invasive ventilation in this setting.

Résultats : We enrolled 60 patients suffering from acute respiratory failure (PaO2/FiO2 ratio <300): 30 consecutive patients treated with non-invasive ventilation and 30 consecutive patients treated with conventional oxygen therapy. Serum levels of soluble Nox2-derived peptide (sNOX2-dp), a marker of NADPH-oxidase activation, and 8-iso-PGF2α and H2O2, markers of oxidative stress, were evaluated at baseline and after 3 h of treatment. At baseline, higher values of sNOX2-dp, 8-iso-PGF2α and H2O2 are associated with lower values of PaO2/FiO2 ratio (p < 0.001). After 3 h, serum levels of sNOX2-dp, H2O2, and 8-iso-PGF2α significantly decrease in patients treated with non-invasive ventilation, but not in patients treated with conventional oxygen therapy. Delta changes of oxidative stress parameters correlate inversely with the delta changes of PaO2/FiO2 (R = -0.623, p < 0.001 for sNOX2-dp; R = -0.428, p < 0.001 for H2O2; R = -0.548, p < 0.001 for 8-iso-PGF2α).

Conclusion : In the acute respiratory failure setting, treatment with non-invasive ventilation reduces the levels of oxidative stress in the first hours. This reduction is associated with an improvement of PaO2/FiO2 ratio as well as in a reduction of NADPH-oxidase activity.

Conclusion (proposition de traduction) : Dans le cadre d'une insuffisance respiratoire aiguë, le traitement par ventilation non invasive réduit les niveaux de stress oxydatif dans les premières heures. Cette réduction est associée à une amélioration du rapport PaO₂/FiO₂ ainsi qu'à une réduction de l'activité de la NADPH-oxydase.

Commentaire : Commentaire dans : Becatti M, Taddei N, Fiorillo C. Oxidative stress management during non-invasive ventilation in acute respiratory failure. Intern Emerg Med. 2018 Mar;13(2):141-142  .

Clinical chameleons: an emergency medicine focused review of carbon monoxide poisoning.
Ng PCY, Long B, Koyfman A. | Intern Emerg Med. 2018 Mar;13(2):223-229
DOI: https://doi.org/10.1007/s11739-018-1798-x
Keywords: Carbon monoxide; Chameleon; Headache; Hyperbaric oxygen; Vomiting

Review

Editorial : Carbon monoxide (CO) is a colorless, odorless gas that is found in the environment, in the home, and in the human body as a normal part of mammalian metabolism. Poisoning from CO, a common exposure, is associated with significant morbidity and mortality if not recognized and treated in a timely manner. This review evaluates the signs and symptoms of CO poisoning, conditions that present similar to CO poisoning, and an approach to the recognition and management for CO poisoning. CO poisoning accounts for thousands of emergency department visits annually. If not promptly recognized and treated, it leads to significant morbidity and mortality. CO poisoning poses a challenge to the emergency physician because it classically presents with non-specific symptoms such as headache, dizziness, nausea, and vomiting. Due to nonspecific presentations, it is easily mistaken for other, more benign diagnoses such as viral infection. The use of specific historical clues such as exposure to non-conventional heat sources or suicide attempts in garages, as well as the use of targeted diagnostic testing with CO-oximetry, can confirm the diagnosis of CO poisoning. Once diagnosed, treatment options range from observation to the use of hyperbaric oxygen. CO poisoning is an elusive diagnosis.

Conclusion : This review evaluates the signs and symptoms CO poisoning, common chameleons or mimics, and an approach to management of CO poisoning.

Conclusion (proposition de traduction) : Cette revue évalue les signes et les symptômes d'intoxication au CO, habituellement atypiques mimants une autre cause, et une approche de prise en charge de l'intoxication au CO.

Impact of red blood cell transfusion on acute coronary syndrome: a meta-analysis.
Wang Y, Shi X, Du R, Chen Y, Zhang Q. | Intern Emerg Med. 2018 Mar;13(2):231-241
DOI: https://doi.org/10.1007/s11739-016-1594-4
Keywords: Acute coronary syndrome; Meta-analysis; Red blood cell transfusion

Original article

Introduction : The impact of red blood cell transfusion on outcomes in patients with acute coronary syndrome is controversial.

Méthode : Pubmed, EMBASE, and Cochrane Library were searched for studies of red blood cell transfusion and acute coronary syndrome that were published in any language, from January 1, 1966, to April 1, 2016. We analyzed 17 observational studies, of 2,525,550 subjects. We conducted a systematic review with meta-analysis of studies assessing the association between blood transfusion and the risk for all-cause mortality and reinfarction.

Résultats : The search yielded 17 observational studies, of 2,525,550 subjects, during a study follow-up period, ranging from 30 days to 5 years. Red blood cell transfusion compared with no blood transfusion is associated with higher short- and long-term all-cause mortality as well as reinfarction rates (adjusted RR 2.23; 95% CI 1.47-3.39; HR 1.93; 95% CI 1.12-3.34; RR 2.61; 95% CI 2.17-3.14, respectively). In hemoglobin-stratified analyses, a graded association between red blood cell transfusion and mortality was observed, transfusion and risk of all-cause mortality was borderline significant at hemoglobin levels below 8.0 g/dL (RR 0.52; 95% CI 0.25-1.06), and was associated with an increased risk of mortality at a hemoglobin above 10 g/dL (RR 3.34; 95% CI 2.25-4.97).

Conclusion : Red blood cell transfusion was associated with an increased risk of short- and long-term mortality as well as myocardial reinfarction. However, transfusion appeared to have beneficial or neutral effects on mortality at hemoglobin levels below 8.0 g/dL, and harmful effects above 10 g/dL. A large definitive randomized controlled trial addressing this issue is urgently required.

Conclusion (proposition de traduction) : La transfusion de globules rouges était associée à un risque accru de mortalité à court et à long terme ainsi qu'à des récidives d'infarctus du myocarde. Cependant, la transfusion a semblé avoir des effets bénéfiques ou neutres sur la mortalité pour des taux d'hémoglobine inférieurs à 8,0 g/dL et des effets nocifs supérieurs à 10 g/dL. Un grand essai contrôlé randomisé définitif traitant de ce problème est urgent.

Novel ECG changes in acute coronary syndromes. Would improvement in the recognition of 'STEMI-equivalents' affect time until reperfusion?.
Wall J, White LD, Lee A. | Intern Emerg Med. 2018 Mar;13(2):243-249
DOI: https://doi.org/10.1007/s11739-016-1595-3
Keywords: Acute coronary syndrome; Coronary angiography; STEMI-equivalent

Original article

Editorial : Current guidelines recommend that patients with non-ST elevation myocardial infarction (NSTEMI) are treated with medical management alone, or in combination with coronary angiography within 24 h. Recent research suggests that NSTEMIs show angiographic evidence of complete occlusion at rates comparable to STEMIs, suggesting a subgroup of NSTEMI patients who require urgent angiography. Novel ECG changes, termed 'STEMI-equivalents', have been described as a way of identifying this subgroup. The aim of this study was to determine whether patients with STEMI-equivalent ECG changes experience similar degrees of myocardial damage, and would thus benefit from urgent PCI. Cardiac catheterisation databases at The Wollongong Hospital were searched for STEMI, and NSTEMI patients with complete occlusion of the culprit vessel, between January 2011 and December 2013. A total of 1429 patients underwent angiography during this time period. Of these, 220 were eligible for ECG analysis. We found 10-25% of NSTEMIs with 'STEMI equivalent' ECG changes correlated with complete vessel occlusion on angiography. These patients demonstrated equivalent initial troponin readings.

Conclusion : Recognition of STEMI-equivalents represent a chance for earlier intervention with prompt coronary angiography, as these findings are often associated with complete occlusion of the culprit vessel. These findings provide further evidence supporting the potential inclusion of STEMI-equivalents in future ACS guidelines.

Conclusion (proposition de traduction) : La reconnaissance des équivalents STEMI représente une chance pour une intervention précoce par angiographie coronaire rapide, car ces résultats sont souvent associés à une occlusion complète de l'artère en cause. Ces résultats amènent d'autres preuves à l'appui de l'inclusion potentielle des équivalents STEMI dans les futures lignes directrices sur les syndromes coronariens aigus.

Evaluation of a novel 5-group classification system of sepsis by vasopressor use and initial serum lactate in the emergency department.
Swenson KE, Dziura JD, Aydin A, Reynolds J, Wira CR. | Intern Emerg Med. 2018 Mar;13(2):257-268
DOI: https://doi.org/10.1007/s11739-017-1607-y
Keywords: Cryptic shock; Lactate; Sepsis; Septic shock; Severe sepsis; Vasopressor

Original article

Editorial : Prognostication in sepsis is limited by disease heterogeneity, and measures to risk-stratify patients in the proximal phases of care lack simplicity and accuracy. Hyperlactatemia and vasopressor dependence are easily identifiable risk factors for poor outcomes. This study compares incidence and hospital outcomes in sepsis based on initial serum lactate level and vasopressor use in the emergency department (ED). In a retrospective analysis of a prospectively identified dual-center ED registry, patients with sepsis were categorized by ED vasopressor use and initial serum lactate level. Vasopressor-dependent patients were categorized as dysoxic shock (lactate >4.0 mmol/L) and vasoplegic shock (≤4.0 mmol/L). Patients not requiring vasopressors were categorized as cryptic shock major (lactate >4.0 mmol/L), cryptic shock minor (>2.0 and ≤4.0 mmol/L), and sepsis without lactate elevation (≤2.0 mmol/L). Of 446 patients included, 4.9% (n = 22) presented in dysoxic shock, 11.7% (n = 52) in vasoplegic shock, 12.1% (n = 54) in cryptic shock major, 30.9% (n = 138) in cryptic shock minor, and 40.4% (n = 180) in sepsis without lactate elevation. Group mortality rates at 28 days were 50.0, 21.1, 18.5, 12.3, and 7.2%, respectively. After adjusting for potential confounders, odds ratios for mortality at 28 days were 15.1 for dysoxic shock, 3.6 for vasoplegic shock, 3.8 for cryptic shock major, and 1.9 for cryptic shock minor, when compared to sepsis without lactate elevation. Lactate elevation is associated with increased mortality in both vasopressor dependent and normotensive infected patients presenting to the emergency department (ED). Cryptic shock mortality (normotension + lactate >4 mmol/L) is equivalent to vasoplegic shock mortality (vasopressor requirement + lactate <4 mmol/L) in our population.

Conclusion : The odds of normotensive, infected patients decompensating is three to fourfold higher with hyperlactemia. The proposed Sepsis-3 definitions exclude an entire group of high-risk ED patients. A simple classification in the ED by vasopressor requirement and initial lactate level may identify high-risk subgroups of sepsis. This study may inform prognostication and triage decisions in the proximal phases of care.

Conclusion (proposition de traduction) : La probabilité de décompensation des patients normotendus infectés est trois à quatre fois plus élevées en présence d'une augmentation des lactates.
La définition Sepsis-3 a conduit à exclure tout un groupe de patients à risque élevé aux urgences.
Une classification simple au service des urgences, qui prend en compte les besoins en vasopresseurs et le taux initial de lactate, pourrait permettre d'identifier des sous-groupes de sepsis à haut risque. Cette étude peut améliorer la pronostication et les décisions du triage dans les phases initiales de soins.

Success rates of pre-hospital difficult airway management: a quality control study evaluating an in-hospital training program.
Trimmel H, Beywinkler C, Hornung S, Kreutziger J, Voelckel WG. | Int J Emerg Med. 2018 Mar 16;11(1):19
DOI: https://doi.org/10.1186/s12245-018-0178-7  | Télécharger l'article au format  
Keywords: Airway management; Austria; Bag-mask-valve ventilation; Crico-thyrotomy; Difficult airway algorithm; Emergency physician; Prehospital care; Supraglottic airway; Tracheal intubation

Educational advances in emergency medicine

Introduction : Competence in emergency airway management is key in order to improve patient safety and outcome. The scope of compulsory training for emergency physicians or paramedics is quite limited, especially in Austria. The purpose of this study was to review the difficult airway management performance of an emergency medical service (EMS) in a region that has implemented a more thorough training program than current regulations require, comprising 3 months of initial training and supervised emergency practice and 3 days/month of on-going in-hospital training as previously reported.

Méthode : This is a subgroup analysis of pre-hospital airway interventions performed by non-anesthesiologist EMS physicians between 2006 and 2016. The dataset is part of a retrospective quality control study performed in the ground EMS system of Wiener Neustadt, Austria. Difficult airway missions recorded in the electronic database were matched with the hospital information system and analyzed.

Résultats : Nine hundred thirty-three of 23060 ground EMS patients (4%) required an airway intervention. In 48 cases, transient bag-mask-valve ventilation was sufficient, and 5 patients needed repositioning of a pre-existing tracheostomy cannula. Eight hundred thirty-six of 877 patients (95.3%) were successfully intubated within two attempts; in 3 patients, a supraglottic airway device was employed first line. Management of 41 patients with failed tracheal intubation comprised laryngeal tubes (n = 21), intubating laryngeal mask (n = 11), ongoing bag-mask-valve ventilation (n = 8), and crico-thyrotomy (n = 1). There was no cannot intubate/cannot ventilate situation. Blood gas analysis at admission revealed hypoxemia in 2 and/or hypercapnia in 11 cases.

Conclusion : During the 11-year study period, difficult airways were encountered in 5% but sufficiently managed in all patients. Thus, the training regime presented might be a feasible and beneficial model for training of non-anesthesiologist emergency physicians as well as paramedics.

Conclusion (proposition de traduction) : Au cours de la période d'étude de 11 ans, une intubation difficile a été rencontrée dans 5 % des cas mais sans échec de l'intubation finale chez tous les patients.
Ainsi, le système de formation présenté pourrait être un modèle réalisable et bénéfique pour la formation des médecins urgentistes non anesthésistes ainsi que pour des ambulanciers paramédicaux (paramedics).

Diagnostic use of lung ultrasound compared to chest radiograph for suspected pneumonia in a resource-limited setting.
Amatya Y, Rupp J, Russell F3, Saunders J, Bales B, House DR. | Int J Emerg Med. 2018 Mar 12;11(1):8
DOI: https://doi.org/10.1186/s12245-018-0170-2  | Télécharger l'article au format  
Keywords: Developing countries; Diagnosis; Lung ultrasound; Nepal; Pneumonia

Original Research

Introduction : Lung ultrasound is an effective tool for diagnosing pneumonia in developed countries. Diagnostic accuracy in resource-limited countries where pneumonia is the leading cause of death is unknown. The objective of this study was to evaluate the sensitivity of bedside lung ultrasound compared to chest X-ray for pneumonia in adults presenting for emergency care in a low-income country.

Méthode : Patients presenting to the emergency department with suspected pneumonia were evaluated with bedside lung ultrasound, single posterioranterior chest radiograph, and computed tomography (CT). Using CT as the gold standard, the sensitivity of lung ultrasound was compared to chest X-ray for the diagnosis of pneumonia using McNemar's test for paired samples. Diagnostic characteristics for each test were calculated.

Résultats : Of 62 patients included in the study, 44 (71%) were diagnosed with pneumonia by CT. Lung ultrasound demonstrated a sensitivity of 91% compared to chest X-ray which had a sensitivity of 73% (p = 0.01). Specificity of lung ultrasound and chest X-ray were 61 and 50% respectively.

Conclusion : Bedside lung ultrasound demonstrated better sensitivity than chest X-ray for the diagnosis of pneumonia in Nepal.

Conclusion (proposition de traduction) : L'échographie pulmonaire au lit du patient a démontré une meilleure sensibilité que la radiographie pulmonaire pour le diagnostic de la pneumonie au Népal.

Predictor variables of abnormal imaging findings of syncope in the emergency department.
Ozturk K, Soylu E, Bilgin C, Hakyemez B, Parlak M. | Int J Emerg Med. 2018 Mar 12;11(1):16
DOI: https://doi.org/10.1186/s12245-018-0180-0  | Télécharger l'article au format  
Keywords: Computed tomography (CT); Emergency department (ED); Magnetic resonance imaging (MRI); Syncope

Original Research

Introduction : This study aimed to describe the pathological findings and to analyze clinical predictors of abnormal imaging findings in patients presenting to the emergency department (ED) with syncope.

Méthode : The database was retrospectively reviewed for all patients who underwent cranial computed tomography (CT) or magnetic resonance imaging (MRI), having the symptom of syncope. Patients were included only if they were from the emergency department and excluded if were under 18 years of age, had known recent intracranial pathology, known brain tumor, or having a history of trauma. The primary outcome was assumed as abnormal head CT or MRI including intracranial hemorrhage, acute or subacute stroke, and newly diagnosed brain mass. Univariate and multivariate logistic regression analysis was utilized to determine the association between clinical variables and any significant pathology in either CT or MR scan.

Résultats : Total of 1230 syncope (717 men and 513 women; range, 18-92 years; mean, 54.5 years) as presenting symptoms were identified in patients receiving either cranial CT or MR scan in the ED. Abnormal findings related to the syncope were observed in 47 (3.8%) patients. The following predictor variables were found to be significantly correlated with acutely abnormal head CT and MRI: a focal neurologic deficit, history of malignancy, hypertension, and age greater than 60 years.

Conclusion : Our data offer that the identification of predictor variables has a potential to decrease the routine use of head CT and MRI in patients admitting to the ED with syncope.

Conclusion (proposition de traduction) : Nos données montrent que l'identification de signes cliniques prédictifs ont le potentiel de diminuer l'utilisation systématique de la tomodensitométrie et de l'IRM crânienne chez les patients admis aux urgences pour une syncope.

Commentaire : C'est une étude rétrospective sur 1230 patients admis pour syncopes. Les signes cliniques identifiés pour nécessiter une imagerie crânienne sont : un déficit neurologique focalisé, des antécédents de cancer, d'hypertension et un âge supérieur à 60 ans.

Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures provide safe and effective pain relief: a prospective observational study in The Netherlands.
Ketelaars R, Stollman JT, van Eeten E, Eikendal T, Bruhn J, van Geffen GJ. | Int J Emerg Med. 2018 Mar 2;11(1):12
DOI: https://doi.org/10.1186/s12245-018-0173-z  | Télécharger l'article au format  
Keywords: Aucun

Original Research

Introduction : The treatment of acute pain in the emergency department is not always optimal. Peripheral nerve blocks using "blind" or nerve stimulator techniques have substantial disadvantages. Ultrasound-guided regional anesthesia may provide quick, safe, and effective pain relief in patients with proximal femoral fractures with severe pain. However, no evidence exists on emergency physician-performed ultrasound-guided regional anesthesia in these patients in Dutch emergency departments. We hypothesized that emergency physicians can be effectively trained to safely perform and implement ultrasound-guided femoral nerve blocks, resulting in effective pain relief in patients with proximal femoral fractures.

Méthode : In this prospective observational study, emergency physicians were trained by expert anesthesiologists to perform ultrasound-guided femoral nerve blocks during a single-day course. Femoral nerve blocks were performed on patients with proximal femoral fractures. A system of direct supervision by skilled anesthesiologists and residents was put in place.

Résultats : A total of 64 femoral nerve blocks were performed. After 30 min, blocks were effective in 69% of patients, and after 60 min, in 83.3%. The mean reduction in pain scores after 30 and 60 min was 3.84 and 4.77, respectively (both p <  0.001). Patients reported a mean satisfaction of 8.42 (1 to 10 scale). No adverse events occurred.

Conclusion : Ultrasound-guided femoral nerve block is an effective, safe, and easy to learn (single-day course) procedure for emergency physicians to implement and perform in the emergency department. Patient satisfaction was high.

Conclusion (proposition de traduction) : Le bloc nerveux écho-guidé est une procédure efficace, sûre et facile à apprendre (cours d'une journée) que les urgentistes peuvent mettre en place et exécuter dans les urgences. La satisfaction des patients était élevée.

A comparison between video laryngoscopy and direct laryngoscopy for endotracheal intubation in the emergency department: A meta-analysis of randomized controlled trials.
Bhattacharjee S, Maitra S, Baidya DK. | J Clin Anesth. 2018 Mar 14;47:21-26
DOI: https://doi.org/10.1016/j.jclinane.2018.03.006
Keywords: Direct laryngoscopy; Emergency department; Emergency intubation; Video laryngoscope; Video laryngoscopy

Original Contributions

Introduction : Direct laryngoscopy is the most commonly used modality for endotracheal intubation in the emergency department. Video laryngoscopy may improve glottic view during laryngoscopy and intubation success rate in such patients. This meta-analysis has been designed to compare clinical efficacy of video laryngoscopy with direct laryngoscopy for endotracheal intubation in the emergency department.

Méthode : Meta-analysis of randomized controlled trial.
SETTING: Randomized controlled trials comparing video laryngoscopy and direct laryngoscopy for endotracheal intubation in adult patients in emergency department. PubMed (1946 to 20th October 2017) and The Cochrane Library databases (CENTRAL) were searched for potentially eligible trials on 20th October 2017.
PATIENTS: Adult patients presenting in the emergency department.
INTERVENTIONS: Video laryngoscopy & direct laryngoscopy for intubation in emergency department.
MEASUREMENT: Primary outcome was 'first intubation success rate' and secondary outcomes were overall intubation success rate, in-hospital mortality and oesophageal intubation rate.

Résultats : Data of 1250 patients from 5 randomized controlled trials have been included in this study. Video laryngoscopy offers no advantage over direct laryngoscopy in terms of first intubation success rate (odds ratio 1.28, 95% CI 0.70, 2.36; p = 0.42), overall intubation success rate (OR 1.26, 95% CI 0.53, 3.01; p = 0.6) or in-hospital mortality (OR 1.25, 95% CI 0.8, 1.95; p = 0.32). However, oesophageal intubation rate is lower with the use of video laryngoscopy (OR 0.09, 95% CI 0.01, 0.7; p = 0.02).

Conclusion : Use of video laryngoscopy for emergency endotracheal intubation in adult patients is associated with reduced oesophageal intubation over direct laryngoscopy. However, no benefit was found in terms of overall intubation success.

Conclusion (proposition de traduction) : L'utilisation de la vidéo laryngoscopie pour l'intubation orotrachéale d'urgence chez les patients adultes est associée à une réduction de l'intubation œsophagienne par rapport à la laryngoscopie directe.
Cependant, aucun avantage n'a été trouvé en termes de succès global d'intubation.

Practical Use of Lactate Levels in the Intensive Care.
Vink EE, Bakker J. | J Intensive Care Med. 2018 Mar;33(3):159-165
DOI: https://doi.org/10.1177/0885066617708563
Keywords: initiation of treatment; intensive care; lactate; prognostication

Analytic Reviews

Editorial : Hyperlactatemia is a strong predictor of mortality in diverse populations of critically ill patients. In this article, we will give an overview of how lactate is used in the intensive care unit. We describe the use of lactate as a predictor of outcome, as a marker to initiate therapy and to monitor adequacy of initiated treatments.

Conclusion : The pathophysiology of hyperlactatemia is complex with hypoxic and nonhypoxic mechanisms, often coinciding. Hyperlactatemia is a strong predictor of mortality in diverse populations of critically ill patients. It is, however, still unclear how lactate levels influence clinical decision-making with regard to admission policies or end-of-life decisions. Increased lactate levels have a prominent place in the early treatment of critically ill patients, whereas the effects later on during ICU admission are unknown. A decrease in lactate levels following initiation of therapy is universally a good sign. An increase in lactate levels or even no change should warrant the treatment team to rethink the diagnosis and rationale of current treatment.

Conclusion (proposition de traduction) : La physiopathologie de l'hyperlactatémie est complexe avec des mécanismes hypoxiques et nonhypoxiques, qui coïncident souvent. L'hyperlactatémie est un puissant prédicteur de mortalité dans diverses populations de patients de réanimation. Cependant, on ne sait pas encore clairement comment les taux de lactate influencent la prise de décision clinique en ce qui concerne les politiques d'admission ou les décisions de fin de vie. L'augmentation des taux de lactate occupe une place prépondérante dans le traitement précoce des patients de réanimation, alors que les effets ultérieurs lors de l'admission à l'USI sont inconnus. Une diminution des taux de lactate après le début du traitement est universellement un bon signe. Une augmentation des taux de lactate ou même aucun changement devrait inciter l'équipe en charge du traitement a repenser le diagnostic et la raison d'être du traitement actuel.

Correlation of Venous Blood Gas and Pulse Oximetry With Arterial Blood Gas in the Undifferentiated Critically Ill Patient.
Zeserson E, Goodgame B, Hess JD, Schultz K, Hoon C, Lamb K, Maheshwari V, Johnson S, Papas M, Reed J, Breyer M. | J Intensive Care Med. 2018 Mar;33(3):176-181
DOI: https://doi.org/10.1177/0885066616652597  | Télécharger l'article au format  
Keywords: blood gas analysis; critical care; oximetry

Review of a Large Clinical Series

Introduction : Blood gas analysis is often used to assess acid-base, ventilation, and oxygenation status in critically ill patients. Although arterial blood gas (ABG) analysis remains the gold standard, venous blood gas (VBG) analysis has been shown to correlate with ABG analysis and has been proposed as a safer less invasive alternative to ABG analysis.
OBJECTIVE: The purpose of this study was to evaluate the correlation of VBG analysis plus pulse oximetry (SpO2) with ABG analysis.

Méthode : We performed a prospective cohort study of patients in the emergency department (ED) and intensive care unit (ICU) at a single academic tertiary referral center. Patients were eligible for enrollment if the treating physician ordered an ABG. Statistical analysis of VBG, SpO2, and ABG data was done using paired t test, Pearson χ2, and Pearson correlation.

Résultats : There were 156 patients enrolled, and 129 patients completed the study. Of the patients completing the study, 53 (41.1%) were in the ED, 41 (31.8%) were in the medical ICU, and 35 (27.1%) were in the surgical ICU. The mean difference for pH between VBG and ABG was 0.03 (95% confidence interval: 0.03-0.04) with a Pearson correlation of 0.94. The mean difference for pCO2 between VBG and ABG was 4.8 mm Hg (95% confidence interval: 3.7-6.0 mm Hg) with a Pearson correlation of 0.93. The SpO2 correlated well with PaO2 (the partial pressure of oxygen in arterial blood) as predicted by the standard oxygen-hemoglobin dissociation curve.

Conclusion : In this population of undifferentiated critically ill patients, pH and pCO2 on VBG analysis correlated with pH and pCO2 on ABG analysis. The SpO2 correlated well with pO2 on ABG analysis. The combination of VBG analysis plus SpO2 provided accurate information on acid-base, ventilation, and oxygenation status for undifferentiated critically ill patients in the ED and ICU.

Conclusion (proposition de traduction) : Dans cette population de patients de réanimation indifférenciés, le pH et la pCO2 sur l'analyse des gaz du sang veineux sont corrélés avec le pH et la pCO2 sur l'analyse des gaz du sang artériel. La SpO2 était bien corrélée avec la pO2 lors de l'analyse des gaz du sang artériel. La combinaison de l'analyse des gaz du sang veineux et de la SpO2 a fourni des informations précises sur l'équilibre acidobasique, la ventilation et l'état d'oxygénation pour les patients de réanimation indifférenciés au service des urgences et dans l'unité de soins intensifs.

Mortality and Resource Utilization After Critical Care Transport of Patients With Hypoxemic Respiratory Failure.
Wilcox SR, Richards JB, Genthon A, Saia MS, Waden H, Gates JD, Cocchi MN, McGahn SJ, Frakes M, Wedel SK. | J Intensive Care Med. 2018 Mar;33(3):182-188
DOI: https://doi.org/10.1177/0885066615623202
Keywords: complications; critical care; hospital mortality; length of stay; mechanical ventilation; outcomes; resource utilization; respiratory failure

Original Research

Introduction : We performed this study to quantify resources required by mechanically ventilated patients with hypoxemia after critical care transport (CCT) and to assess short-term clinical outcomes.

Méthode : We performed a retrospective review of transports of patients with severe hypoxemic respiratory failure from referring hospitals to 3 tertiary care hospitals to assess the outcomes including in-hospital mortality, ventilator days, intensive care unit length of stay (LOS), hospital LOS, disposition, and reported neurologic status on hospital discharge as well as medical interventions specific to acute respiratory failure and critical care.

Résultats : Of 230 patients transported with hypoxemic respiratory failure, 152 survived to hospital discharge, for a mortality rate of 34.5%, despite a predicted mortality of 64% by Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Twenty-five percent of patients were treated with neuromuscular blockade, 10.1% received inhaled pulmonary vasodilators, and extracorporeal membrane oxygenation was initiated in 2.6%.

Conclusion : In this cohort with hypoxemic respiratory failure transported to tertiary care facilities, patients had a mortality rate comparable to patients with acute respiratory distress syndrome treated with best practices and a mortality rate lower than predicted based on APACHE-II score. The risks of CCT are outweighed by the benefits of transfer to a tertiary care facility, and pretransport hypoxemia should not be used as an absolute contraindication to transport.

Conclusion (proposition de traduction) : Dans cette cohorte présentant une insuffisance respiratoire hypoxémique transportée dans des établissements de soins tertiaires, les patients présentaient un taux de mortalité comparable à celui des patients présentant un syndrome de détresse respiratoire aiguë traité selon les meilleures pratiques et un taux de mortalité inférieur au score APACHE-II. Les avantages du transport dans un établissement de soins critiques sont compensés par les avantages du transfert dans un établissement de soins tertiaires, et l’hypoxémie avant le transport ne doit pas être utilisée comme une contre-indication absolue au transport.

Prevalence of substance abuse among young adults with myocardial infarction.
Singh A, Collins B, Biery D, Qamar A, Fatima A, Gupta A, Defilippis E, Ramsis M, Pipilas D, Nasir K, Di Carli M, Bhatt D, Blankstein R . | J Am Coll Cardiol. 2018 March 20:71(11);178
DOI: https://doi.org/10.1016/S0735-1097(18)30719-8  | Télécharger l'article au format  
Keywords: Aucun

Poster Contributions

Introduction : Substance abuse is an increasingly recognized risk factor for myocardial infarction (MI) & is associated with significantly higher morbidity & mortality. Our objective was to assess its prevalence in a cohort of young adults who experience their first MI at ≤ 50 years of age.

Méthode : We retrospectively analyzed records of patients presenting with an MI under the age of 50 at two large academic hospitals. All cases were adjudicated as Type 1 or Type 2 MI, based on the 3rd Universal Definition. Substance abuse was determined by review of records for (a) patient-reported substance abuse within the past week, or (b) detection on a toxicology screen. Vital status was identified by linkage with Social Security. Cox proportional hazards modeling was performed for survival free from all-cause death.

Résultats : The cohort consisted of 3836 patients of whom 55% (2098) had a Type 1 MI & 45% (1738) had a Type 2 MI. Abuse of one or more of the following- opiates (including heroin), cannabis, cocaine - was present in 663 (17%) patients. The most commonly abused substances were: opiates & cannabis which were present in 378 (10%) & 289 (7%) patients, respectively. Results stratified by type of MI are illustrated in the Figure. Substance abuse was associated with significantly higher mortality (HR 1.25; p=0.01) after adjusting for age, type of MI, Charlson comorbidity index & creatinine.

Conclusion : Substance abuse is present in nearly 20% patients who experience an MI at age ≤50 & is associated with worse all-cause mortality.

Conclusion (proposition de traduction) : Une toxicomanie est présente chez près de 20 % des patients ≤ 50 ans qui présentent un infarctus du myocarde et est associée à une mortalité toutes causes confondues.

Cocaine and Marijuana Use among Young Adults Presenting with Myocardial Infarction: The Partners YOUNG-MI Registry.
DeFilippis EM, Singh A, Divakaran S, Gupta A, Collins BL, Biery D, Qamar A, Fatima A, Ramsis M, Pipilas D, Rajabi R, Eng M, Hainer J, Klein J, Januzzi JL, Nasir K, Di Carli MF, Bhatt DL, Blankstein R. | J Am Coll Cardiol. 2018 Mar 5. pii: S0735-1097(18)33383-7
DOI: https://doi.org/10.1016/j.jacc.2018.02.047
Keywords: cocaine; marijuana; myocardial infarction; substance abuse; young adults

Original article

Introduction : Substance abuse is increasingly prevalent among young adults but data on cardiovascular outcomes remain limited.
OBJECTIVES: Our objective was to assess the prevalence of cocaine and marijuana use in adults with their first myocardial infarction (MI) at ≤50 years and determine its association with long-term outcomes.

Méthode : We retrospectively analyzed records of patients presenting with a Type 1 MI at ≤50 years at two academic hospitals from 2000-2016. Substance abuse was determined by review of records for either patient-reported substance abuse during the week prior to MI or detection on toxicology screen. Vital status was identified by the Social Security Administration's Death Masterfile. Cause of death was adjudicated using electronic health records and death certificates. Cox modeling was performed for survival free from all-cause and cardiovascular death.

Résultats : 2097 patients had Type 1 MI (mean age 44±5.1 years, 19.3% female, 73% white) with median follow-up of 11.2 years (interquartile range: 7.3-14.2). Use of cocaine and/or marijuana was present in 224 (10.7%) patients; cocaine in 99 (4.7%) patients and marijuana in 125 (6.0%). Individuals with substance use had significantly lower rates of diabetes (14.7% versus 20.4%, p = 0.05) and hyperlipidemia (45.7% versus 60.8%, p < 0.001), but were significantly more likely to use tobacco (70.3% versus 49.1%, p < 0.001). The use of cocaine and/or marijuana was associated with significantly higher cardiovascular (HR 2.22; 95% CI 1.27 - 3.7, p=0.005) and all-cause mortality (HR 1.99; 95% CI 1.35 - 2.97, p=0.001) after adjusting for baseline covariates.

Conclusion : Cocaine and/or marijuana use is present in 10% of patients with an MI at age ≤50 years and is associated with worse all-cause and cardiovascular mortality. These findings reinforce current recommendations for substance use screening among young adults with an MI, and highlight the need for counseling to prevent future adverse events.

Conclusion (proposition de traduction) : La consommation de cocaïne et/ou de marijuana est présente chez 10 % des patients faisant un infarctus à l'âge de 50 ans et est associée à une mortalité toutes causes confondues et à une mortalité cardiovasculaire plus élevée.
Ces résultats renforcent les recommandations actuelles sur le dépistage de la consommation de substances chez les jeunes adultes présentant un infarctus, et soulignent le besoin de donner des conseils pour prévenir les événements indésirables futurs.

Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome: The SECURE-PCI Randomized Clinical Trial..
Berwanger O, and all.; SECURE-PCI Investigators. | JAMA. 2018 Mar 11
DOI: https://doi.org/10.1001/jama.2018.2444
Keywords: Aucun

Original Investigation

Introduction : The effects of loading doses of statins on clinical outcomes in patients with acute coronary syndrome (ACS) and planned invasive management remain uncertain.
OBJECTIVE: To determine if periprocedural loading doses of atorvastatin decrease 30-day major adverse cardiovascular events (MACE) in patients with ACS and planned invasive management.

Méthode : Multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites in Brazil among 4191 patients with ACS evaluated with coronary angiography to proceed with a percutaneous coronary intervention (PCI) if anatomically feasible. Enrollment occurred between April 18, 2012, and October 6, 2017. Final follow-up for 30-day outcomes was on November 6, 2017.
INTERVENTIONS: Patients were randomized to receive 2 loading doses of 80 mg of atorvastatin (n = 2087) or matching placebo (n = 2104) before and 24 hours after a planned PCI. All patients received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication.
MAIN OUTCOMES AND MEASURES: The primary outcome was MACE, defined as a composite of all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization through 30 days.

Résultats : Among the 4191 patients (mean age, 61.8 [SD, 11.5] years; 1085 women [25.9%]) enrolled, 4163 (99.3%) completed 30-day follow-up. A total of 2710 (64.7%) underwent PCI, 333 (8%) underwent coronary artery bypass graft surgery, and 1144 (27.3%) had exclusively medical management. At 30 days, 130 patients in the atorvastatin group (6.2%) and 149 in the placebo group (7.1%) had a MACE (absolute difference, 0.85% [95% CI, -0.70% to 2.41%]; hazard ratio, 0.88; 95% CI, 0.69-1.11; P = .27). No cases of hepatic failure were reported; 3 cases of rhabdomyolysis were reported in the placebo group (0.1%) and 0 in the atorvastatin group.

Conclusion : Among patients with ACS and planned invasive management with PCI, periprocedural loading doses of atorvastatin did not reduce the rate of MACE at 30 days. These findings do not support the routine use of loading doses of atorvastatin among unselected patients with ACS and intended invasive management.

Conclusion (proposition de traduction) : Chez les patients présentant un syndrome coronarien aigu nécessitant une intervention coronarienne percutanée planifiée, les doses de charge péri-procédurales d'atorvastatine n'ont pas réduit le taux d'événements cardiovasculaires indésirables majeurs à 30 jours. Ces résultats ne sont pas en faveur de l'utilisation systématique des doses de charge d'atorvastatine chez les patients non sélectionnés atteints de syndrome coronarien aigu nécessitant un geste invasif programmé.

Delmas J, Quenot JP, Constantin JM, Perbet S. | Méd Intensive Réa. 2018 March;27(2):114–121
DOI: https://doi.org/10.3166/rea-2018-0021
Keywords: Intubation; Hypotension; Hypnotic agents; Sedation; Vasopressors

Update

Editorial : The occurrence of cardiovascular collapse after endotracheal intubation in ICU patients is frequent. The identification of risk factors related to the patient (elderly, severe septic respiratory disease with marked impact, history of cardio-respiratory diseases) and to the procedure (hypnotics, mechanical ventilation) is important. It must make it possible to anticipate the different treatments of the post-intubation shock state within the framework of a bundle: presence of two operators, optimized preoxygenation, fluid challenge, vasopressors, agents for rapid sequence induction, preparation and initiation of maintenance sedation, capnography, protective ventilation

Conclusion (proposition de traduction) : La survenue d’un état de choc postintubation d’un patient de réanimation est fréquente. L’identification de facteurs de risque liés au patient (sujet âgé, pathologie respiratoire grave septique avec retentissement marqué, antécédents cardiorespiratoires) et à la procédure (hypnotiques, ventilation mécanique) est importante. Elle doit permettre d’anticiper des moyens de traitement de l’état de choc postintubation dans le cadre d’un bundle : présence de deux opérateurs, préoxygénation optimisée, expansion volémique, vasopresseurs, agents pour une induction en séquence rapide, préparation et initiation de la sédation d’entretien, capnographie, ventilation protectrice.

Brunet J, Valette X, Daubin C. | Méd Intensive Réa. 2018 March;27(2):122-132
DOI: https://doi.org/10.3166/rea-2018-0017
Keywords: Cardiac Arrest; Extracorporeal Life Support; Extracorporeal Cardiopulmonary Resuscitation; Prognosis

Update

Editorial : The benefit of extracorporeal cardiopulmonary resuscitation (ECPR) compared to conventional cardiopulmonary resuscitation in the management of refractory cardiac arrest remains unclear. The purpose of this systematic review is to provide an update in this field. The effect of ECPR on survival and neurological outcome in refractory out-of-hospital cardiac arrest of cardiac origin could be very limited. In contrast, the ECPR could be more effective than conventional cardiopulmonary resuscitation in selected patients with in-hospital cardiac arrest of cardiac origin or related to drug overdose. The benefit of ECPR is more contrasted in patients with refractory cardiac arrest associated with deep hypothermia following accidental exposure, a drowning or an avalanche. Further studies are still needed to clarify patients with refractory cardiac arrest who are the most likely ones to get benefited from ECPR.

Conclusion (proposition de traduction) : Le bénéfice d’une réanimation cardiopulmonaire (RCP) extracorporelle en comparaison d’une réanimation conventionnelle sur la survie et le pronostic neurologique à long terme des patients victimes d’un arrêt cardiaque réfractaire reste encore incertain. Il pourrait être très différent selon que la RCP soit considérée dans les arrêts cardiaques extrahospitaliers ou intrahospitaliers, d’origine cardiaque ou pas, en contexte toxicologique ou d’hypothermie. L’objectif de cet article est une mise au point sur l’apport de l’assistance circulatoire extracorporelle dans la prise en charge des arrêts cardiaques réfractaires à partir des recherches cliniques les plus récentes. Ainsi, l’apport d’une RCP extracorporelle dans les arrêts cardiaques réfractaires extrahospitaliers d’origine cardiaque est probablement limité, même au sein de populations hautement sélectionnées. En revanche, son intérêt est probablement plus important dans les arrêts cardiaques réfractaires intrahospitaliers d’origine cardiaque sous réserve d’une bonne sélection des patients. Enfin, si des résultats encourageants ont été rapportés dans les cas d’arrêt cardiaque réfractaire de cause toxique ; en revanche, ils sont plus contrastés concernant les arrêts cardiaques réfractaires associés à une hypothermie profonde suite à une exposition accidentelle au froid, à une noyade ou une avalanche. Des recherches bien conduites sont encore nécessaires pour préciser les contextes et les indications pour lesquels les patients seraient en droit d’attendre un bénéfice médical d’une RCP extracorporelle.

Llitjos JF, Cariou A. | Méd Intensive Réa. 2018 March;27(2):133-142
DOI: https://doi.org/10.3166/rea-2018-0003
Keywords: Cardiac arrest; Oxygen; Cardiopulmonary resuscitation; Oxidative stress

Update

Editorial : Oxygen toxicity is currently suspected when used in patients resuscitated from a cardiac arrest. Although essential during cardio-pulmonary resuscitation, oxygen provided in larger amounts might increase tissue damages provoked by this global ischemia-reperfusion syndrome. Experimentally, exposition of animals to hyperoxia during and after cardiopulmonary resuscitation increases oxidative stress and may worsen prognosis, mostly because it increases brain damages. However, it is unclear if these experimental observations are transposable to the clinical scene: in humans, results from several retrospective studies suggest a deleterious effect of hyperoxia in cardiac arrest, but most of these studies suffer from several methodological biases and their conclusion have been partly contradicted in subsequent studies. While waiting for the results coming from ongoing trials, recent international guidelines recommend titrating the oxygen treatment as soon as possible during resuscitation and after return of spontaneous circulation in order to maintain an arterial saturation between 94% and 98%.

Conclusion (proposition de traduction) : Un effet toxique de l’oxygène est aujourd’hui suspecté chez les patients pris en charge pour un arrêt cardiaque. Indispensable pendant la réanimation cardiopulmonaire (RCP), l’administration d’oxygène en quantité trop importante pourrait cependant majorer les lésions provoquées par le syndrome d’ischémie–reperfusion globale. Expérimentalement, l’exposition des animaux à une hyperoxie pendant et après la RCP augmente les phénomènes en rapport avec le stress oxydatif et semble responsable d’une aggravation du pronostic, au travers notamment des lésions cérébrales. Cependant, la transposition clinique de ces observations est incertaine : chez l’homme, les résultats de certaines études rétrospectives suggèrent un effet délétère de l’hyperoxie post-arrêt cardiaque, mais ces études sont entachées de nombreux biais méthodologiques, et leurs conclusions ont été en partie remises en question dans des études ultérieures. En attendant les résultats des investigations cliniques en cours, les recommandations internationales actuelles préconisent de titrer dès que possible l’oxygène administré pendant et après la RCP pour maintenir une saturation de l’oxygène entre 94 et 98 %.

Darreau C, Delbove A, Saint-Martin M, Jacquier S, Martino F et Lerolle N. | Méd Intensive Réa. 2018 March;27(2):153-160
DOI: https://doi.org/10.3166/rea-2018-0020
Keywords: Septic shock; Intubation; Mechanical ventilation

Update

Editorial : Intubation strategy during septic shock may potentially impact outcome. However, recent guidelines do not put forward any recommendation and few studies have been published on this topic. Potential benefits (improving oxygenation, diaphragmatic rest…) and side effects (intubation risk, diaphragm induced atrophy, mechanical ventilation induced lung damage, sedation induced vaspolegia…) may impact differently in every patient. Loss of consciousness or severe acute respiratory failure are straightforward indication for intubation, nevertheless, such indications do not apply in many patients. This systematic review aims at synthesizing the data on intubation from the recent largest studies on septic shock and from pathophysiological studies. Finally, the results of a post hoc analysis of the SEPSISPAM study are presented. The multicenter survey on intubation INTUBATIC is detailed (inclusion completed).

Conclusion (proposition de traduction) : La place de l’intubation dans le choc septique reste mal définie sans recommandation dictée par les sociétés savantes. Cette problématique met en balance les effets potentiellement bénéfiques de la ventilation mécanique (amélioration de l’oxygénation, repos musculaire diaphragmatique…) et délétères (risque du geste d’intubation, atrophie diaphragmatique, lésions pulmonaires induites par la ventilation, vasoplégie liée à la sédation…). L’intubation ne se discute pas lors des cas extrêmes de coma profond ou d’insuffisance respiratoire aiguë sévère. Néanmoins, la place de l’intubation dans les situations intermédiaires est actuellement peu étudiée et non codifiée. Cette mise au point a pour but d’apporter au lecteur une synthèse des résultats issus des dernières grandes études sur le choc septique. L’analyse suggère une association probable, non exclusive, entre gravité et taux d’intubation, qui reste à préciser. Bien que ces études n’aient pas étudié cette question, les données générales décrivent les caractéristiques « patient » et les données ventilatoires. Enfin, les résultats d’une étude spécifique sur le sujet et le projet de recherche en cours INTUBATIC (inclusions terminées) sont présentés, ce qui apportera peut-être une réponse à cette question dans les mois à venir.

Cariou A, Payen JF, Asehnoune K, Audibert G, Botte A, Brissaud O, Debaty G, Deltour S, Deye N, Engrand N, Francony G, Legriel S, Levy B, Meyer P, Orban JC, Renolleau S, Vigué B, De Saint Blanquat L, Mathien C, Velly L. | Méd Intensive Réa. 2018 March;27(2):172-192
DOI: https://doi.org/10.3166/rea-2018-0005  | Télécharger l'article au format  
Keywords: Aucun

Recommendations

Introduction : Les effets protecteurs de l’hypothermie sont connus de longue date. Ces effets ont été étudiés et décrits dès la fin des années 1950, puis semblent être tombés dans l’oubli pendant une vingtaine d’années avant que les réanimateurs relancent l’intérêt de cette méthode thérapeutique. Les données expérimentales montrent que l’hypothermie exerce des effets principalement neuroprotecteurs selon plusieurs mécanismes d’action.
Actuellement, l’application d’une hypothermie légère à modérée ou le maintien de la normothermie est devenue habituelle en réanimation pour prévenir ou limiter l’apparition de lésions supplémentaires (essentiellement cérébrales) au cours d’une agression tissulaire. Cette modalité thérapeutique correspond à un contrôle de la température centrale du patient. Elle peut faire appel à différents moyens et cibler des niveaux de température différents en fonction du contexte clinique et des indications. Il convient donc d’utiliser le terme « contrôle ciblé de la température (CCT)», appellation appropriée car elle regroupe l’ensemble des interventions qui peuvent être effectuées pour atteindre et maintenir un certain niveau de température chez un malade donné.
En fonction des situations, le niveau de température ciblé peut être différent. Le CCT peut correspondre à un traitement visant simplement à prévenir la fièvre et à maintenir la normothermie, ou à abaisser la température centrale jusqu’à des niveaux très bas, engendrant alors une hypothermie.
Le CCT est actuellement utilisé dans de nombreuses situations de réanimation, essentiellement dans le domaine de la neuroprotection. Les indications du CCT sont cependant associées à des niveaux de preuve hétérogènes et à une littérature riche mais parfois contradictoire. Dans ce contexte, il est apparu utile de procéder à une évaluation des données disponibles, permettant d’élaborer des recommandations à l’intention des utilisateurs.

Méthode : La méthode de travail utilisée pour l’élaboration de ces recommandations est la méthode GRADE®. Cette méthode permet, après une analyse quantitative de la littérature de déterminer séparément la qualité des preuves, c’est à dire une estimation de la confiance que l’on peut avoir dans l’analyse de l’effet de l’intervention quantitative et d’autre part un niveau de recommandation. L’analyse de la qualité des preuves est réalisée pour chaque étude puis un niveau global de preuve est défini pour une question et un critère donné. La formulation finale des recommandations est binaire, soit positive soit négative et soit forte soit faible. La force de la recommandation est déterminée en fonction de facteurs clés, validée par les experts après un vote, en utilisant la méthode Delphi et GRADE Grid. Pour délivrer une recommandation sur un critère, au moins 50% des experts doivent exprimer une opinion qui va globalement dans la même direction, tandis que moins de 20% d’entre eux expriment une opinion contraire. Pour qu’une recommandation soit forte, au moins 70% des participants doivent avoir une opinion qui va globalement dans la même direction.

Résultats : L’intérêt potentiel du CCT en réanimation a été identifié dans cinq situations cliniques : arrêt cardiaque (AC), traumatisme crânien (TC), accident vasculaire cérébral (AVC), autres agressions cérébrales, et états de choc. Un champ supplémentaire sur les modalités pratiques de mise en œuvre du CCT a été rajouté. Quinze experts et deux coordinateurs d’experts ont acceptés de réfléchir sur le sujet.
Une recherche bibliographique extensive sur les 10 dernières années a été réalisée à partir des bases de données PubMed et Cochrane. Pour être retenues dans l’analyse, les publications devaient être postérieures à 2005 et en langue anglaise ou française. Une analyse spécifique de la littérature pédiatrique a été réalisée.
Après synthèse du travail des experts et application de la méthode GRADE, 33 recommandations ont été formalisées par le comité d’organisation. Parmi les recommandations, 4 sont fortes (Grade 1 +/-), 13 sont faibles (Grade 2 +/-) et, pour 16 recommandations, la méthode GRADE® ne pouvait pas s’appliquer et celles-ci correspondent à un avis d’experts.

Conclusion (proposition de traduction) : La totalité des recommandations ont été soumises à un groupe de relecture pour une cotation type Delphi. Après 2 tours de cotations et divers amendements, un accord fort a été obtenu pour 33 (100 %) des recommandations.

Axillary and Tympanic Temperature Measurement in Children and Normal Values for Ages.
Oguz F, Yildiz I, Varkal MA, Hizli Z, Toprak S, Kaymakci K, Saygili SK, Kilic A, Unuvar E. | Pediatr Emerg Care. 2018 Mar;34(3):169-173
DOI: https://doi.org/10.1097/PEC.0000000000000693
Keywords: Aucun

Original Articles

Introduction : The aim of the study was define the normal values of tympanic and axillary body temperature in healthy children.

Méthode : This observational cross-sectional study was performed in healthy children aged 0 to 17 years who visited the ambulatory general pediatric of Istanbul Medical Faculty.

Résultats : Of 1364 children, 651 (47.7%) were girls and 713 were boys, the mean (SD, range) age was 72.5 (53.6, 1-204) months. The mean (SD) axillary body temperature was 36.04°C (0.46°C; minimum, 35.0°C; maximum, 37.6°C). The 95th and 99th percentiles were 36.8°C and 37.0°C, respectively. The mean (SD) tympanic body temperature was 36.91°C (0.46°C; minimum, 35.15°C; maximum, 37.9°C). The 95th and 99th percentiles were 37.6°C and 37.8°C, respectively. There were statistically significant differences between sexes for only tympanic body temperatures. Both axillary and tympanic body temperatures were statistically higher in 0 to 2 months compared with other age groups. For this age group, the 99th percentile was 37.5°C for axillary and 37.85°C for tympanic temperature.

Conclusion : Axillary and tympanic body temperatures should be considered as fever when they are more than 37.0°C and 37.8°C, respectively. For 0 to 2 months, fever is 37.5°C and 37.85°C in axillary and tympanic temperatures, respectively.

Conclusion (proposition de traduction) : Les températures corporelles axillaires et tympaniques doivent être considérées comme de la fièvre lorsqu'elles sont supérieures à 37,0° C et 37,8° C, respectivement.
De 0 à 2 mois, les températures axillaires et tympaniques devant être considéré comme de la fièvre sont à 37,5° C et de 37,85° C, respectivement.

Factors Predicting Lung Contusions in Critically Ill Trauma Children: A Multivariate Analysis of 330 Cases.
Chaari A, Chelly H, Fourati H, Mnif Z, Chtara K, Baccouche N, Bahloul M, Bouaziz M. | Pediatr Emerg Care. 2018 Mar;34(3):198-201
DOI: https://doi.org/10.1097/PEC.0000000000000756
Keywords: Aucun

Original Articles

Introduction : The aim of the study was to identify factors predicting lung contusion in trauma children

Méthode : Retrospective study conducted for a period of 8 years (January 01, 2005-December 31, 2012) in a medical surgical intensive care unit. All trauma patients younger than 15 years were included. Two groups were compared: those with lung contusions (C+ group) and those without lung contusions (C- group).

Résultats : We included 330 patients. The mean (SD) age was 7.6 (4.3) years. Chest injury was diagnosed in 70 patients (21.2%). All our patients needed mechanical ventilation. Lung contusions were diagnosed in 43 patients (13% of all patients and 61.4% of patients with chest trauma). In multivariate analysis, independent factors predicting lung contusion were road traffic accident (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.2-8.6; P = 0.019), increased Pediatric Risk of Mortality (PRISM) score (OR, 1.1; 95% CI, 1.1-1.2; P = 0.017), hepatic contusion (OR, 4.8; 95% CI, 1.3-17.1; P = 0.017), and pelvic ring fracture (OR, 3.5; 95% CI, 1.1-10.5; P = 0.026). Death occurred in 46 patients (13.9%). Intensive care unit mortality was significantly higher in the C+ group (OR, 2.5; 95% CI, 1.2-5.4; P = 0.021). However, mortality was not different between the 2 groups after adjusting for PRISM score (OR, 1.2; 95% CI, 0.5-2.9; P = 0.752) or after adjusting for Injury Severity Score (OR, 0.7; 95% CI, 0.3-2.1; P = 0.565).

Conclusion : Lung contusion is common in critically ill children with chest trauma. The diagnosis should be considered in patients with road traffic accident, increased PRISM score, hepatic contusion, and pelvic ring fracture.

Conclusion (proposition de traduction) : Une contusion pulmonaire est fréquente chez les enfants en situation critique lors d'un traumatisme thoracique. Le diagnostic doit être suspecté chez les enfants victimes d'un accident de la route, devant une augmentation du score PRISM (Pediatric Risk of Mortality  ), devant une contusion hépatique et devant une fracture de l'anneau pelvien.

Need for Lumbar Puncture in Children Younger Than 12 Months Presenting With Simple Febrile Seizure.
Son YY, Kim GH, Byeon JH, Eun SH, Eun BL. | Pediatr Emerg Care. 2018 Mar;34(3):212-215
DOI: https://doi.org/10.1097/PEC.0000000000000779
Keywords: Aucun

Original articles

Introduction : Recently, conflicting results have been reported regarding the necessity of routine lumbar puncture in children less than 12 months of age with simple febrile seizure. The aims of this study were to evaluate the results of lumbar puncture in children younger than 60 months of age with febrile seizure and to reassess the need for lumbar puncture in children younger than 12 months with simple febrile seizure.

Méthode : A retrospective chart review was performed in patients younger than 60 months who presented with febrile seizure and underwent lumbar puncture from January 2005 to January 2015.

Résultats : A total of 1249 patients presenting with febrile seizure were admitted. Of these, 816 met inclusion criteria for presenting with simple febrile seizure. Lumbar puncture was performed in 75 patients (9.2%; age, mean ± SD, 12.05 ± 9.13 months; male/female, 31/44), who were reviewed. Sixty-six (88.0%) of 75 patients were younger than 12 months. Five patients (6.7%) showed pleocytosis in cerebrospinal fluid, and 4 of them were younger than 1 year of age. Three patients (4.0%) had bacterial meningitis and were 4, 8, and 12 months. Streptococcus pneumoniae (2 patients) and Klebsiella pneumoniae (1 patient) were isolated in cerebrospinal fluid. Nobody had neurologic signs suggesting bacterial meningitis, and all of them completed scheduled immunizations and were up-to-date.

Conclusion : Lumbar puncture should be considered in every child younger than 12 months of age with a simple febrile seizure owing to lack of abnormal neurologic sign even if immunization is up-to-date.

Conclusion (proposition de traduction) : Une ponction lombaire doit être envisagée chez tous les enfants de moins de 12 mois présentant une crise convulsive hyperthermique isolée en raison de l'absence de signes neurologiques spécifiques, même si la vaccination est à jour.

Cerebral saturation in cardiac arrest patients measured with near-infrared technology during pre-hospital advanced life support. Results from Copernicus I cohort study.
Genbrugge C, De Deyne C, Eertmans W, Anseeuw K, Voet D, Mertens I, Sabbe M, Stroobants J, Bruckers L, Mesotten D, Jans F, Boer W, Dens J. | Resuscitation. 2018 Mar 23. pii: S0300-9572(18)30141-2
DOI: https://doi.org/10.1016/j.resuscitation.2018.03.031
Keywords: Advanced life support; Cardiac arrest; Cerebral oximetry; Cerebral saturation; Out-of hospital cardiac arrest; Pre-hospital

Original articles

Introduction : To date, monitoring options during pre-hospital advanced life support (ALS) are limited. Regional cerebral saturation (rSO2) may provide more information concerning the brain during ALS. We hypothesized that an increase in rSO2 during ALS in out-of hospital cardiac arrest (OHCA) patients is associated with return of spontaneous circulation (ROSC).

Méthode : A prospective, non-randomized multicenter study was conducted in the pre-hospital setting of six hospitals in Belgium. Cerebral saturation was measured during pre-hospital ALS by a medical emergency team in OHCA patients. Cerebral saturation was continuously measured until ALS efforts were terminated or until the patient with sustained ROSC (>20 min) arrived at the emergency department. To take the longitudinal nature of the data into account, a linear mixed model was used. The correlation between the repeated measures of a patient was handled by means of ​a random intercept and a random slope. Our primary analysis tested the association of rSO2 with ROSC.

Résultats : Of the 329 patients 110 (33%) achieved ROSC. First measured rSO2 was 30% ± 18 in the ROSC group and 24% ± 15 in the no-ROSC group (p = .004; mean ± SD). Higher mean rSO2 values were observed in the ROSC group compared to the no-ROSC group (41% ± 13 versus 33% ± 13 respectively; p < 0.001). The median increase in rSO2, measured from start until two minutes before ROSC, was higher in the ROSC group (ROSC group 17% (IQR 6-29)) than in the no-ROSC group (8% (IQR 2-13); p < 0.001). An increase in rSO2 above 15% was associated with ROSC (OR 4.5; 95%CI 2.747-7.415; p < 0.001).

Conclusion : Regional cerebral saturation measurements can be used during pre-hospital ALS as an additional marker to predict ROSC. An increase of at least 15% in rSO2 during ALS is associated with a higher probability of ROSC.

Conclusion (proposition de traduction) : Les mesures régionales de saturation cérébrale peuvent être utilisées pendant la réanimation cardiaque spécialisée pré-hospitalière comme marqueur additionnel pour prédire la RACS. Une augmentation d'au moins 15 % du rSO₂ au cours de la réanimation cardiaque spécialisée est associée à une probabilité plus élevée de RACS.

Out-of-hospital cardiac arrest: Probability of bystander defibrillation relative to distance to nearest automated external defibrillator.
Sondergaard KB, Hansen SM, Pallisgaard JL, Gerds TA, Wissenberg M, Karlsson L, Lippert FK, Gislason GH, Torp-Pedersen C, Folke F. | Resuscitation. 2018 Mar;124:138-144
DOI: https://doi.org/10.1016/j.resuscitation.2017.11.067
Keywords: AED; Bystander defibrillation; Distance; OHCA

Clinical Papers

Introduction : Despite wide dissemination of automated external defibrillators (AEDs), bystander defibrillation rates remain low. We aimed to investigate how route distance to the nearest accessible AED was associated with probability of bystander defibrillation in public and residential locations.

Méthode : We used data from the nationwide Danish Cardiac Arrest Registry and the Danish AED Network to identify out-of-hospital cardiac arrests and route distances to nearest accessible registered AED during 2008-2013. The association between route distance and bystander defibrillation was described using restricted cubic spline logistic regression.

Résultats : We included 6971 out-of-hospital cardiac arrest cases. The proportion of arrests according to distance in meters (≤100, 101-200, >200) to the nearest accessible AED was: 4.6% (n=320), 5.3% (n=370), and 90.1% (n=6281), respectively. For cardiac arrests in public locations, the probability of bystander defibrillation at 0, 100 and 200m from the nearest AED was 35.7% (95% confidence interval 28.0%-43.5%), 21.3% (95% confidence interval 17.4%-25.2%), and 13.7% (95% confidence interval 10.1%-16.8%), respectively. The corresponding numbers for cardiac arrests in residential locations were 7.0% (95% confidence interval -2.1%-16.1%), 1.5% (95% confidence interval 0.002%-2.8%), and 0.9% (95% confidence interval 0.0005%-1.7%), respectively.

Conclusion : In public locations, the probability of bystander defibrillation decreased rapidly within the first 100m route distance from cardiac arrest to nearest accessible AED whereas the probability of bystander defibrillation was low for all distances in residential areas.

Conclusion (proposition de traduction) : Dans les lieux publics, la probabilité de défibrillation par les témoins diminuait rapidement dans les 100 premiers mètres entre le lieu des arrêts cardiaques et l'emplacement des DEA les plus proches, alors que la probabilité de défibrillation par les témoins était faible pour toutes les distances dans les zones résidentielles.

Commentaire : Voir l'analyse de Christopher M and al. dans Resuscitation. 2018 Mar;124:A15-A16  . Improving bystander defibrillation for out-of-hospital cardiac arrest: Capability, opportunity and motivation.

Determinants of occurrence and survival after sudden cardiac arrest-A European perspective: The ESCAPE-NET project.
Empana JP, Blom MT, Bӧttiger BW, Dagres N, Dekker JM, Gislason G, Jouven X, Meitinger T, Ristagno G, Schwartz PJ, Jonsson M, Tfelt-Hansen J, Truhlar A, Tan HL; ESCAPE-NET Investigators. | Resuscitation. 2018 Mar;124:7-13
DOI: https://doi.org/10.1016/j.resuscitation.2017.12.011  | Télécharger l'article au format  
Keywords: Automated external defibrillator; Genetics; Resuscitation; Sudden cardiac arrest

Clinical Papers

Introduction : The ESCAPE-NET project ("European Sudden Cardiac Arrest network- towards Prevention, Education and New Effective Treatments") aims to study: (1) risk factors and mechanisms for the occurrence of sudden cardiac arrest (SCA) in the population, and (2) risk factors and treatment strategies for survival after SCA on a European scale.

Méthode : This is an Horizon2020 funded program of the European Union, performed by a European public-private consortium of 16 partners across 10 EU countries. There are 11 deep-phenotyped SCA cohorts for the study of risk factors and treatment strategies for survival after SCA, and 5 deep-phenotyped observational prospective population cohorts for the study of risk factors for occurrence of SCA. Personalized risk scores for predicting SCA onset and for predicting survival after SCA will be derived and validated.

Résultats : The 11 clinical studies with SCA cases comprise 85,790 SCA cases; the 5 observational prospective population cohorts include 53,060 subjects. A total of 15,000 SCA samples will be genotyped for common and rare variants at the Helmholtz Zentrum München (Germany) using the Illumina Global Screening Array which contains > 770,000 SNPs, and after imputation, a database of an estimated > 9 million variants will be available for genome wide association studies. Standardization of risk factors definition and outcomes is ongoing. An Executive Committee has been created along with a Collaboration Policy document.

Conclusion : ESCAPE-NET will complement ongoing efforts on SCA outside Europe and within Europe including the EuReCa project.

Conclusion (proposition de traduction) : ESCAPE-NET complétera les efforts en cours sur l'arrêt cardiaque inopiné en dehors de l'Europe et en Europe, y compris le projet EuReCa.

Commentaire : Retrouvez le projet Euopéen sur le site ESCAPE-NET  . The European Sudden Cardiac Arrest network towards Prevention, Education, New Effective Treatment.
ESCAPE-NET rassemble les informations sur de grandes cohortes d'arrêts cardiaques inopinés à l'échelon européen, y compris les échantillons d'ADN recueillis pendant la réanimation.
Ces cohortes permettent d'identifier des données sur de nouveaux facteurs de risque potentiels, jusqu'ici sous-estimés, notamment les facteurs de stress socio-économiques et psychosociaux.

Lower-dose epinephrine administration and out-of-hospital cardiac arrest outcomes.
Fisk CA, Olsufka M, Yin L, McCoy AM, Latimer AJ, Maynard C, Nichol G, Larsen J, Cobb LA, Sayre MR. | Resuscitation. 2018 Mar;124:43-48
DOI: https://doi.org/10.1016/j.resuscitation.2018.01.004
Keywords: Cardiac arrest; Emergency medical services; Epinephrine

Clinical papers

Introduction : International guidelines recommend administration of 1 mg of intravenous epinephrine every 3-5 min during cardiac arrest. The optimal dose of epinephrine is not known. We evaluated the association of reduced frequency and dose of epinephrine with survival after out-of-hospital cardiac arrest (OHCA).

Méthode : Included were patients with non-traumatic OHCA treated by advanced life support (ALS) providers from January 1, 2008 to June 30, 2016. During the before period, providers were instructed to give epinephrine 1 mg intravenously at 4 min followed by additional 1 mg doses every eight minutes to patients with OHCA with a shockable rhythm and 1 mg doses every two minutes to patients with a non-shockable rhythm (higher dose). On October 1, 2012, providers were instructed to reduce the dose of epinephrine treatment during out-of-hospital cardiac arrest (OHCA): 0.5 mg at 4 and 8 min followed by additional doses of 0.5 mg every 8 min for shockable rhythms and 0.5 mg every 2 min for non-shockable rhythms (lower dose). Patients with shockable initial rhythms were analyzed separately from those with non-shockable initial rhythms. The primary outcome was survival to hospital discharge with a secondary outcome of favorable neurological status (Cerebral Performance Category [CPC] 1 or 2) at hospital discharge. Multiple logistic regression modeling was used to adjust for age, sex, presence of a witness, bystander CPR, and response interval.

Résultats : 2255 patients with OHCA were eligible for analysis. Of these, 24.6% had an initially shockable rhythm. Total epinephrine dose per patient decreased from a mean ± standard deviation of 3.4 ± 2.3 mg-2.6 ± 1.9 mg (p < 0.001) in the shockable group and 3.5 ± 1.9 mg-2.8 ± 1.7 mg (p < 0.001) in the non-shockable group. Among those with a shockable rhythm, survival to hospital discharge was 35.0% in the higher dose group vs. 34.2% in the lower dose group. Among those with a non-shockable rhythm, survival was 4.2% in the higher dose group vs. 5.1% in the lower dose group. Lower dose vs. higher dose was not significantly associated with survival: adjusted odds ratio, aOR 0.91 (95% CI 0.62-1.32, p = 0.61) if shockable and aOR 1.26 (95% CI 0.79-2.01, p = 0.33) if non-shockable. Lower dose vs. higher dose was not significantly associated with favorable neurological status at discharge: aOR 0.84 (95% CI 0.57-1.24, p = 0.377) if shockable and aOR 1.17 (95% CI 0.68-2.02, p = 0.577) if non-shockable.

Conclusion : Reducing the dose of epinephrine administered during out-of-hospital cardiac arrest was not associated with a change in survival to hospital discharge or favorable neurological outcomes after OHCA.

Conclusion (proposition de traduction) : La réduction de la dose d'épinéphrine (Adrénaline) administrée lors d'un arrêt cardiaque extrahospitalier n'a pas été associée à un changement dans la survie à la sortie de l'hôpital ou à des résultats neurologiques favorables après un arrêt cardiaque extrahospitalier.

Patient, health service factors and variation in mortality following resuscitated out-of-hospital cardiac arrest in acute coronary syndrome: Analysis of the Myocardial Ischaemia National Audit Project.
Couper K, Kimani PK, Gale CP, Quinn T, Squire IB, Marshall A, Black JJM, Cooke MW, Ewings B, Long J, Perkins GD. | Resuscitation. 2018 Mar;124:49-57
DOI: https://doi.org/10.1016/j.resuscitation.2018.01.011  | Télécharger l'article au format  
Keywords: Acute coronary syndrome; Myocardial infarction; Out-of-hospital cardiac arrest

Clinical papers

Introduction : To determine patient and health service factors associated with variation in hospital mortality among resuscitated cases of out-of-hospital cardiac arrest (OHCA) with acute coronary syndrome (ACS).

Méthode : In this cohort study, we used the Myocardial Ischaemia National Audit Project database to study outcomes in patients hospitalised with resuscitated OHCA due to ACS between 2003 and 2015 in the United Kingdom. We analysed variation in inter-hospital mortality and used hierarchical multivariable regression models to examine the association between patient and health service factors with hospital mortality.

Résultats : We included 17604 patients across 239 hospitals. Overall hospital mortality was 28.7%. In 94 hospitals that contributed at least 60 cases, mortality by hospital ranged from 10.7% to 66.3% (median 28.6%, IQR 23.2% to 39.1%)). Patient and health service factors explained 36.1% of this variation. After adjustment for covariates, factors associated with higher hospital mortality included increasing serum glucose, ST-Elevation myocardial infarction (STEMI) diagnosis, and initial admission to a primary percutaneous coronary intervention (pPCI) capable hospital. Hospital OHCA volume was not associated with mortality. The key modifiable factor associated with lower mortality was early reperfusion therapy in STEMI patients.

Conclusion : There was wide variation in inter-hospital mortality following resuscitated OHCA due to ACS that was only partially explained by patient and health service factors. Hospital OHCA volume and pPCI capability were not associated with lower mortality. Early reperfusion therapy was associated with lower mortality in STEMI patients.

Conclusion (proposition de traduction) : Il y avait une grande variation dans la mortalité entre les hôpitaux après un arrêt cardiaque extrahospitalier réanimé au cours d'un syndrome coronarien aigu qui n'était que partiellement expliqué par les facteurs liés aux patients et aux services de santé. Le volume d'arrêt cardiaque hospitalier extrahospitalier et la capacité d'intervention coronarienne percutanée primaire n'étaient pas associés à une mortalité plus faible. Le traitement précoce par reperfusion était associé à une mortalité plus faible chez les patients atteints d'un infarctus du myocarde avec surélévation du segment ST.

Influence of chest compression artefact on capnogram-based ventilation detection during out-of-hospital cardiopulmonary resuscitation.
Leturiondo M, Ruiz de Gauna S, Ruiz JM, Julio Gutiérrez J, Leturiondo LA, González-Otero DM, Russell JK, Zive D, Daya M. | Resuscitation. 2018 Mar;124:63-68
DOI: https://doi.org/10.1016/j.resuscitation.2017.12.013
Keywords: Advanced life support; Capnography; Cardiopulmonary resuscitation; Chest compression artefact; Ventilation

Clinical papers

Introduction : Capnography has been proposed as a method for monitoring the ventilation rate during cardiopulmonary resuscitation (CPR). A high incidence (above 70%) of capnograms distorted by chest compression induced oscillations has been previously reported in out-of-hospital (OOH) CPR. The aim of the study was to better characterize the chest compression artefact and to evaluate its influence on the performance of a capnogram-based ventilation detector during OOH CPR.

Méthode : Data from the MRx monitor-defibrillator were extracted from OOH cardiac arrest episodes. For each episode, presence of chest compression artefact was annotated in the capnogram. Concurrent compression depth and transthoracic impedance signals were used to identify chest compressions and to annotate ventilations, respectively. We designed a capnogram-based ventilation detection algorithm and tested its performance with clean and distorted episodes.

Résultats : Data were collected from 232 episodes comprising 52 654 ventilations, with a mean (±SD) of 227 (±118) per episode. Overall, 42% of the capnograms were distorted. Presence of chest compression artefact degraded algorithm performance in terms of ventilation detection, estimation of ventilation rate, and the ability to detect hyperventilation.

Conclusion : Capnogram-based ventilation detection during CPR using our algorithm was compromised by the presence of chest compression artefact. In particular, artefact spanning from the plateau to the baseline strongly degraded ventilation detection, and caused a high number of false hyperventilation alarms. Further research is needed to reduce the impact of chest compression artefact on capnographic ventilation monitoring.

Conclusion (proposition de traduction) : La détection de la ventilation par capnogramme pendant la RCP à l'aide de notre algorithme a été compromise par la présence d'artefact de compression thoracique. En particulier, l'artefact s'étendant du plateau à la ligne de base a fortement dégradé la détection de la ventilation et a causé un nombre élevé de fausses alarmes d'hyperventilation. D'autres recherches sont nécessaires pour réduire l'impact des artefacts de compression thoracique sur la surveillance de la ventilation capnographique.

Duration of cardiopulmonary resuscitation in patients without prehospital return of spontaneous circulation after out-of-hospital cardiac arrest: Results from a severity stratification analysis.
Funada A, Goto Y, Tada H, Teramoto R, Shimojima M, Hayashi K, Kawashiri MA, Yamagishi M. | Resuscitation. 2018 Mar;124:69-75
DOI: https://doi.org/10.1016/j.resuscitation.2018.01.008
Keywords: Cardiopulmonary resuscitation; Epidemiology; Out-of-hospital cardiac arrest

Clinical papers

Introduction : The relationship between duration of cardiopulmonary resuscitation (CPR) and post-arrest outcomes based on severity stratification in out-of-hospital cardiac arrest (OHCA) patients without prehospital return of spontaneous circulation (ROSC) remains unclear.

Méthode : We analysed 420,959 adult patients without prehospital ROSC in the All-Japan OHCA registry for 4 years. Prehospital CPR duration was defined as the time from CPR initiation by emergency medical service (EMS) providers to hospital arrival. The primary outcome was 1-month neurologically intact survival (cerebral performance category 1 or 2, CPC 1-2).

Résultats : The rate of overall 1-month CPC 1-2 was 0.45% (1899/420,959). Using recursive partitioning analysis to predict 1-month CPC 1-2, we stratified patients into 4 groups with 3 predictors: patients aged <75 years with initial shockable rhythm (1-month CPC 1-2 rate, 6.15%), those aged ≥75 years with initial shockable rhythm (1.32%), those with EMS-witnessed arrest and initial non-shockable rhythm (1.62%), and those with EMS-unwitnessed arrest and initial non-shockable rhythm (0.15%). Prehospital CPR duration was negatively associated with 1-month CPC 1-2 (adjusted odds ratio 0.94 per 1-min increment; 95% confidence interval 0.94-0.95). Prehospital CPR durations beyond which the dynamic probability of 1-month CPC 1-2 decreased to <1% were 26 min, 10 min, 7 min, and at all times in above-mentioned stratification, respectively.

Conclusion : In OHCA patients without prehospital ROSC, those aged <75 years with initial shockable rhythm had acceptable 1-month CPC 1-2 rate. However, CPR efforts lasting 26 min or over before hospital arrival could be futile.

Conclusion (proposition de traduction) : Chez les patients en arrêt cardiaque extrahospitalier sans récupération d'activité cardiaque spontanée (RACS), ceux âgés de moins de 75 ans avec un rythme initial choquable avaient un taux de CPC de 1 à 2 à 1 mois acceptable.
Cependant, les efforts de RCP qui durent 26 min ou plus, avant l'arrivée à l'hôpital, pourraient s'avérer inutiles.

The association between tidal volume and neurological outcome following in-hospital cardiac arrest.
Moskowitz A, Grossestreuer AV, Berg KM, Patel PV, Ganley S, Casasola Medrano M, Cocchi MN, Donnino MW; Center for Resuscitation Science.. | Resuscitation. 2018 Mar;124:106-111
DOI: https://doi.org/10.1016/j.resuscitation.2017.12.031
Keywords: Mechanical ventilation

Clinical papers

Introduction : Prior investigation has found that mechanical ventilation with lower tidal volumes (Vt) following out-of-hospital cardiac arrest is associated with better neurologic outcomes. The relationship between Vt and neurologic outcome following in-hospital cardiac arrest (IHCA) has not previously been explored. In the present study, we investigate the association between Vt and neurologic outcome following IHCA.

Méthode : This was an observational study using a prospectively collected database of IHCA patients at a tertiary care hospital in the United States. The relationship between time-weighted average Vt per predicted body weight (PBW) over the first 6- and 48 h after cardiac arrest and neurologic outcome were assessed using propensity-score adjusted logistic regression.

Résultats : Of 185 IHCA patients who received invasive mechanical ventilation within 6 h of return of spontaneous circulation (ROSC), the average Vt over the first 6 h was 7.7 ± 2.0 ml/kg and 68 (36.8%) patients received an average Vt > 8.0 ml/kg. Of 121 patients who received mechanical ventilation for at least 48 h post-ROSC, the average Vt was 7.6 ± 1.5 ml/kg and 46 (38.0%) patients received an average Vt > 8.0 ml/kg. There was no relationship between Vt/PBW over the first 6- or 48 h post-ROSC and neurologic outcome (OR 0.99; 95%CI 0.84-1.16; p = 0.89; OR 1.03; 95%CI 0.78-1.37; p = 0.83 respectively).

Conclusion : This study did not identify a relationship between Vt and neurologic outcome following IHCA. This contrasts with results in OHCA, where higher Vt has been associated with worse neurologic outcome. Additional investigation is needed with respect to other potential benefits of low-Vt post IHCA.

Conclusion (proposition de traduction) : Cette étude n'a pas identifié un rapport entre le Vt et le résultat neurologique suite à un arrêt cardiaque intrahospitalier. Cela contraste avec les résultats dans l'arrêt cardiaque extrahospitalier, où un Vt plus élevé a été associé à de plus mauvais résultats neurologiques. Des études supplémentaires sont nécessaires en ce qui concerne d'autres avantages potentiels du Vt moins élevé dans l'arrêt cardiaque intrahospitalier.

Timing of focused cardiac ultrasound during advanced life support - A prospective clinical study.
Aagaard R, Løfgren B, Grøfte T, Sloth E, Nielsen RR, Frederiksen CA, Granfeldt A, Bøtker MT. | Resuscitation. 2018 Mar;124:126-131
DOI: https://doi.org/10.1016/j.resuscitation.2017.12.012
Keywords: Focused cardiac ultrasound; Image quality; In-hospital cardiac arrest

Clinical papers

Introduction : Focused cardiac ultrasound can potentially identify reversible causes of cardiac arrest during advanced life support (ALS), but data on the timing of image acquisition are lacking. This study aimed to compare the quality of images obtained during rhythm analysis, bag-mask ventilations, and chest compressions.

Méthode : Adult patients in cardiac arrest were prospectively included during 23 months at a Danish community hospital. Physicians who had completed basic ultrasound training performed subcostal focused cardiac ultrasound during rhythm analysis, bag-mask ventilations, and chest compressions. Image quality was categorised as either useful for interpretation or not. Two echocardiography experts rated images useful for interpretation if all the following characteristics could be determined: 1) right ventricle larger than left ventricle, 2) pericardial fluid, and 3) collapsing ventricles.

Résultats : Images were obtained from 60 of 114 patients undergoing ALS. A higher proportion of the images obtained during rhythm analysis and bag-mask ventilations were useful for interpretation when compared with chest compressions (rhythm analysis vs chest compressions: OR 2.2 (95%CI 1.3-3.8), P = 0.005; bag mask ventilations vs chest compressions: OR 2.0 (95%CI 1.1-3.7), P = 0.03). There was no difference between images obtained during rhythm analysis and bag-mask ventilations (OR 1.1 (95%CI 0.6-2.0), P = 0.74).

Conclusion : The quality of focused cardiac ultrasound images obtained during rhythm analysis and bag-mask ventilations was superior to that of images obtained during chest compressions. There was no difference in the quality of images obtained during rhythm analysis and bag-mask ventilations. Bag-mask ventilations may constitute an overlooked opportunity for image acquisition during ALS.

Conclusion (proposition de traduction) : La qualité des images d'échographie cardiaque obtenues, auprès du patient, pendant l'analyse du rythme et pendant les ventilations au masque facial (avec un BAVU) était supérieure à celles obtenues pendant le massage cardiaque. Il n'y avait aucune différence dans la qualité des images obtenues pendant l'analyse du rythme et celles obtenues pendant les ventilations au masque facial (au BAVU).
Les ventilations au masque facial (au BAVU) peuvent constituer l'occasion pour l'acquisition des images d'échographie pendant la réanimation spécialisée (Advanced Cardiaque Life Support - ACLS).

2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.
Powers WJ, Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL; American Heart Association Stroke Council. | Stroke. 2018 Mar;49(3):e46-e110
DOI: https://doi.org/10.1161/STR.0000000000000158  | Télécharger l'article au format  
Keywords: AHA Scientific Statements; secondary prevention; stroke; therapeutics

AHA/ASA Guideline

Introduction : The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 guidelines and subsequent updates.

Méthode : Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft guideline was performed by 4 expert peer reviewers and by the members of the Stroke Council's Scientific Statements Oversight Committee and Stroke Council Leadership Committee. These guidelines use the American College of Cardiology/American Heart Association 2015 Class of Recommendations and Levels of Evidence and the new American Heart Association guidelines format.

Résultats : These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings.

Conclusion : These guidelines are based on the best evidence currently available. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Conclusion (proposition de traduction) : Ces recommandations sont basées sur les meilleures preuves actuellement disponibles. Dans de nombreux cas, cependant, il existe seulement des données limitées démontrant le besoin urgent de poursuivre la recherche sur le traitement de l'AVC ischémique aigu.

External Validation of Risk Scores for Major Bleeding in a Population-Based Cohort of Transient Ischemic Attack and Ischemic Stroke Patients.
Hilkens NA, Li L, Rothwell PM, Algra A, Greving JP. | Stroke. 2018 Mar;49(3):601-606
DOI: https://doi.org/10.1161/STROKEAHA.117.019259  | Télécharger l'article au format  
Keywords: antiplatelet agents; bleeding; human; risk; stroke

Original contributions

Introduction : The S2TOP-BLEED score may help to identify patients at high risk of bleeding on antiplatelet drugs after a transient ischemic attack or ischemic stroke. The score was derived on trial populations, and its performance in a real-world setting is unknown. We aimed to externally validate the S2TOP-BLEED score for major bleeding in a population-based cohort and to compare its performance with other risk scores for bleeding.

Méthode : We studied risk of bleeding in 2072 patients with a transient ischemic attack or ischemic stroke on antiplatelet agents in the population-based OXVASC (Oxford Vascular Study) according to 3 scores: S2TOP-BLEED, REACH, and Intracranial-B2LEED3S. Performance was assessed with C statistics and calibration plots.

Résultats : During 8302 patient-years of follow-up, 117 patients had a major bleed. The S2TOP-BLEED score showed a C statistic of 0.69 (95% confidence interval [CI], 0.64-0.73) and accurate calibration for 3-year risk of major bleeding. The S2TOP-BLEED score was much more predictive of fatal bleeding than nonmajor bleeding (C statistics 0.77; 95% CI, 0.69-0.85 and 0.50; 95% CI, 0.44-0.58). The REACH score had a C statistic of 0.63 (95% CI, 0.58-0.69) for major bleeding and the Intracranial-B2LEED3S score a C statistic of 0.60 (95% CI, 0.51-0.70) for intracranial bleeding. The ratio of ischemic events versus bleeds decreased across risk groups of bleeding from 6.6:1 in the low-risk group to 1.8:1 in the high-risk group.

Conclusion : The S2TOP-BLEED score shows modest performance in a population-based cohort of patients with a transient ischemic attack or ischemic stroke. Although bleeding risks were associated with risks of ischemic events, risk stratification may still be useful to identify a subgroup of patients at particularly high risk of bleeding, in whom preventive measures are indicated.

Conclusion (proposition de traduction) : Le score S2TOP-BLEED montre une performance modeste dans une cohorte basée sur la population de patients présentant un accident ischémique transitoire ou un accident vasculaire cérébral ischémique. Bien que les risques d'hémorragie soient associés aux risques d'événements ischémiques, la stratification du risque peut néanmoins être utile pour identifier un sous-groupe de patients présentant un risque particulièrement élevé de saignement, chez qui des mesures préventives sont indiquées.

Long-Term Survival After Intravenous Thrombolysis for Ischemic Stroke: A Propensity Score-Matched Cohort With up to 10-Year Follow-Up.
Muruet W, Rudd A, Wolfe CDA, Douiri A. | Stroke. 2018 Mar;49(3):607-613
DOI: https://doi.org/10.1161/STROKEAHA.117.019889  | Télécharger l'article au format  
Keywords: activities of daily living; prognosis; propensity score; risk; stroke

Original contributions

Introduction : Intravenous thrombolysis with alteplase is one of the few approved treatments for acute ischemic stroke; nevertheless, little is known about its long-term effects on survival and recovery because clinical trials follow-up times are limited.

Méthode : Patients registered between January 2005 and December 2015, to the population-based South London Stroke Register of first-ever strokes. Propensity score was used to match thrombolyzed and control cases to a 1:2 ratio by demographical and clinical covariates. The primary outcome was survival up to 10 years using Kaplan-Meier estimates, Cox proportional hazards, and restricted mean survival time. Secondary outcomes included stroke recurrence and functional status (Barthel Index and Frenchay Activities Index scores) at 5 years.

Résultats : From 2052 ischemic strokes, 246 treated patients were matched to 492 controls. Median follow-up time 5.45 years (interquartile range, 4.56). Survival was higher in the treatment group (median, 5.72 years) compared with control group (4.98 years, stratified log-rank test <0.001). The number needed to treat to prevent 1 death at 5 years was 12 and 20 at 10 years. After Cox regression analysis, thrombolysis reduced risk of mortality by 37% (hazard ratio, 0.63; 95% confidence interval [CI], 0.48-0.82) at 10 years; however, after introducing a multiplicative interaction term into the model, mortality risk reduction was 42% (hazard ratio, 0.58; 95% CI, 0.40-0.82) at 10 years for those arriving within 3 hours to the hospital. On average, in a 10-year period, treated patients lived 1 year longer than controls. At 5 years, thrombolysis was associated with independence (Barthel Index≥90; odds ratio, 3.76; 95% CI, 1.22-13.34) and increased odds of a higher Frenchay Activities Index (proportional odds ratio, 2.37; 95% CI, 1.16-4.91). There was no difference in stroke recurrence.

Conclusion : Thrombolysis with intravenous alteplase is associated with improved long-term survival and functional status after ischemic stroke.

Conclusion (proposition de traduction) : La thrombolyse avec l’alteplase par voie intraveineuse est associée à une amélioration de la survie à long terme et de l’état fonctionnel après un AVC ischémique.

Outcomes and predictors of failure of non-invasive ventilation in patients with community acquired pneumonia in the ED.
Al-Rajhi A, Murad A, Li PZ, Shahin J. | Am J Emerg Med. 2018 Mar;36(3):347-351
DOI: https://doi.org/10.1016/j.ajem.2017.08.016
Keywords: Aucun

Original Contribution

Introduction : We set out to describe the use and analyze the predictors of non-invasive ventilation failure in patients with community-acquired pneumonia who receive non-invasive ventilation as first line ventilatory therapy in the emergency department.

Méthode : A retrospective cohort study was conducted among consecutive patients with community acquired pneumonia requiring ventilator support presenting to two tertiary care university-affiliated emergency departments. Multivariable logistic regression analysis was used to determine predictors of non-invasive ventilation failure at initiation of non-invasive ventilation and at two hours of non-invasive ventilation use.

Résultats : After excluding patients with a do not resuscitate order status, 163 (74.8%) patients with community acquired pneumonia were initially treated with non-invasive ventilation on initial presentation to the emergency department. Non-invasive ventilation failure occurred in 50% of patients and was found to be associated with the absence of chronic obstructive airway disease, APACHE II score, the need for hemodynamic support and the number of CXR quadrants involved. Two-hour physiological parameters associated with non-invasive ventilation failure included higher respiratory rate, lower serum pH and the ongoing need of hemodynamic support.

Conclusion : In conclusion, the use of non-invasive ventilation to support patients presenting to the emergency department with respiratory failure and community acquired pneumonia is common and is associated with a significant failure rate. Hemodynamic support is a strong predictor of failure. The selection of the appropriate patient and monitoring of physiological parameters while on NIV is crucial to ensure successful treatment.

Conclusion (proposition de traduction) : En conclusion, l'utilisation de la ventilation non invasive pour ventiler les patients se présentant aux urgences avec une insuffisance respiratoire et une pneumonie acquise communautaire est fréquente et est associée à un taux d'échec significatif. La suppléance hémodynamique est un bon prédicteur de l'échec.
Le choix du patient approprié et la surveillance des paramètres physiologiques pendant la VNI sont cruciaux pour assurer le succès du traitement.

72h returns: A trigger tool for diagnostic error.
Aaronson E, Borczuk P, Benzer T, Mort E, Temin E. | Am J Emerg Med. 2018 Mar;36(3):359-361
DOI: https://doi.org/10.1016/j.ajem.2017.08.019
Keywords: Aucun

Original Contribution

Introduction : Patients who return to the Emergency Department (ED) within 72h of discharge are often used for ED Quality Assurance efforts, however little is known about the yield of this kind of review and the types of errors it identifies. Our objective was to identify the prevalence, types and severity of errors in these cases.

Méthode : Retrospective review of patients who presented to an urban, university affiliated ED between 10/1/2012-9/30/2015 who returned within 72 h requiring hospital admission.

Résultats : There were 413,167 ED visits during the study period with 2001 (0.48%) patients who returned within 72h and were admitted to the hospital. An event requiring further investigation was identified in 59 (2.95%) of these patients and 50 (2.49%) of them were deemed to represent a deviation from optimal care. Of these, 48 (96%) represented diagnostic error. When a standard diagnostic process of care framework was applied to these, the majority of cases represented failures in the initial diagnostic pathway (29 cases, 60.4%). When Error Severity Codes were applied, 16 (32%) resulted in minor harm and 34 (68%) resulted in major harm or death.

Conclusion : Screening of 72h ED returns has low yield in identifying suboptimal care, with less than 3% of cases representing deviations from standard care. Of these, the majority represent cognitive errors in the diagnostic pathway. These reviews may be useful as a tool for Ongoing Professional Practice Evaluation of individual clinicians, however likely serve less value in identifying systems issues contributing to unsafe care.

Conclusion (proposition de traduction) : Le dépistage des ré-hospitalisation à 72h aux urgences a un faible rendement pour l'identification des soins sous-optimaux, avec moins de 3 % des cas représentant des écarts par rapport aux soins standards. Parmi ceux-ci, la majorité représente des erreurs cognitives de diagnostic. Des examens peuvent être utiles en tant qu'outil pour l'évaluation de la pratique professionnelle continue de chaque clinicien, mais ils sont probablement moins utiles pour identifier les problèmes systémiques qui contribuent aux soins non sécuritaires.

The relationship between emergency department volume and patient complexity.
Hahn B, Zuckerman B, Durakovic M, Demissie S. | Am J Emerg Med. 2018 Mar;36(3):366-369
DOI: https://doi.org/10.1016/j.ajem.2017.08.023
Keywords: Aucun

Original research article

Introduction : Forecasting emergency department (ED) visits is a well-studied topic. The importance of understanding the complexity of patients along with the days and times of varying patient volumes is critical for planning medical and ancillary staffing. Though multiple studies stratify their results based on severity of disease, severity was determined by triage status. The goal of this study was to utilize a novel method to evaluate the correlation between daily emergency department patient complexity, based on Current Procedure Terminology (CPT) code, and day of the week.

Méthode : This was a retrospective study of subjects presenting to the ED between January 1, 2010 and December 31, 2015. We identified the correlation between subjects with each CPT code who were evaluated on a specific day of the week and evaluated the day before, the day of and the day after a legal holiday.

Résultats : During the study period 312,550 (48%) male and 336,348 (52%) female subjects were identified. No correlation between daily ED patient complexity, based on CPT code, and day of the week (p=0.75) or any legal holidays were identified. Individual significant differences were noted among day of the week and particular CPT code as well as legal holiday and particular CPT code with no appreciable trend or pattern.

Conclusion : There was no correlation between daily ED patient complexity based on CPT code and day of the week or daily ED patient acuity and legal holiday. In light of these data, emergency department staffing and resource allocation patterns may need to be revisited.

Conclusion (proposition de traduction) : Il n'y avait pas de corrélation entre la complexité quotidienne des patients du service des urgences en fonction du code de terminologie de procédure courante et le jour de la semaine ou le volume d’activité quotidienne des patients du service des urgences et les jours fériés.
À la lumière de ces données, la dotation en personnel d'urgence et les modèles d'affectation des ressources pourraient devoir être revus.

Commentaire : Le « Current Procedural Terminology » (CPT) utilisée aux États‐Unis est le système équivalent à nos « Groupes homogènes de séjours » (GHS) en France.

Measurement of blood lactate, D-dimer, and activated prothrombin time improves prediction of in-hospital mortality in adults blunt trauma.
Umebachi R, Taira T, Wakai S, Aoki H, Otsuka H, Nakagawa Y, Inokuchi S. | Am J Emerg Med. 2018 Mar;36(3):370-375
DOI: https://doi.org/10.1016/j.ajem.2017.08.025
Keywords: Activated prothrombin time; Blunt trauma; D-dimer; Lactate; Mortality

Original research article

Introduction : Trauma patients in high need of emergency treatment could be more accurately identified if their risk of mortality could be predicted more precisely. This can be achieved by including biomarkers that can be evaluated quickly in emergency department (ED) triage assessments on admission.

Méthode : This retrospective observational study was conducted by reviewing the medical records of adult blunt trauma patients admitted to Tokai University Hospital in Japan between January 1, 2010 and December 31, 2014. This study was performed with the approval of the Tokai University Ethics Review Committee.

Résultats : There were 4256 trauma patients admitted at the Tokai University Hospital between January 1, 2010 and December 31, 2014. We excluded the following patients: 162 with penetrating trauma, 238 with burn injuries, and 13 with unknown causes of trauma. There were 3843 remaining patients with blunt trauma; however this sample was further narrowed by excluding 303 who were dead-on-arrival, 1533 for whom lactate or D-dimer levels or APTT were not measured on ED admission, 96 aged 14 years or younger, and 110 for whom > 3 h had elapsed between the time of injury and blood sampling to assess lactate or D-dimer levels or APTT. Thus, 1691 total patients were included in this study.

Conclusion : In conclusion, the ability of a prediction model to predict in-hospital mortality in adult blunt trauma patients improved following the addition of blood lactate concentration, D-dimer concentration, and APTT measured on ED arrival as explanatory variables.

Conclusion (proposition de traduction) : En conclusion, la capacité d'un modèle de prédiction à prédire la mortalité hospitalière chez les patients adultes atteints de traumatisme contondant s'est améliorée à la suite de l'ajout de la concentration de lactate sanguin, de la concentration de D-dimères et du TCA mesurés à l'arrivée.

Can low-dose of ketamine reduce the need for morphine in renal colic? A double-blind randomized clinical trial.
Abbasi S, Bidi N, Mahshidfar B, Hafezimoghadam P, Rezai M, Mofidi M, Farsi D. | Am J Emerg Med. 2018 Mar;36(3):376-379
DOI: https://doi.org/10.1016/j.ajem.2017.08.026
Keywords: Ketamine; Morphine; Pain; Renal colic

Original research article

Introduction : The combination of morphine with low doses of ketamine (MK) has been utilized in the Emergency Department (ED) compared with morphine and placebo (MP) for the treatment of acute pain in few studies. The purpose of this study was to compare the effect of MP with MK for the treatment of severe pain with renal colic of patients who had been referred to the ED.

Méthode : This study is a double blind randomized clinical trial on patients with severe renal colic pain who were referred to the ED. Patients were enrolled with pain severity of at least 6 of the 10 visual analogue scales (VAS). Patients were divided into two groups: Morphine 0.1mg/kg and placebo (MP group) and morphine 0.1mg/kg and ketamine 0.15mg/kg (MK group). Pain of patients was studied in 10, 30, 60, 90, and 120min after injection.

Résultats : Totally, 106 patients were enrolled in study groups. Assessment of the average pain during 120min at 10 and 30min after the start in the drug, MK group was significantly lower than the MP group (p=0.019 and p=0.003 respectively).

Conclusion : Given that combinations of morphine with low doses of ketamine in patients with renal colic pain causes more pain and morphine consumption reduction then this combination is suggested as an alternative treatment that could be utilized in patients with renal colic.

Conclusion (proposition de traduction) : Étant donné que des associations de morphine et de faibles doses de kétamine chez les patients souffrant de colique néphrétique entraînent une diminution de la douleur et de la consommation en morphine, cette association est suggérée comme traitement alternatif pouvant être utilisé chez les patients atteints de colique néphrétique.

Commentaire : Voir en complément, l'étude en double aveugle, randomisée et contre placebo publiée en novembre 2014 dans Acad Emerg Med de Beaudoin FL : Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial  . Il concluait aussi à l'efficacité des faibles doses de ketamine mais proposait plutôt 0,3 mg/kg comme peut-être plus efficace que 0,15 mg/kg (posologie post-opératoire dans la chirurgie rénale), mais au prix d'événements indésirables mineurs plus importants.

Safety events in pediatric out-of-hospital cardiac arrest.
Hansen M, Eriksson C, Skarica B, Meckler G, Guise JM. | Am J Emerg Med. 2018 Mar;36(3):380-383
DOI: https://doi.org/10.1016/j.ajem.2017.08.028  | Télécharger l'article au format  
Keywords: Emergency medical services; Heart arrest; Pediatrics

Original research article

Introduction : The objective of this study was to explore the types of patient safety events that take place during pediatric out-of-hospital cardiac arrest resuscitation.

Méthode : Retrospective medical record review from a single large urban EMS system of EMS-treated pediatric (<18years of age) out-of-hospital cardiac arrests (OHCA) occurring between 2008 and 2011. A chart review tool was developed for this project and each chart was reviewed by a multidisciplinary review panel. Safety events were identified in the following clinical domains: resuscitation; assessment, impression/diagnosis, and clinical decision making; airway/breathing; fluids and medications; procedures; equipment; environment; and system.

Résultats : From a total of 497 critical transports during the study period, we identified 35 OHCA cases (7%). A total of 87% of OHCA cases had a safety event identified. Epinephrine overdoses were identified in 31% of the OHCA cases, most of which were 10-fold overdoses. Other medication errors included failure to administer epinephrine when indicated and administration of atropine when not indicated. In 20% of OHCA cases, 3 or more intubation attempts took place or intubation attempts were ultimately not successful. Lack of end-tidal C02 use for tube confirmation was also common. The most common arrest algorithm errors were placing an advanced airway too early (before administration of epinephrine) and giving a medication not included in the algorithm, primarily atropine, both occurring in almost 1/3 of cases.

Conclusion : Safety events were common during pediatric OHCA resuscitation especially in the domains of medications, airway/breathing, and arrest algorithms.

Conclusion (proposition de traduction) : Des événements indésirables ont été retrouvés fréquemment au cours de la réanimation pédiatrique de l'arrêt cardiaque extra-hospitalier, en particulier en ce qui concerne l'administration des médicaments (posologies), la gestion des voies respiratoires et l'application des algorithmes de prise en charge de l’arrêt cardiaque pédiatrique.

Management of Factor Xa inhibitor-associated life-threatening major hemorrhage: A retrospective multi-center analysis.
Milling TJ Jr, Clark CL, Feronti C, Song SS, Torbati SS, Fermann GJ, Weiss J, Patel D. | Am J Emerg Med. 2018 Mar;36(3):396-402
DOI: https://doi.org/10.1016/j.ajem.2017.08.042
Keywords: Aucun

Original Contribution

Introduction : Factor Xa (FXa) inhibitors, used for stroke prevention in atrial fibrillation and venous thromboembolism treatment and prevention, are the dominant non-Vitamin K oral anticoagulants on the market. While major bleeding may be less common with these agents compared to warfarin, it is always a risk, and little has been published on the most serious bleeding scenarios. This study describes a cohort of patients with FXa inhibitor-associated life-threatening bleeding events, their clinical characteristics, interventions and outcomes.

Méthode : We performed a retrospective, 5-center review of FXa inhibitor-treated major bleeding patients. Investigators identified potential cases by cross-referencing ICD-9/10 codes for hemorrhage with medication lists. Investigators selected cases they deemed to require immediate reversal of coagulopathy, and reviewed charts for characteristics, reversal strategies and other interventions, and outcomes.

Résultats : A total of 56 charts met the inclusion criteria for the retrospective cohort, including 29 (52%) gastrointestinal bleeds (GIB), 19 (34%) intracranial hemorrhages (ICH) and 8 (14%) others. Twenty-four (43%) patients received various factor or plasma products, and the remainder received supportive care. Thirty-day mortality was 21% (n=12). Re-anticoagulation within 30-days occurred in 23 (41%) patients. Thromboembolic events (TEEs) occurred in 6 (11%) patients. No differences were observed in outcomes by treatment strategy.

Conclusion : This cohort of FXa inhibitor-associated major bleeding scenarios deemed appropriate for acute anticoagulant reversal illustrates the variable approaches in the absence of a specific reversal agent.

Conclusion (proposition de traduction) : Cette cohorte de scénarios de saignements majeurs associés aux inhibiteurs du facteur Xa et jugés appropriés pour l'inversion aiguë des anticoagulants illustre les approches variables en l'absence d'un agent d'inversion spécifique.

Cerebral oximetry versus end tidal CO2 in predicting ROSC after cardiac arrest.
Singer AJ, Nguyen RT, Ravishankar ST, Schoenfeld ER, Thode HC Jr, Henry MC, Parnia S. | Am J Emerg Med. 2018 Mar;36(3):403-407
DOI: https://doi.org/10.1016/j.ajem.2017.08.046
Keywords: Accuracy; Cerebral oximetry; End tidal CO(2); Resuscitation; Return of spontaneous circulation

Original Contribution

Introduction : Both end tidal CO2 (ETCO2) and cerebral oxygen saturations (rSO2) have been studied to determine their ability to monitor the effectiveness of CPR and predict return of spontaneous circulation (ROSC). We compared the accuracy of ETCO2 and rSO2 at predicting ROSC in ED patients with out-of-hospital cardiac arrest (OHCA).

Méthode : We performed a prospective, observational study of adult ED patients presenting in cardiac arrest. We collected demographic and clinical data including age, gender, presenting rhythm, rSO2, and ETCO2. We used receiver operating characteristic curves to compare how well rSO2 and ETCO2 predicted ROSC.

Résultats : 225 patients presented to the ED with cardiac arrest between 10/11 and 10/14 of which 100 had both rSO2 and ETCO2 measurements. Thirty three patients (33%) had sustained ROSC, only 2 survived to discharge. The AUCs for rSO2 and ETCO2 were similar (0.69 [95% CI, 0.59-0.80] and 0.77 [95% CI, 0.68-0.86], respectively), however, rSO2 and ETCO2 were poorly correlated (0.12, 95% CI, -0.08-0.31). The optimal cutoffs for rSO2 and ETCO2 were 50% and 20mm Hg respectively. At these cutoffs, ETCO2 was more sensitive (100%, 95% CI 87-100 vs. 48%, 31-66) but rSO2 was more specific (85%, 95% CI, 74-92 vs. 45%, 33-57).

Conclusion : While poorly correlated, rSO2 and ETCO2 have similar diagnostic characteristics. ETCO2 is more sensitive and rSO2 is more specific at predicting ROSC in OHCA.

Conclusion (proposition de traduction) : Bien que faiblement corrélés, la saturation en oxygène cérébral régional (rSO₂) et l'EtCO₂ ont des caractéristiques diagnostiques similaires. L'EtCO₂ est plus sensible et le rSO₂ est plus spécifique pour prédire la RACS dans l'arrêt cardiaque extra-hospitalier.

Commentaire : Sur la technique, vous pouvez consulter l'article dans Réanimation en 2013, de Ter Minassian : Oxymétrie cérébrale   et l'article des Journées Lilloises d'Anesthésie Réanimation et de Médecine d'Urgence (JLAR) en 2016, de Robin : Oxymétrie cérébrale par spectrométrie de proche infrarouge  .
Sur la thèmatique ACR, voir : les résultats de l'étude de cohorte Copernicus I   dans Resuscitation de mars 2018 et les articles dans Acad Emerg Med. 2016 Aug;23(8):851-62   de Cournoyer en 2016 et J Emerg Med. 2016 Jan;50(1):198-207   de Genbrugge en 2015.

Predicting 72-hour emergency department revisits.
Pellerin G, Gao K, Kaminsky L. | Am J Emerg Med. 2018 Mar;36(3):420-424
DOI: https://doi.org/10.1016/j.ajem.2017.08.049
Keywords: Crowding; ED revisits; Prediction; Wait time

Original Contribution

Introduction : To develop a predictive model that hospitals or healthcare systems can use to identify patients at high risk of revisiting the ED within 72h so that appropriate interventions can be delivered.

Méthode : This study employed multivariate logistic regression in developing the predictive model. The study data were from four Veterans medical centers in Upstate New York; 21,141 patients in total with ED visits were included in the analysis. Fiscal Year (FY) 2013 data were used to predict revisits in FY 2014. The predictive variables were patient demographics, prior year healthcare utilizations, and comorbidities. To avoid overfitting, we validated the model by the split-sample method. The predictive power of the model is measured by c-statistic.

Résultats : In the first model using only patient demographics, the c-statistics were 0.55 (CI: 0.52-0.57) and 0.54 (95% CI: 0.51-0.56) for the development and validation samples, respectively. In the second model with prior year utilization added, the c-statistics were 0.70 (95% CI: 0.68-0.72) for both samples. In the final model where comorbidities were added, the c-statistics were 0.74 (CI: 0.72-0.76) and 0.73 (95% CI: 0.71-0.75) for the development and validation samples, respectively.

Conclusion : Reducing ED revisits not only lowers healthcare cost but also shortens wait time for those who critically need ED care. However, broad intervention for every ED visitor is not feasible given limited resources. In this study, we developed a predictive model that hospitals and healthcare systems can use to identify "frequent flyers" for early interventions to reduce ED revisits.

Conclusion (proposition de traduction) : Réduire les visites aux urgences permet non seulement de réduire les coûts des soins de santé, mais aussi de réduire les temps d'attente pour ceux qui ont un besoin urgent de soins aux urgences. Cependant, des interventions plus longues pour chaque consultants des urgences n'est pas réalisable étant donné les ressources limitées.
Dans cette étude, nous avons développé un modèle prédictif que les hôpitaux et les systèmes de soins de santé peuvent utiliser pour identifier les « habitués » précocement afin de réduire les visites à l'urgence.

The evaluation of the sensitivity and specificity of wrist examination findings for predicting fractures.
Eyler Y, Sever M, Turgut A, Yalcin N, Zafer N, Suner A, Aksay E, Yesilaras M. | Am J Emerg Med. 2018 Mar;36(3):425-429
DOI: https://doi.org/10.1016/j.ajem.2017.08.050
Keywords: Clinical Decision Rules; Emergency; Radiography; Wrist Fractures; Wrist Trauma

Original contribution

Introduction : The aim of this study was to evaluate the sensitivity and specificity of physical examination findings and functional tests in adult acute wrist trauma patients who presented to the emergency department (ED) and to create a reliable and practical clinical decision rule for determining the necessity of radiography in wrist trauma.

Méthode : This prospective observational study was conducted in a tertiary ED. Each patient was checked for 18 physical examination findings and functional tests. Patients with suspected fracture were enrolled consecutively. Antero-posterior and lateral wrist views were performed for each patient. All radiographical studies were interpreted by an orthopedic surgeon. The prevalence, sensitivity and specificity, negative and positive predictive values of each finding were calculated. A modeling for predicting fractures was created using computer.

Résultats : 207 patients were evaluated and 69 patients (33.3%) had fractures. The most common encounterd fracture site was distal radius (29.5%). The most sensitive examination finding was pain in dorsiflexion (95.7%) and the most specific finding was ecchymosis (97.8%). Wrist edema, deformity and pain aggravated by pronation were found to be strong predictors of fracture. The area under the receiver operating characteristic curve at internal validation for a prediction model based on these three predictors was 0.88 (95% CI: 0.83-0,93). The overall sensitivity and specificity of this model were 94% (95% CI: 85-98%) and 51% (95% CI 43-60%) respectively. According to the model created in this study, 34% of acute blunt wrist trauma patients do not require any X-ray imaging.

Conclusion : This triple modeling may be used as an effective decision rule for predicting all wrist fractures in the ED and in the disaster setting.

Conclusion (proposition de traduction) : Ces trois signes (œdème du poignet, déformation et douleur à la pronation) peuvent être utilisés comme une base de décision efficace pour prédire toutes les fractures du poignet aux urgences et en situation de catastrophe.

Placement of a cervical collar increases the optic nerve sheath diameter in healthy adults.
Woster CM, Zwank MD, Pasquarella JR, Wewerka SS, Anderson JP, Greupner JT, Motalib S. | Am J Emerg Med. 2018 Mar;36(3):430-434
DOI: https://doi.org/10.1016/j.ajem.2017.08.051
Keywords: Cervical collar; Optic nerve sheath diameter; Trauma

Original contribution

Introduction : Blunt head trauma is a common cause of increased intracranial pressure (ICP). Ultrasound measurement of the optic nerve sheath diameter (OSND) is an accurate and non-invasive way to detect increased ICP. Blunt trauma patients are often immobilized in a rigid cervical spine collar. Our objective was to describe the changes in ONSD following the placement of a c-collar and determine if any changes were time-dependent.

Méthode : We performed a prospective cohort study measuring the ONSD of healthy volunteers before and after placement of a c-collar. Two physicians obtained the measurements. Each eye was scanned twice using a standardized technique. This was done before c-collar placement, 5min after placement and 20min after placement. A mean of both eyes was calculated and analyzed using descriptive statistics. An intraclass correlation coefficient (ICC) was used to assess inter-rater reliability.

Résultats : Twenty study participants with a mean age of 37.1years old were enrolled. The mean baseline ONSD was 3.77mm (95% CI 3.48-4.07). The mean ONSD 5 min after the c-collar was placed was 4.47 (95% CI 4.17-4.78). The mean ONSD at 20min after c-collar placement was 4.53 (95% CI 4.13-4.92). These changes were statistically significant (p=0.003 and <0.001). Reliability was relatively strong overall (ICC=0.74; 95% CI: 0.65, 0.81).

Conclusion : The placement of a cervical collar increased the ONSD at 5min and this change remained increased at 20min. Future study should assess whether similar results are found in patients with blunt head trauma.

Conclusion (proposition de traduction) : La mise en place d'un collier cervical a augmenté le diamètre de la gaine du nerf optique à 5 min et ce changement est resté augmenté pendant 20 min.
Une future étude devrait évaluer si des résultats similaires sont retrouvés chez les patients victimes d'un traumatisme crânien sévère.

Commentaire : Cette étude de faisabilité va dans le sens des recommandations Norvégienne de 2017 : The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury  . En effet, elle argumentait que les colliers cervicaux rigides pouvaient augmenter la pression intracrânienne en induisant une douleur ou en bloquant le retour veineux de la circulation crânienne.

Impact of rapid response car system on ECMO in out-of-hospital cardiac arrest: A retrospective cohort study.
Sato R, Kuriyama A, Nasu M, Gima S, Iwanaga W, Takada T, Kitahara Y, Fukui H, Yonemori T, Yagi M. | Am J Emerg Med. 2018 Mar;36(3):442-445
DOI: https://doi.org/10.1016/j.ajem.2017.08.055
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Extracorporeal circulation; Extracorporeal membrane oxygenation; Out-of-hospital cardiac arrest

Original contribution

Introduction : Extracorporeal life support (ECLS) has been reported to be more effective than conventional cardiopulmonary resuscitation (CPR). In ECLS, a shorter time from arrival to implantation of extracorporeal membrane oxygenation (ECMO; door-to-ECMO) time was predicted to be associated with better survival rates. This study aimed to examine the impact of the physician-based emergency medical services (P-EMS) using a rapid response car (RRC) on door-to-ECMO time in patients with out-of-hospital cardiac arrest (OHCA).

Méthode : In this retrospective cohort study, adult patients with OHCA who were admitted to a Japanese tertiary care hospital from April 2012 to December 2016 and underwent venoarterial ECMO were included. Patients were either transferred by emergency medical service (EMS only group) or RRC (RRC group). Primary outcome was door-to-ECMO time. Wilcoxon rank-sum test was used to compare the outcome between the two groups.

Résultats : A total of 34 patients were included in this study, and outcome data were available for all patients. The door-to-ECMO time was significantly shorter in the RRC group than in the EMS only group (median, 23min vs. 36min; P=0.006). Additionally, the RRC was also associated with earlier successful intubation and intravenous adrenaline administration.

Conclusion : The physician-based RRC system was associated with a shorter door-to-ECMO time and successful advanced procedures in prehospital settings. Combination of the RRC system with ECLS may lead to better outcomes in patients with OHCA.

Conclusion (proposition de traduction) : Le système de réponse rapide par ambulance armé par des médecins était associé à un temps de transport jusqu'à la porte de l'ECMO plus court et à des procédures avancées réussies en extra-hospitalier. La combinaison d'un système de réponse rapide en ambulance associé à l'ECLS peut donner de meilleurs résultats chez les patients en ACR extra-hospitalier.

Echocardiography in cardiac arrest: An emergency medicine review.
Long B, Alerhand S, Maliel K, Koyfman A. | Am J Emerg Med. 2018 Mar;36(3):488-493
DOI: https://doi.org/10.1016/j.ajem.2017.12.031
Keywords: ireAsystole; Cardiac arrest; Echocardiography; Non-shockable; Point-of-care ultrasound; Pulseless electrical activity; Shockable; Ultrasound; Ventricular fibrillation; Ventricular tachycardia

Reviews

Introduction : Cardiac arrest management primarily focuses on optimal chest compressions and early defibrillation for shockable cardiac rhythms. Non-shockable rhythms such as pulseless electrical activity (PEA) and asystole present challenges in management. Point-of-care ultrasound (POCUS) in cardiac arrest is promising.

Méthode : his review provides a focused assessment of POCUS in cardiac arrest, with an overview of transthoracic (TTE) and transesophageal echocardiogram (TEE), uses in arrest, and literature support.

Résultats : Cardiac arrest can be distinguished between shockable and non-shockable rhythms, with management varying based on the rhythm. POCUS provides a diagnostic and prognostic tool in the emergency department (ED), which may improve accuracy in clinical decision-making. Several protocols incorporate POCUS based on different cardiac views. TTE includes parasternal long axis, parasternal short axis, apical 4-chamber, and subxiphoid views, which may be used in cardiac arrest for diagnosis of underlying cause and potential prognostication. TEE is conducted by inserting the probe into the esophagus of intubated patients, with several studies evaluating its use in cardiac arrest. It is associated with few adverse effects, while allowing continued compressions (and evaluation of those compressions) and not interrupting resuscitation efforts.

Conclusion : POCUS is a valuable diagnostic and prognostic tool in cardiac arrest, with recent literature supporting its diagnostic ability. TTE can guide resuscitation efforts dependent on the rhythm, though TTE should not interrupt other resuscitation measures. TEE can be useful during arrest, but further studies based in the ED are needed.

Conclusion (proposition de traduction) : L'échographie au lit du patient est un outil diagnostique et pronostique précieux dans l'arrêt cardiaque, avec une littérature récente mettant en avant sa capacité diagnostique. L'échocardiographie transthoracique peut guider les gestes de réanimation en fonction du rythme, bien que l'échocardiographie transthoracique ne devrait pas interrompre d'autres mesures de réanimation. L'échocardiographie transœsophagienne peut être utile pendant l'arrêt cardiaque, mais d'autres études sont nécessaire dans les services d'urgences.

Commentaire : Pour rappel, l'un des objectifs de l'échographie dans l'arrêt cardiaque est de rechercher des causes potentiellement curables telles qu'un épanchement péricardique avec tamponnade, une hypovolémie, une insuffisance cardiaque droite observée dans une embolie pulmonaire, une dissection aortique proximale, une rupture de paroi septale ou libre, une dysfonction valvulaire grave ou un pneumothorax.
Elle permet également une évaluation de l'activité cardiaque pendant l'arrêt (c'est-à-dire identifier une activité cardiaque organisée, une FV, un arrêt de l’activité cardiaque).

Appropriateness and Complications of Peripheral Venous Catheters Placed in an Emergency Department.
Guihard B, Rouyer F, Serrano D, Sudrial J, Combes X. | J Emerg Med. 2018 Mar;54(3):281-286
DOI: https://doi.org/10.1016/j.jemermed.2017.10.005
Keywords: emergency; peripheral venous catheter; phlebitis

Original Contributions

Introduction : The insertion of peripheral venous catheters (PVCs) is the invasive procedure most frequently performed in hospitals, and it could be associated with complications. The appropriateness of PVC placement, however, has not been carefully analyzed.
OBJECTIVES: We conducted a study to assess the rate of PVC placement in our Emergency Department (ED), their use, their immediate or potential usefulness, and their complications.

Méthode : In this descriptive prospective study, we recorded every PVC placed in our ED during 1 week and assessed its appropriateness in terms of its use and potential usefulness. We then followed the patients transferred to medical wards to determine the duration of PVC maintenance and any complications.

Résultats : PVCs (n = 210) were placed for 34% (n = 207) of the 605 patients admitted to the ED during the study period. Of these PVCs, 27% (n = 52) were not used and 43% (n = 91) were considered ineffective. Follow-up covered 92 patients with PVCs transferred to medical wards. We recorded seven episodes of phlebitis (8%) and no infections, local or systemic. The mean duration of PVS maintenance in the medical wards was 40 h from insertion. Of the PVCs with complications, 43% were ineffective. The mean duration of maintenance of the PVCs that led to complications was 80 h, compared with 35 h for those without complications (p < 0.02).

Conclusion : In accordance with the literature, half of the PVCs inserted in our ED were ineffective; half the PVCs causing complications were avoidable.

Conclusion (proposition de traduction) : Conformément à la littérature, la moitié des VVP posées dans notre service des urgences n'étaient pas indiquées ; la moitié des VVP entrainaient des complications évitables.

Intravenous Flecainide for Emergency Department Management of Acute Atrial Fibrillation.
Markey GC, Salter N, Ryan J. | J Emerg Med. 2018 Mar;54(3):320-327
DOI: https://doi.org/10.1016/j.jemermed.2017.11.016
Keywords: atrial fibrillation; cardioversion; flecainide; recent onset

Clinical Review

Introduction : Atrial fibrillation (AF) is the most commonly encountered dysrhythmia in the emergency department, and its prevalence is increasing. A substantial proportion of these patients have recent-onset AF (<48 h). The poor prognosis associated with AF is being increasingly recognized, and there is some evidence for better outcomes in younger patients with recent-onset AF when sinus rhythm is restored. Flecainide is recommended in the latest international guidelines for cardioversion of recent-onset AF, but its safety and efficacy relative to other recommended agents are unclear.
OBJECTIVE: Our aim was to clarify the Level 1 evidence for the use of i.v. flecainide in acute AF.

Méthode : We performed a systematic review and meta-analysis of the literature. Medline, Ovid, Embase, and Cochrane Central databases were searched for relevant studies. Only randomized controlled trials (RCTs) of i.v. flecainide for acute conversion of recent-onset AF were selected for meta-analysis.

Résultats : Four hundred and three studies were screened, of which 11 RCTs were eligible for meta-analysis. Flecainide had high efficacy for cardioversion within 2 h (number needed to treat [NNT] = 1.8). Efficacy was superior to propafenone, amiodarone, procainamide, ibutilide, and sotalol (NNT = 4.3). There was no statistically significant difference in pro-dysrhythmia compared to these anti-dysrhythmics or placebo.

Conclusion : Intravenous flecainide cardioversion could be a safe and effective option for emergency physicians to restore sinus rhythm in selected patients with acute AF.

Conclusion (proposition de traduction) : La cardioversion intraveineuse par flécaïnide pourrait être une option sûre et efficace pour les urgentistes pour rétablir un rythme sinusal chez certains patients atteints de FA aiguë.

Air Versus Ground Transportation in Isolated Severe Head Trauma: A National Trauma Data Bank Study.
Aiolfi A, Benjamin E, Recinos G, De Leon Castro A, Inaba K, Demetriades D. | J Emerg Med. 2018 Mar;54(3):328-334
DOI: https://doi.org/10.1016/j.jemermed.2017.11.019
Keywords: ground transport; helicopter transport; isolated severe head trauma; outcomes

Selected Topics: Aeromedical Emergencies

Introduction : The effect of prehospital helicopter emergency medical services (HEMS) on mortality has been analyzed previously in polytrauma patients with discordant results.
OBJECTIVE: Our aim was to compare outcomes in patients with isolated severe blunt traumatic brain injuries (TBIs) transported by HEMS or ground emergency medical services (GEMS).

Méthode : We conducted a National Trauma Data Bank study (2007-2014). All adult patients (≥16 years old) who sustained an isolated severe blunt TBI and were transported by HEMS or GEMS were included in the study.

Résultats : There were 145,559 patients who met the inclusion criteria. Overall, 116,391 (80%) patients were transported via GEMS and 29,168 (20%) via HEMS. Median transportation time was longer for HEMS patients (41 vs. 25 min; p < 0.001). HEMS patients were more likely to have hypotension (2.7% vs. 1.5%; p < 0.001), Glasgow Coma Scale (GCS) score < 9 (38.2% vs. 10.9%; p < 0.001), and head Abbreviation Injury Scale (AIS) score of 5 (20.1% vs. 9.7%; p < 0.001). Stepwise logistic regression analysis identified age ≥ 65 years old, male sex, hypotension, GCS score < 9, prehospital intubation, and head AIS scores 4 and 5 as independent predictors of mortality. Helicopter transportation was independently associated with improved survival (odds ratio [OR] 0.55; 95% confidence interval [CI] 0.47-0.67; p < 0.001). Admission to a Level I trauma center was an independent predictor of survival (OR 0.64; 95% CI 0.53-0.82; p = 0.001). Regardless of head AIS, helicopter transport was an independent predictor of survival (AIS 3: OR 0.35; p < 0.001; AIS 4: OR 0.44; p < 0.001; AIS 5: OR 0.76; p < 0.001). A prolonged transport time was not an independent predictor of mortality.

Conclusion : Helicopter transport, in adult patients with isolated severe TBI, is associated with improved survival.

Conclusion (proposition de traduction) : Le transport par hélicoptère, chez les patients adultes présentant un traumatisme crânien grave isolé, est associé à une amélioration de la survie.

Hip Dislocations in the Emergency Department: A Review of Reduction Techniques.
Gottlieb M | J Emerg Med. 2018 Mar;54(3):339-347
DOI: https://doi.org/10.1016/j.jemermed.2017.12.002
Keywords: dislocation; hip; reduction; relocation

Techniques and Procedures

Introduction : Hip dislocations are a common presentation in the Emergency Department (ED) and require urgent reduction to reduce the risk of avascular necrosis. Over 90% of all dislocations can successfully be reduced in the ED and there is evidence that cases awaiting operative reduction result in significant delays.

Discussion : While there is limited data comparing specific techniques, the individual success rates of most maneuvers range from 60-90%. Additionally, each technique has distinct advantages and limitations associated with its use.

Conclusion : It is important for Emergency Physicians to be familiar with several different reduction techniques in case the initial reduction attempt is unsuccessful or patient characteristics limit the use of certain maneuvers. This article reviews a number of reduction techniques for hip dislocations, variations on these techniques, and advantages and disadvantages for each approach.

Conclusion (proposition de traduction) : Il est important que les médecins urgentistes connaissent plusieurs techniques de réduction au cas où la tentative de réduction initiale échoue ou si les caractéristiques du patient limitent l'utilisation de certaines manœuvres.
Cet article passe en revue un certain nombre de techniques de réduction pour les luxations de la hanche, les variantes, les avantages et les inconvénients de chaque approche.

Evidence-Based Review of Pharmacotherapy for Acute Agitation. Part 1: Onset of Efficacy.
Zun LS | J Emerg Med. 2018 Mar;54(3):364-374
DOI: https://doi.org/10.1016/j.jemermed.2017.10.011
Keywords: acute agitation; antipsychotics; management; onset; treatment

Pharmacology in Emergency Medicine

Introduction : The main goal of antipsychotic medication in the management of acute agitation in the emergency department is to rapidly induce calm without oversedation, enabling patients to participate in their own care. However, there is a paucity of comparative studies, particularly with newer fast-acting second-generation antipsychotic agents.
OBJECTIVE OF THE REVIEW: This structured evidence-based review compared the onset of efficacy of antipsychotic treatments for acute agitation using data from randomized controlled trials identified by a literature search of the PubMed database.

Méthode : Based on findings from 28 blinded randomized controlled trials, onset of efficacy was rapid and generally observed at the first time point after intramuscular administration of ziprasidone (15-30 min) or olanzapine (15-30 min), but was more likely to be delayed with intramuscular haloperidol, even when combined with lorazepam (30-60 min), and intramuscular aripiprazole (45-90 min). When administered orally, rapid onset of efficacy was also consistently observed at the first assessment time point with olanzapine (15-120 min), risperidone (30-120 min), and sublingual asenapine (15 min). Significant effects were apparent for inhaled loxapine within 10-20 min. Effects were apparent within approximately 5-10 min with i.v. droperidol. Onset of efficacy was typically more rapid with second-generation antipsychotic agents than benzodiazepines, but data are limited.

Résultats : Based on findings from 28 blinded randomized controlled trials, onset of efficacy was rapid and generally observed at the first time point after intramuscular administration of ziprasidone (15-30 min) or olanzapine (15-30 min), but was more likely to be delayed with intramuscular haloperidol, even when combined with lorazepam (30-60 min), and intramuscular aripiprazole (45-90 min). When administered orally, rapid onset of efficacy was also consistently observed at the first assessment time point with olanzapine (15-120 min), risperidone (30-120 min), and sublingual asenapine (15 min). Significant effects were apparent for inhaled loxapine within 10-20 min. Effects were apparent within approximately 5-10 min with i.v. droperidol. Onset of efficacy was typically more rapid with second-generation antipsychotic agents than benzodiazepines, but data are limited.

Conclusion : Although the patient populations of trials included in this review do not truly reflect that of the emergency department, the results provide useful information to emergency physicians on the rapid efficacy of certain newer-generation antipsychotic agents for the treatment of acutely agitated patients.

Conclusion (proposition de traduction) : Bien que les populations d'essais cliniques incluses dans cette revue ne reflètent pas vraiment celles du service des urgences, les résultats donnent des informations utiles aux médecins urgentistes sur la rapidité de l'efficacité de certains agents antipsychotiques de nouvelle génération pour le traitement des patients agités.

Increased risk of fibrinolysis shutdown among severely injured trauma patients receiving tranexamic acid.
Meizoso JP, Dudaryk R, Mulder MB, Ray JJ, Karcutskie CA, Eidelson SA, Namias N, Schulman CI, Proctor KG. | J Trauma Acute Care Surg. 2018 Mar;84(3):426-432
DOI: https://doi.org/10.1097/TA.0000000000001792
Keywords: Aucun

AAST 2017 Podium Paper

Introduction : The association between tranexamic acid (TXA) and fibrinolysis shutdown is unknown. We hypothesize that TXA is associated with fibrinolysis shutdown in critically injured trauma patients.

Méthode : Two hundred eighteen critically injured adults admitted to the intensive care unit at an urban Level I trauma center from August 2011 to January 2015 who had thromboelastography performed upon intensive care unit admission were reviewed. Groups were stratified based on fibrinolysis shutdown, which was defined as LY30 of 0.8% or less. Continuous variables were expressed as mean ± standard deviation or median (interquartile range). Poisson regression analysis was used to determine predictors of shutdown.

Résultats : Patients were age 46 ± 18 years, 81% male, 75% blunt trauma, Injury Severity Score of 28 ± 13, 16% received TXA, 64% developed fibrinolysis shutdown, and mortality was 15%. In the first 24 hours, 4 (2-9) units packed red blood cells and 2 (0-6) units fresh frozen plasma were administered. Those with shutdown had worse initial systolic blood pressure (114 ± 38 mm Hg vs. 129 ± 43 mm Hg, p = 0.006) and base deficit (-5 ± 6 mEq/L vs -3 ± 5 mEq/L, p = 0.013); received more packed red blood cells [6 (2-11) vs. 2 (1-5) units, p < 0.0001], and fresh frozen plasma [3 (0-8) vs. 0 (0-4) units, p < 0.0001]; and more often received TXA (23% vs. 4%, p <0.0001). After controlling for confounders, TXA (relative risk, 1.35; 95% confidence interval, 1.10-1.64; p = 0.004) and cryoprecipitate transfusion (relative risk, 1.29; 95% confidence interval, 1.07-1.56; p = 0.007) were independently associated with fibrinolysis shutdown.

Conclusion : Patients who received TXA were at increased risk of fibrinolysis shutdown compared with patients who did not receive TXA. We recommend that administration of TXA be limited to severely injured patients with evidence of hyperfibrinolysis and recommend caution in those with evidence of fibrinolysis shutdown.

Conclusion (proposition de traduction) : Les patients ayant reçu de l'acide tranexamique présentaient un risque accru d'arrêt de la fibrinolyse comparativement aux patients ne recevant pas d'acide tranexamique. Nous recommandons que l'administration d'acide tranexamique soit limitée aux patients en situation critique présentant des signes d'hyperfibrinolyse et recommande la prudence chez ceux présentant des signes d'arrêt de la fibrinolyse.

Clinical relevance of a p value: Does tranexamic acid save lives after trauma or postpartum hemorrhage?.
Dobson GP, Doma K, Letson HL. | J Trauma Acute Care Surg. 2018 Mar;84(3):532-536
DOI: https://doi.org/10.1097/TA.0000000000001779
Keywords: Aucun

Current Opinions

Editorial : Tranexamic acid (TXA), an antifibrinolytic agent, has been widely publicized as saving lives after traumatic hemorrhage in the CRASH-2, MATTERs, and PED-TRAX trials and more recently after postpartum hemorrhage (PPH) in the World Maternal Antifibrinolytic (WOMAN) trial. Prophylactic administration of TXA is also increasingly used in major elective and emergency surgery to reduce excessive bleeding, transfusion requirements, and possible reexploration.

Conclusion : In conclusion, although we agree that TXA may have an early survival benefit in patients who are severely bleeding with or without shock,3,31 the results of the WOMAN trial are only a beginning toward “saving one in three mothers who would oth- erwise bleed to death after childbirth,” even if the drug is admin- istered within 3 hours. We believe that the trial investigators and social media have overstated the significance of the WOMAN trial results, and combining the WOMAN and CRASH-2 data in a meta-analysis may result in inherent bias. The need for a consensus on what constitutes adequate statistical evidence for a drug to be clinically useful, and do no harm, is at the heart of our commentary. TXA should not be viewed as a one-size-fits- all approach to treat blood loss in civilian- or combat-related trauma or PPH, but rather we propose the incorporation of a more precision-based set of guidelines for TXA administration to reduce trauma-related and maternal mortality and morbidity.

Conclusion (proposition de traduction) : En conclusion, bien que nous soyons d'accord que l'acide tranexamique peut avoir un bénéfice de survie précoce chez les patientes qui saignent sévèrement avec ou sans choc, les résultats de l'essai WOMAN ne sont qu'un début vers « sauver une mère sur trois qui saignerait à mort après l'accouchement », même si le médicament est administré dans les 3 heures. Nous croyons que les investigateurs de l'essai et les médias sociaux ont surestimé l'importance des résultats de l'essai WOMAN, et la combinaison des données WOMAN et CRASH-2 dans une méta-analyse peut entraîner un biais inhérent.
Le besoin d'un consensus sur ce qui constitue une preuve statistique adéquate pour qu'un médicament soit cliniquement utile et ne cause aucun tort est au cœur de notre commentaire. L'acide tranexamique ne devrait pas être considéré comme une approche unique pour traiter la perte de sang dans les traumatismes civils ou militaires, ou les hémorragies post-partum, mais nous proposons plutôt l'incorporation d'un ensemble de lignes directrices plus précises pour l'administration de l'acide tranexamique afin de réduire la mortalité et la morbidité liées aux traumatismes et à la maternité.

The Alvarado Score Should Be Used To Reduce Emergency Department Length of Stay and Radiation Exposure in Select Patients with Abdominal Pain.
Coleman JJ, Carr BW, Rogers T, Field MS, Zarzaur BL, Savage SA, Hammer PM, Brewer BL, Feliciano DV, Rozycki GS. | J Trauma Acute Care Surg. 2018 Mar 8 - Publish Ahead of Print():
DOI: https://doi.org/10.1097/TA.0000000000001885
Keywords: Aucun

Original article

Introduction : Abdominal pain is a common reason patients seek treatment in emergency departments (ED), and computed tomography (CT) is frequently used for diagnosis; however, length of stay in the ED and risks of radiation remain a concern. The hypothesis of this study was the Alvarado Score (AS) could be used to reduce CT scans and decrease ED length of stay (LOS) for patients with suspected acute appendicitis (AA).

Méthode : A retrospective review of patients who underwent CT to rule out AA from January 1st, 2015, to December 31st, 2015 was performed. Patient demographics, past medical history, ED documentation, operative interventions, complications, and LOS were all collected. AS was calculated from the medical record. Time to CT completion was calculated from times the patient was seen by ED staff, CT order, and CT report.

Résultats : 492 patients (68.1% female, median age 33) met inclusion criteria. Most CT scans (70%) did not have findings consistent with AA. Median AS for AA on CT scan was 7, compared to 3 for negative CT (p<0.001). 100% of female patients with AS= 10 and males with AS ≥9 had AA confirmed by surgical pathology. Conversely, ≤ 5% of female patients with AS ≤ 2 and 0% of male patients with AS ≤ 1 were diagnosed with AA. 106 patients (21.5%) had an AS within these ranges and collectively spent 10,239 minutes in the ED from the time of the CT order until the radiologist’s report.

Conclusion : Males with an AS of ≥ 9 and Females with AS of 10 should be considered for treatment of AA without imaging. Males with AS ≤ 1 and females with AS ≤ 2 or less can be safely discharged with follow-up. Using AS, a significant proportion of patients can avoid the radiation risk, the increased cost, and increased ED LOS associated with CT.

Conclusion (proposition de traduction) : Les hommes ayant un score alvarado ≥ 9 et les femmes ayant un score Alvarado à 10 doivent être pris en charge pour un traitement chirurgical d'une l'appendicite aiguë sans recours à l'imagerie médicale. Les hommes ayant un score Alvarado ≤ 1 et les femmes ayant un score Alvarado ≤ 2 ou moins peuvent être renvoyés à domicile en toute sécurité après la prise en charge aux urgences.
Le score Alvarado, peut éviter pour une proportion importante de patients l'exposition aux rayonnements ionisants, l'augmentation des coûts et l'augmentation de la durée du séjour dans les services d'urgence associée à la réalisation d'un scanner abdominal.

Hydrocortisone plus Fludrocortisone for Adults with Septic Shock.
Annane D, and all; CRICS-TRIGGERSEP Network. | N Engl J Med. 2018 Mar 1;378(9):809-818
DOI: https://doi.org/10.1056/NEJMoa1705716
Keywords: Aucun

Original article

Introduction : Septic shock is characterized by dysregulation of the host response to infection, with circulatory, cellular, and metabolic abnormalities. We hypothesized that therapy with hydrocortisone plus fludrocortisone or with drotrecogin alfa (activated), which can modulate the host response, would improve the clinical outcomes of patients with septic shock.

Méthode : In this multicenter, double-blind, randomized trial with a 2-by-2 factorial design, we evaluated the effect of hydrocortisone-plus-fludrocortisone therapy, drotrecogin alfa (activated), the combination of the three drugs, or their respective placebos. The primary outcome was 90-day all-cause mortality. Secondary outcomes included mortality at intensive care unit (ICU) discharge and hospital discharge and at day 28 and day 180 and the number of days alive and free of vasopressors, mechanical ventilation, or organ failure. After drotrecogin alfa (activated) was withdrawn from the market, the trial continued with a two-group parallel design. The analysis compared patients who received hydrocortisone plus fludrocortisone with those who did not (placebo group).

Résultats : Among the 1241 patients included in the trial, the 90-day mortality was 43.0% (264 of 614 patients) in the hydrocortisone-plus-fludrocortisone group and 49.1% (308 of 627 patients) in the placebo group (P=0.03). The relative risk of death in the hydrocortisone-plus-fludrocortisone group was 0.88 (95% confidence interval, 0.78 to 0.99). Mortality was significantly lower in the hydrocortisone-plus-fludrocortisone group than in the placebo group at ICU discharge (35.4% vs. 41.0%, P=0.04), hospital discharge (39.0% vs. 45.3%, P=0.02), and day 180 (46.6% vs. 52.5%, P=0.04) but not at day 28 (33.7% and 38.9%, respectively; P=0.06). The number of vasopressor-free days to day 28 was significantly higher in the hydrocortisone-plus-fludrocortisone group than in the placebo group (17 vs. 15 days, P<0.001), as was the number of organ-failure-free days (14 vs. 12 days, P=0.003). The number of ventilator-free days was similar in the two groups (11 days in the hydrocortisone-plus-fludrocortisone group and 10 in the placebo group, P=0.07). The rate of serious adverse events did not differ significantly between the two groups, but hyperglycemia was more common in hydrocortisone-plus-fludrocortisone group.

Conclusion : In this trial involving patients with septic shock, 90-day all-cause mortality was lower among those who received hydrocortisone plus fludrocortisone than among those who received placebo.

Conclusion (proposition de traduction) : Dans cet essai concernant des patients avec un choc septique, la mortalité toutes causes confondues à 90 jours était plus faible chez les patients sous hydrocortisone et fludrocortisone que chez ceux sous placebo.

Commentaire : Le fludrocortisone est un minéralocorticoïde commercialisé sous le nom FLUCORTAC. Il doit toujours être associé à un glucocorticoïde.

A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis.
Franklin D, Babl FE, Schlapbach LJ, Oakley E, Craig S, Neutze J, Furyk J, Fraser JF, Jones M, Whitty JA, Dalziel SR, Schibler A. | N Engl J Med. 2018 Mar 22;378(12):1121-1131
DOI: https://doi.org/10.1056/NEJMoa1714855  | Télécharger l'article au format  
Keywords: Aucun

Original Article

Introduction : High-flow oxygen therapy through a nasal cannula has been increasingly used in infants with bronchiolitis, despite limited high-quality evidence of its efficacy. The efficacy of high-flow oxygen therapy through a nasal cannula in settings other than intensive care units (ICUs) is unclear.

Méthode : In this multicenter, randomized, controlled trial, we assigned infants younger than 12 months of age who had bronchiolitis and a need for supplemental oxygen therapy to receive either high-flow oxygen therapy (high-flow group) or standard oxygen therapy (standard-therapy group). Infants in the standard-therapy group could receive rescue high-flow oxygen therapy if their condition met criteria for treatment failure. The primary outcome was escalation of care due to treatment failure (defined as meeting ≥3 of 4 clinical criteria: persistent tachycardia, tachypnea, hypoxemia, and medical review triggered by a hospital early-warning tool). Secondary outcomes included duration of hospital stay, duration of oxygen therapy, and rates of transfer to a tertiary hospital, ICU admission, intubation, and adverse events.

Résultats : The analyses included 1472 patients. The percentage of infants receiving escalation of care was 12% (87 of 739 infants) in the high-flow group, as compared with 23% (167 of 733) in the standard-therapy group (risk difference, -11 percentage points; 95% confidence interval, -15 to -7; P<0.001). No significant differences were observed in the duration of hospital stay or the duration of oxygen therapy. In each group, one case of pneumothorax (<1% of infants) occurred. Among the 167 infants in the standard-therapy group who had treatment failure, 102 (61%) had a response to high-flow rescue therapy.

Conclusion : Among infants with bronchiolitis who were treated outside an ICU, those who received high-flow oxygen therapy had significantly lower rates of escalation of care due to treatment failure than those in the group that received standard oxygen therapy.

Conclusion (proposition de traduction) : Parmi les nourrissons atteints de bronchiolite qui ont été traités en dehors d'une USI, ceux qui ont reçu une oxygénothérapie à débit élevé présentaient des taux d'escalade des soins nettement inférieurs en raison d'un échec thérapeutique par rapport à ceux du groupe ayant reçu une oxygénothérapie standard.

Commentaire : Voir l'analyse de l'article sur le site Medscape : Nouvelle technique d’oxygénothérapie dans la bronchiolite du nourrisson - Medscape - 3 oct 2018  . Rédigé par le Dr Dominique Savary.

Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/ SIGN and NICE.
White J, Paton JY, Niven R, Pinnock H on behalf of the British Thoracic Society. | Thorax. 2018 March;73:293–297
DOI: https://dx.doi.org/10.1136/thoraxjnl-2017-211189  | Télécharger l'article au format  
Keywords: Aucun

Research and Guideline updates

Conclusion : In considering the areas where differences occur between the recommendations made in BTS/SIGN and NICE guidelines, it is clear that close scrutiny of the evidence base shows that there is often more in common between the guidelines than might appear at first glance. It is hoped that this examination of the differences highlighted in this article will assist clinicians in making decisions with their patients.
Our understanding of asthma is evolving and our assessment of treatments must evolve with it. Further research to clarify the areas where data are currently limited or absent is urgently required in order that further updates can offer the best evidence-based advice.

Conclusion (proposition de traduction) : En examinant les domaines où des différences apparaissent entre les recommandations formulées dans les directives BTS/SIGN et NICE, il est clair qu'un examen minutieux de la base de données montre qu’il y a souvent plus de points communs entre les directives qu’au premier abord. On espère que cet examen des différences soulignées dans cet article aidera les cliniciens à prendre des décisions avec leurs patients.
Notre compréhension de l'asthme évolue et notre évaluation des traitements doit évoluer avec elle. Des recherches plus approfondies visant à clarifier les domaines dans lesquels les données sont actuellement limitées ou absentes sont nécessaires de manière urgente afin que d'autres mises à jour puissent offrir les meilleurs conseils fondés sur des preuves.

Utility of point-of-care musculoskeletal ultrasound in the evaluation of emergency department musculoskeletal pathology.
Situ-LaCasse E, Grieger RW, Crabbe S, Waterbrook AL, Friedman L, Adhikari S. | World J Emerg Med. 2018 Mar;9(4):262-266
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2018.04.004  | Télécharger l'article au format  
Keywords: Emergency department; Musculoskeletal; Point-of-care ultrasound

original articles

Introduction : To evaluate the utilization of point-of-care ultrasound (POCUS) for the assessment of emergency department (ED) patients with musculoskeletal symptoms and the impact of musculoskeletal POCUS on medical decision-making and patient management in the ED.

Méthode : This was a retrospective review of ED patients presenting with musculoskeletal symptoms who received a POCUS over a 3.5-year period. An ED POCUS database was reviewed for musculoskeletal POCUS examinations used for medical decision-making. Electronic medical records were then reviewed for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of musculoskeletal POCUS on patient management in ED.

Résultats : A total of 264 subjects (92 females, 172 males) and 292 musculoskeletal POCUS examinations were included in the final analysis. Most common symptomatic sites were knee (31.8%) and ankle (16.3%). Joint effusion was the most common finding on musculoskeletal POCUS, noted in 33.7% of the patients, and subcutaneous edema/cobblestoning was found in 10.2% of the patients. Muscle or tendon rupture was found in 2.3% of the patients, and 1.9% of the patients had joint dislocation. Bursitis or bursa fluid was found in 3.4% of patients, and tendonitis/tendinopathy was found in 2.3%. Twenty percent of them were ultrasound-guided musculoskeletal procedures, and most of them (73.3%) were arthrocentesis. Of the included studies, all except three either changed or helped guide patient management as documented in the patients' medical records.

Conclusion : Our study findings illustrate the utility of POCUS in the evaluation of a variety of musculoskeletal pathologies in the ED.

Conclusion (proposition de traduction) : Les résultats de notre étude illustrent l'utilité de l'échographie au point d'intervention pour évaluer diverses pathologies musculo-squelettiques au service des urgences.

Enoxaparin dosing errors in the emergency department.
Jellinek-Cohen SP, Li M, Husk G. | World J Emerg Med. 2018;9(3):195-202
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2018.03.006  | Télécharger l'article au format  
Keywords: Dosing errors; Emergency department; Enoxaparin; Weight-based dosing

Original article

Introduction : The study aimed to determine the frequency of enoxaparin dosing errors for patients who had a measured emergency department (ED) weight compared to those who did not have a measured ED weight, and to determine if demographic variables (e.g., weight, height, age, English-speaking, race) impact the likelihood of receiving an inappropriate dose.

Méthode : This is a retrospective, electronic chart review of patients who received a dose of enoxaparin in the ED between January 1, 2008 and July 1, 2013. We identified all patients >18 years who received a dose of enoxaparin while in the ED, were admitted, and had at least one inpatient weight within the first four days of hospitalization. Patients were excluded if they received enoxaparin for prophylaxis or a dose of more than 1.25 mg/kg.

Résultats : A total of 1,944 patients were included. Patients were more likely to experience an error if they did not have a measured ED weight. Over-doses of >10 mg were more likely to occur in patients without a measured ED weight. Patients with no documented ED weight or with a staff-estimated ED weight were more likely to experience a dosing error than those with a patient-stated weight. Patients were more likely to experience an error if their first inpatient weight was more than 96 kg, they were more than 175-cm tall, or were English speaking.

Conclusion : Dosing errors are more likely to occur when patients are not weighed in the ED. Modifications to current workflows to incorporate weighing those patients who receive weight-dosed medications may be warranted.

Conclusion (proposition de traduction) : Les erreurs de dosage sont plus susceptibles de se produire lorsque les patients ne sont pas pesés aux urgences. Il pourrait être justifié de modifier les flux de travail actuels afin d'intégrer la pesée des patients a qui l'on administre des médicaments à dose pondérale.

Pre-recorded instructional audio vs. dispatchers' conversational assistance in telephone cardiopulmonary resuscitation: A randomized controlled simulation study.
Birkun A, Glotov M, Ndjamen HF, Alaiye E, Adeleke T, Samarin S. | World J Emerg Med. 2018 Mar;9(3):165-171
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2018.03.001  | Télécharger l'article au format  
Keywords: Audio instructions; Cardiac arrest; Cardiopulmonary resuscitation; Dispatcher; Instructional aid; Telephone CPR

Original article

Introduction : To assess the effectiveness of the telephone chest-compression-only cardiopulmonary resuscitation (CPR) guided by a pre-recorded instructional audio when compared with dispatcher-assisted resuscitation.

Méthode : It was a prospective, blind, randomised controlled study involving 109 medical students without previous CPR training. In a standardized mannequin scenario, after the step of dispatcher-assisted cardiac arrest recognition, the participants performed compression-only resuscitation guided over the telephone by either: (1) the pre-recorded instructional audio (n=57); or (2) verbal dispatcher assistance (n=52). The simulation video records were reviewed to assess the CPR performance using a 13-item checklist. The interval from call reception to the first compression, total number and rate of compressions, total number and duration of pauses after the first compression were also recorded.

Résultats : There were no significant differences between the recording-assisted and dispatcher-assisted groups based on the overall performance score (5.6±2.2 vs. 5.1±1.9, P>0.05) or individual criteria of the CPR performance checklist. The recording-assisted group demonstrated significantly shorter time interval from call receipt to the first compression (86.0±14.3 vs. 91.2±14.2 s, P<0.05), higher compression rate (94.9±26.4 vs. 89.1±32.8 min-1) and number of compressions provided (170.2±48.0 vs. 156.2±60.7).

Conclusion : When provided by untrained persons in the simulated settings, the compression-only resuscitation guided by the pre-recorded instructional audio is no less efficient than dispatcher-assisted CPR. Future studies are warranted to further assess feasibility of using instructional audio aid as a potential alternative to dispatcher assistance.

Conclusion (proposition de traduction) : Lorsqu'elle est fournie par des personnes non formées dans les milieux simulés, la réanimation par compression uniquement guidée par l'instruction audio préenregistrée n'est pas moins efficace que la réanimation cardio-respiratoire assistée par un répartiteur (assistant de régulation). Des études futures sont justifiées pour évaluer davantage la faisabilité de l'utilisation de l'aide audio didactique comme solution de rechange possible à l'aide du répartiteur (assistant de régulation).