Bibliographie de Médecine d'Urgence

Mois d'avril 2018

Academic Emergency Medicine

Syncope Prognosis Based on Emergency Department Diagnosis: A Prospective Cohort Study.
Toarta C, Mukarram M, Arcot K, Kim SM, Gaudet S, Sivilotti MLA, Rowe BH, Thiruganasambandamoorthy V. | Acad Emerg Med. 2018 Apr;25(4):388-396
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Keywords: Aucun

Original contributions

Introduction : Relatively little is known about outcomes after disposition among syncope patients assigned various diagnostic categories during emergency department (ED) evaluation. We sought to measure the outcomes among these groups within 30 days of the initial ED visit.

Méthode : We prospectively enrolled adult syncope patients at six EDs and excluded patients with presyncope, persistent mental status changes, intoxication, seizure, and major trauma. Patient characteristics, ED management, diagnostic impression (presumed vasovagal, orthostatic, cardiac, or other/unknown) at the end of the ED visit, and physicians' confidence in assigning the etiology were collected. Serious outcomes at 30 days included death, arrhythmia, myocardial infarction, structural heart disease, pulmonary embolism, and hemorrhage.

Résultats : A total of 5,010 patients (mean ± SD age = 53.4 ± 23.0 years; 54.8% females) were enrolled; 3.5% suffered serious outcomes-deaths (0.3%), arrhythmias (1.8%), nonarrhythmic cardiac (0.5%), and noncardiac (0.9%) including pulmonary embolism (0.2%). The cause of syncope was presumed as vasovagal among 53.3% and cardiac in 5.4% of patients. The proportion of patients with ED investigations (p < 0.001) and short-term serious outcomes (p < 0.01) increased in each diagnostic category in the following order: presumed vasovagal, orthostatic hypotension, other/unknown cause, and cardiac. No deaths occurred in patients with presumed vasovagal syncope. A higher proportion of all serious outcomes occurred among patients suspected of cardiac syncope in the ED (p < 0.01). Confidence was highest among physicians for a presumed vasovagal syncope diagnosis and lowest when the cause was other/unknown.

Conclusion : Short-term serious outcomes strongly correlated with the etiology assigned in the ED visit. The importance of the physician's clinical judgment should be further studied to determine if it should become incorporated in risk-stratification tools for prognostication and safe management of ED syncope patients.

Conclusion (proposition de traduction) : L'évolution clinique défavorable à court terme étaient fortement corrélée avec l'étiologie identifiée au cours de la consultation au service des urgences. L'importance du jugement clinique du médecin devrait être davantage étudiée afin de déterminer si elle devrait être incorporée dans les outils de stratification des risques pour le pronostic et la gestion sécuritaire des patients présentant une syncope au service des urgences.

Commentaire : Etude multicentrique prospective sur plus de 5 000 patients. Une étiologie cardiaque était retrouvée dans 5,4 % des cas et une étiologie vaso-vagale dans 53,3 %.
Pour mémoire, une recommandation de pratique clinique européenne est parue en mars 2018 : Guidelines for the diagnosis and management of syncope  .

Clinical Examination for Acute Aortic Dissection: A Systematic Review and Meta-analysis.
Ohle R, Kareemi HK, Wells G, Perry JJ. | Acad Emerg Med. 2018 Apr;25(4):397-412
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Keywords: Aucun

Original contributions

Introduction : Acute aortic dissection is a life-threatening condition due to a tear in the aortic wall. It is difficult to diagnose and if missed carries a significant mortality.

Méthode : We conducted a librarian-assisted systematic review of PubMed, MEDLINE, Embase, and the Cochrane database from 1968 to July 2016. Titles and abstracts were reviewed and data were extracted by two independent reviewers (agreement measured by kappa). Studies were combined if low clinical and statistical heterogeneity (I2 < 30%). Study quality was assessed using the QUADAS-2 tool. Bivariate random effects meta analyses using Revman 5 and SAS 9.3 were performed.

Résultats : We identified 792 records: 60 were selected for full text review, nine studies with 2,400 participants were included (QUADAS-2 low risk of bias, κ = 0.89 [for full-text review]). Prevalence of aortic dissection ranged from 21.9% to 76.1% (mean ± SD = 39.1% ± 17.1%). The clinical findings increasing probability of aortic dissection were 1) neurologic deficit (n = 3, specificity = 95%, positive likelihood ratio [LR+] = 4.4, 95% confidence interval [CI] = 3.3-5.7, I2 = 0%) and 2) hypotension (n = 4, specificity = 95%, LR+ = 2.9 95% CI = 1.8-4.6, I2 = 42%), and decreasing probability were the absence of a widened mediastinum (n = 4, sensitivity = 76%-95%, negative likelihood ratio [LR-] = 0.14-0.60, I2 = 93%) and an American Heart Association aortic dissection detection (AHA ADD) risk score < 1 (n = 1, sensitivity = 91%, LR- = 0.22, 95% CI = 0.15-0.33).

Conclusion : Suspicion for acute aortic dissection should be raised with hypotension, pulse, or neurologic deficit. Conversely, a low AHA ADD score decreases suspicion. Clinical gestalt informed by high- and low-risk features together with an absence of an alternative diagnosis should drive investigation for acute aortic dissection.

Conclusion (proposition de traduction) : Une dissection aortique doit être suspectée devant une hypotension artérielle, une bradycardie (ou l'absence de pouls) ou déficit neurologique. Inversement, un score de détection de dissection aortique de l'American Heart Association faible (< 1) diminue le risque.
Les formes cliniques regroupant les caractéristiques à haut et faible risque de dissection aortique ainsi que l'absence de diagnostic alternatif devrait guider l'examen clinique de la dissection aortique aiguë.

Commentaire : Méta-analyse qui regroupe 60 études pour 2 400 patients.
L'apparition d'un déficit neurologique et d'une hypotension avait une sensibilité, pour le diagnostic, de 95 %, chacun. La sensibilité des autres signes était pour la stratification des risques de l'AHA de 91 % et pour l'élargissement du médiastin de 75 %.
Commentaire dans le même numéro : Acute Aortic Dissection: Is ThereSomething Better than Physician Gestalt?   par Smith LM et Miller CD.

Development of a Patient Decision Aid for Syncope in the Emergency Department: the SynDA Tool.
Probst MA, Hess EP, Breslin M, Frosch DL, Sun BC, Langan MN, Richardson LD. | Acad Emerg Med. 2018 Apr;25(4):425-433
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Keywords: Aucun

original contributions

Introduction : The objective was to develop a patient decision aid (DA) to promote shared decision making (SDM) for stable, alert patients who present to the emergency department (ED) with syncope.

Méthode : Using input from patients, clinicians, and experts in the field of syncope, health care design, and SDM, we created a prototype of a paper-based DA to engage patients in the disposition decision (admission vs. discharge) after an unremarkable ED evaluation for syncope. In phase 1, we conducted one-on-one semistructured exploratory interviews with 10 emergency physicians and 10 ED syncope patients. In phase 2, we conducted one-on-one directed interviews with 15 emergency care clinicians, five cardiologists, and 12 ED syncope patients to get detailed feedback on DA content and design. We iteratively modified the aid using feedback from each interviewee until clarity and usability had been optimized.

Résultats : The 11 × 17-inch, paper-based DA, titled SynDA, includes four sections: 1) explanation of syncope, 2) explanation of future risks, 3) personalized 30-day risk estimate, and 4) disposition options. The personalized risk estimate is calculated using a recently published syncope risk-stratification tool. This risk estimate is stated in natural frequency and graphically displayed using a 100-person color-coded pictogram. Patient-oriented questions are included to stimulate dialogue between patient and clinician. At the end of the development process, patient and physician participants expressed satisfaction with the clarity and usability of the DA.

Conclusion : We iteratively developed an evidence-based DA to facilitate SDM for alert syncope patients after an unremarkable ED evaluation. Further testing is required to determine its effects on patient care. This DA has the potential to improve care for syncope patients and promote patient-centered care in emergency medicine.

Conclusion (proposition de traduction) : Nous avons développé de façon itérative une aide à la décision fondée sur des données probantes afin de faciliter la prise de décision partagée pour les patients présentant un syncope après une évaluation initiale a service des urgences. Des tests supplémentaires sont nécessaires pour déterminer ses effets sur les soins aux patients.
Cette aide à la décision a le potentiel d'améliorer la prise en charge des syncopes et de promouvoir les soins centrés sur le patient en médecine d'urgence.

A Risk Assessment Score and Initial High-sensitivity Troponin Combine to Identify Low Risk of Acute Myocardial Infarction in the Emergency Department.
Pickering JW, Flaws D, Smith SW, Greenslade J, Cullen L, Parsonage W, Carlton E, Mark Richards A, Troughton R, Pemberton C, George PM, Than MP. | Acad Emerg Med. 2018 Apr;25(4):434-443.
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Keywords: Aucun

Original contributions

Introduction : Early discharge of patients with presentations triggering assessment for possible acute coronary syndrome (ACS) is safe when clinical assessment indicates low risk, biomarkers are negative, and electrocardiograms (ECGs) are nonischemic. We hypothesized that the Emergency Department Assessment of Chest Pain Score (EDACS) combined with a single measurement of high-sensitivity cardiac troponin (hs-cTn) could allow early discharge of a clinically meaningful proportion of patients.

Méthode : We pooled data from four patient cohorts from New Zealand and Australia presenting to an emergency department with symptoms suggestive of ACS. The primary outcome was major adverse cardiac events (MACE) within 30 days of presentation. In patients with a nonischemic ECG we evaluated the sensitivity for MACE and percentage low risk of every combination of high-sensitivity cardiac troponin T (hs-cTnT) concentration and high-sensitivity cardiac troponin I (hs-cTnI) concentration with EDACS. We used a standard smoothing technique on the probability density function for hs-cTn and EDACS and applied bootstrapping to determine the optimal threshold combinations, namely, the combination that maximized the percentage low risk with ≥98.5% sensitivity for MACE.

Résultats : From 2,536 patients, 2,258 presented without an ischemic ECG of whom 272 (12.1%) had a MACE within 30 days. The optimal threshold for hs-cTnI was 7 ng/L combined with an EDACS threshold of 16 (36.8% patients low risk). The optimal thresholds for hs-cTnT were 8 ng/L combined with an EDACS threshold of 15 (30.2% patients low risk).

Conclusion : Single measurements of both hs-cTnI and hs-cTnT at presentation combined with EDACS to identify over 30% of patients as low risk and therefore eligible for safe early discharge after only one blood draw.

Conclusion (proposition de traduction) : Une seule mesure de hs-cTnI et de hs-cTnT lors de la présentation combinées avec l'évaluation du score de douleur thoracique aux urgences (score canadien EDACS) permettent d'identifier plus de 30 % des patients comme étant à faible risque et donc susceptible d'être sortant à l'issu de ce seul dosage sans danger.

Commentaire : Le score canadien EDACs (Emergency Department Assessment of Chest Pain Score) a été publié dans : Than M and al. Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol. Emerg Med Australas. 2014 Feb;26(1):34-44  .
Vous pouvez trouver le calcul en ligne sur MdCalc+  .

Hot Off the Press: Prehospital Advanced Cardiac Life Support for Out-of-hospital Cardiac Arrest.
Morgenstern J, Heitz C, Milne WK. | Acad Emerg Med. 2018 Apr;25(4):453-455
Keywords: Aucun

Original contribution

Editorial : This retrospective cohort study examined the rate of survival to hospital discharge among adult patients with out-of-hospital cardiac arrest, comparing patients who received care only from basic cardiac life support (BCLS)-trained emergency medical service (EMS) crews to patients who had an advanced cardiac life support (ACLS)-trained EMS crew on scene at some point during the resuscitation.

Conclusion : There was no difference in the primary outcome of rate of survival to hospital discharge (10.9% with ACLS care and 10.6% with BCLS care, p = 0.67).

Conclusion (proposition de traduction) : Il n'y avait pas de différence entre le taux de survie à la sortie de l'hôpital (10,9 % avec les soins ACLS et 10,6 % avec les soins BCLS, p = 0,67).

Commentaire : Vision Nord-américaine du SMUR : la conclusion, en filigrane, est qu'il n'est pas nécessaire de médicaliser le pré-hospitalier ! On peut toutefois s'interroger sur le niveau de formation comparer à des SMUR français.

Academic Emergency Medicine Education and Training

60 seconds to survival: A pilot study of a disaster triage video game for prehospital providers.
Cicero MX, Whitfill T, Munjal K, Madhok M, Diaz MCG, Scherzer DJ, Walsh BM, Bowen A, Redlener M, Goldberg SA, Symons N, Burkett J, Santos JC, Kessler D, Barnicle RN, Paesano G, Auerbach MA.. | AEM Education and Training. 2018 April;2(2):100–106
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Keywords: Aucun

Original contribution

Introduction : Paramedics and emergency medical technicians (EMTs) perform triage at disaster sites. There is aneed for disaster triage training. Live simulation training is costly and difficult to deliver. Screen-based simulationsmay overcome these training barriers. We hypothesized that a screen-based simulation, 60 Seconds to Survival(60S), would be associated with in-game improvements in triage accuracy.

Méthode : This was a prospective cohort study of a screen-based simulation intervention, 60S. Participantsincluded emergency medical services (EMS) personnel from 21 EMS agencies across 12 states. Participantsperformed assessments (e.g., check for pulse) and actions (e.g., reposition the airway) for 12 patients in eachscenario and assigned color-coded triage levels (red, yellow, green, or black) to each patient. Participantsreceived on-screen feedback about triage performance immediately after each scenario. A scoring system wasdesigned to encourage accurate and timely triage decisions. Participants who played 60S included practicingEMTs, paramedics, and nurses as well as students studying to assume these roles. Participants played the gameat least three times over 13 weeks.

Résultats : In total, 2,234 participants began game play and 739 completed the study and were included in theanalysis. Overall, the median number of plays of the game was just above the threshold inclusion criteria (three ormore plays) with a median of four plays during the study period (interquartile range [IQR] = 3–7). There was asignificant difference in triage accuracy from the first play of the game to the last play of the game. Medianbaseline triage accuracy in the game was 89.7% (IQR = 82.1%–94.9%), which then increased to a median of100% at the last game play (IQR = 87.5%–100.0%; p < 0.001). There was some variability in median triageaccuracy on fourth through 11th game plays, ranging from 95% to 100%, and on the 12th to 16th plays, themedian accuracy was sustained at 100%. There was a significant decrease in the rate of undertriage: from 10.3%(IQR = 5.1% –18.0%) to 0 (IQR = 0%–12.5%; p < 0.001).

Conclusion : 60 Seconds to Survival is associated with improved in-game triage accuracy. Further study of thecorrelation between in-game triage accuracy and improvements in live simulation or real-world triage decisions iswarranted.

Conclusion (proposition de traduction) : 60 Seconds to Survival est associé à une meilleure précision de triage dans le jeu. Une étude plus poussée de la corrélation entre la précision du triage dans le jeu et des améliorations dans la simulation en direct ou les décisions de triage dans le monde réel est justifiée.

Commentaire : Voir l'article de Cicero MX. 60 seconds to survival: A pilot study of a disaster triage video game for prehospital providers. Am J Disaster Med. 2017 Spring;12(2):75-83  . Attention, le lien ne fonctionne pas !

Designing and Implementing Emergency Department Pain Management Curriculum: A Delphi Approach.
Paziana K, Timpano E, Stolbach A. | AEM Education and Training. 2018 April;2(2):121-129
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Keywords: Aucun

Original Contribution

Introduction : Our primary objective was to use the Delphi method (DM) to choose learning objectives for an Internet‐based pain management teaching module for emergency care providers. The DM is a structured communication technique that uses systematic, interactive data gathering to reach a consensus among a panel of experts.

Méthode : We extracted preliminary educational objectives from nationwide pain fellowship training programs. After redundant objectives and those relating to procedures outside the scope of emergency medicine (EM) were removed, 23 preliminary objectives remained. We enlisted experts in EM, medical toxicology, anesthesia, pain, psychiatry, and medical education to evaluate the objectives in repeated rounds. Based on the time we had designated for teaching (3 hours) and our estimate of 15 to 20 minutes for each learning objective, we aimed for nine to 12 final learning objectives. The expert panel rated the 23 preliminary objectives with a 5‐point Likert scale. Experts were blinded to each other's answers. When 80% of experts agreed with proposed objectives, objectives were considered “accepted” and retained. When 80% of experts disagreed with proposed objectives, the objectives were considered “rejected” and discarded. The remaining objectives were considered in subsequent rounds. In the first round, one objective was rejected and four were accepted. In the second round, four objectives were rejected and five were accepted. Having reached nine objectives the panel unanimously agreed that the nine objectives were sufficient to be used as a foundation for teaching modules.

Résultats : Using the DM, our expert panel identified nine educational objectives that were used as the foundation for an educational module. Of the nine objectives, three were categorized as “medical knowledge,” two as “pharmacologic knowledge,” two as “patient communication,” and two as “systems‐based practice.” The learning objectives are as follows: recognize common barriers to treating pain; understand alternative interventional therapies used to treat different kinds of pain their implications, benefits, and risks; identify common component symptoms that may exacerbate chronic pain (i.e., depression, anxiety, delirium, cachexia, dyspnea); study the major drug groups used to treat different kinds of pain; recognize the risks of polypharmacy; set realistic expectations with patients early in their presentation to the emergency department (ED); educate patients as the risks of different classes of pain medications, including risk of addiction; understand the legal and regulatory issues that govern pain management in the ED; and understand in‐hospital resources available for patient follow up and referral to pain clinics.

Conclusion : We successfully used the DM to develop educational objectives for an e‐learning module. Further work should evaluate educational outcomes of the teaching module.

Conclusion (proposition de traduction) : Nous avons utilisé avec succès le SM pour élaborer des objectifs éducatifs pour un module d'apprentissage en ligne. D'autres travaux devraient évaluer les résultats éducatifs du module d'enseignement.

Brief, Web‐based Education Improves Lay Rescuer Application of a Tourniquet to Control Life‐threatening Bleeding.
Goolsby CA, Strauss‐Riggs K, Klimczak V, Gulley K, Luis Rojas L, Cassandra Godar C, Raiciulescu S, Kellermann AL, Kirsch TD. | AEM Education and Training. 2018 April;2(2):154-161
Keywords: Aucun

Original contribution

Introduction : The objective was to determine whether brief, Web‐based instruction several weeks prior to tourniquet application improves layperson success compared to utilizing just‐in‐time (JiT) instructions alone.
Background: Stop the Bleed is a campaign to educate laypeople to stop life‐threatening hemorrhage. It is based on U.S. military experience with lifesaving tourniquet use. While previous research shows simple JiT instructions boost laypeople's success with tourniquet application, the optimal approach to educate the public is not yet known.

Méthode : This is a prospective, nonblinded, randomized study. Layperson participants from the Washington, DC, area were randomized into: 1) an experimental group that received preexposure education using a website and 2) a control group that did not receive preexposure education. Both groups received JiT instructions. The primary outcome was the proportion of subjects that successfully applied a tourniquet to a simulated amputation. Secondary outcomes included mean time to application, mean placement position, ability to distinguish bleeding requiring a tourniquet from bleeding requiring direct pressure only, and self‐reported comfort and willingness to apply a tourniquet.

Résultats : Participants in the preexposure group applied tourniquets successfully 75% of the time compared to 50% success for participants with JiT alone (p < 0.05, risk ratio = 1.48, 95% confidence interval = 1.21–1.82). Participants place tourniquets in a timely fashion, are willing to use them, and can recognize wounds requiring tourniquets.

Conclusion : Brief, Web‐based training, combined with JiT education, may help as many as 75% of laypeople properly apply a tourniquet. These findings suggest that this approach may help teach the public to Stop the Bleed.

Conclusion (proposition de traduction) : Une formation brève sur le Web, combinée une formation à besoins très ciblés, et à des moments précis, peut aider jusqu'à 75 % des intervenants non secouriste professionnel à appliquer correctement un garrot. Ces résultats suggèrent que cette approche peut aider à apprendre au public à arrêter un saignement.

Identifying the Emergency Medicine Personality: A Multisite Exploratory Pilot Study.
Jordan J, Linden JA, Maculatis MC, Gene Hern H, Schneider JI, Wills CP, Marshall JP, Friedman A, Yarris LM. | AEM Education and Training. 2018 April 16;2(2):91–99
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Keywords: Aucun

Original contribution

Introduction : This study aimed to understand the personality characteristics of emergency medicine (EM) residents and assess consistency and variations among residency programs.

Méthode : In this cross‐sectional study, a convenience sample of residents (N = 140) at five EM residency programs in the United States completed three personality assessments: the Hogan Personality Inventory (HPI)—describing usual tendencies; the Hogan Development Survey (HDS)—describing tendencies under stress or fatigue; and the Motives, Values, and Preferences Inventory (MVPI)—describing motivators. Differences between EM residents and a normative population of U.S. physicians were examined with one‐sample t‐tests. Differences between EM residents by program were analyzed using one‐way analysis of variance tests.

Résultats : One‐hundred forty (100%), 124 (88.6%), and 121 (86.4%) residents completed the HPI, HDS, and MVPI, respectively. For the HPI, residents scored lower than the norms on the adjustment, ambition, learning approach, inquisitive, and prudence scales. For the HDS, residents scored higher than the norms on the cautious, excitable, reserved, and leisurely scales, but lower on bold, diligent, and imaginative scales. For the MVPI, residents scored higher than the physician population norms on altruistic, hedonistic, and aesthetics scales, although lower on the security and tradition scales. Residents at the five programs were similar on 22 of 28 scales, differing on one of 11 scales of the HPI (interpersonal sensitivity), two of 11 scales of the HDS (leisurely, bold), and three of 10 scales of the MVPI (aesthetics, commerce, and recognition).

Conclusion : Our findings suggest that the personality characteristics of EM residents differ considerably from the norm for physicians, which may have implications for medical students’ choice of specialty. Additionally, results indicated that EM residents at different programs are comparable in many areas, but moderate variation in personality characteristics exists. These results may help to inform future research incorporating personality assessment into the resident selection process and the training environment.

Conclusion (proposition de traduction) : Nos résultats suggèrent que les caractéristiques de la personnalité des résidents urgentistes diffèrent considérablement de la norme pour les médecins, ce qui peut avoir des implications pour le choix de spécialité des étudiants en médecine. De plus, les résultats indiquent que les résidents des services d'urgence de différents programmes sont comparables dans de nombreux domaines, mais qu'il existe une variation modérée des caractéristiques de la personnalité. Ces résultats peuvent aider à éclairer la recherche future incorporant l'évaluation de la personnalité dans le processus de sélection des résidents et l'environnement de formation.

Commentaire : Ils sont hédonistes, altruistes et n’ont pas le sens du commerce : ce sont les urgentistes - Medscape - 25 avr 2018   : La personnalité des chefs de clinique urgentistes diffère de celle des autres étudiants en médecine : ils sont hédonistes, enthousiastes, précautionneux, altruistes, esthètes, réservés et ils n’ont pas le sens du commerce bien qu’ils aient besoin de reconnaissance…. Et ce quelle que soit l’université où ils étudient. C’est très probablement du fait de cette personnalité atypique dans le milieu médical qu’ils ont choisi de se tourner vers la médecine d’urgence.

American Journal of Respiratory and Critical Care Medicine

An Observational Study of the Efficacy of Cisatracurium Compared with Vecuronium in Patients with or at Risk for Acute Respiratory Distress Syndrome.
Sottile PD, Kiser TH, Burnham EL, Ho PM, Allen RR, Vandivier RW, Moss M; Colorado Pulmonary Outcomes Research Group (CPOR). | Am J Respir Crit Care Med. 2018 Apr 1;197(7):897-904
Keywords: acute respiratory distress syndrome; mechanical ventilators; neuromuscular blockade; patient outcome assessment

Original Article

Introduction : The neuromuscular blocking agent cisatracurium may improve mortality for patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Other neuromuscular blocking agents, such as vecuronium, are commonly used and have different mechanisms of action, side effects, cost, and availability in the setting of drug shortages.
OBJECTIVES: To determine whether cisatracurium is associated with improved outcomes when compared with vecuronium in patients at risk for and with ARDS.

Méthode : Using a nationally representative database, patients who were admitted to the ICU with a diagnosis of ARDS or an ARDS risk factor, received mechanical ventilation, and were treated with a continuous infusion of neuromuscular blocking agent for at least 2 days within 2 days of hospital admission were included. Patients were stratified into two groups: those who received cisatracurium or vecuronium. Propensity matching was used to balance both patient- and hospital-specific factors. Outcomes included hospital mortality, duration of mechanical ventilation, ICU and hospital duration, and discharge location.

Résultats : Propensity matching successfully balanced all covariates for 3,802 patients (1,901 per group). There was no significant difference in mortality (odds ratio, 0.932; P = 0.40) or hospital days (-0.66 d; P = 0.411) between groups. However, patients treated with cisatracurium had fewer ventilator days (-1.01 d; P = 0.005) and ICU days (-0.98 d; P = 0.028) but were equally likely to be discharged home (odds ratio, 1.19; P = 0.056).

Conclusion : When compared with vecuronium, cisatracurium was not associated with a difference in mortality but was associated with improvements in other clinically important outcomes. These data suggest that cisatracurium may be the preferred neuromuscular blocking agent for patients at risk for and with ARDS.

Conclusion (proposition de traduction) : Comparé au vécuronium, le cisatracurium n'a pas été associé à une différence de mortalité, mais a été associé à des améliorations dans d'autres résultats cliniquement importants.
Ces données suggèrent que le cisatracurium pourrait être l'agent de blocage neuromusculaire préféré chez les patients à risque et avec un SDRA.

Pulmonary Vasodilator Therapy in Shock-associated Cardiac Arrest.
Morgan RW, Sutton RM, Karlsson M, Lautz AJ, Mavroudis CD, Landis WP, Lin Y, Jeong S, Craig N, Nadkarni VM, Kilbaugh TJ, Berg RA. | Am J Respir Crit Care Med. 2018 Apr 1;197(7):905-912
Keywords: cardiopulmonary resuscitation; heart arrest; inhaled nitric oxide; shock

Original article

Introduction : Many in-hospital cardiac arrests are precipitated by hypotension, often associated with systemic inflammation. These patients are less likely to be successfully resuscitated, and novel approaches to their treatment are needed.
OBJECTIVES: To determine if the addition of inhaled nitric oxide (iNO) to hemodynamic-directed cardiopulmonary resuscitation (HD-CPR) would improve short-term survival from cardiac arrest associated with shock and systemic inflammation.

Méthode : In 3-month-old swine (n = 21), LPS was intravenously infused, inducing systemic hypotension. Ventricular fibrillation was induced, and animals were randomized to blinded treatment with either: 1) HD-CPR with iNO, or 2) HD-CPR without iNO. During HD-CPR, chest compression depth was titrated to peak aortic compression pressure of 100 mm Hg, and vasopressor administration was titrated to coronary perfusion pressure greater than or equal to 20 mm Hg. Defibrillation attempts began after 10 minutes of resuscitation. The primary outcome was 45-minute survival.

Résultats : The iNO group had higher rates of 45-minute survival (10 of 10 vs. 3 of 11; P = 0.001). During cardiopulmonary resuscitation, the iNO group had lower pulmonary artery relaxation pressure (mean ± SEM, 10.9 ± 2.4 vs. 18.4 ± 2.4 mm Hg; P = 0.03), higher coronary perfusion pressure (21.1 ± 1.5 vs. 16.9 ± 1.0 mm Hg; P = 0.005), and higher aortic relaxation pressure (36.6 ± 1.6 vs. 30.4 ± 1.1 mm Hg; P < 0.001) despite shallower chest compressions (5.88 ± 0.25 vs. 6.46 ± 0.40 cm; P = 0.02) and fewer vasopressor doses in the first 10 minutes (median, 4 [interquartile range, 3-4] vs. 5 [interquartile range, 5-6], P = 0.03).

Conclusion : The addition of iNO to HD-CPR in LPS-induced shock-associated cardiac arrest improved short-term survival and intraarrest hemodynamics.

Conclusion (proposition de traduction) : L'utilisation de NO inhalé au cours de la réanimation cardio-pulmonaire axée sur l'hémodynamique dans l'arrêt cardiaque induit par un choc en réponse à une stimulation par du lipopolysaccharide (LPS) a amélioré la survie à court terme et l'hémodynamique pendant l'arrêt.

Anaesthesia Critical Care & Pain Medicine

Management of septic shock in intermediate care unit.
Meaudre E, Nguyen C, Contargyris C, Montcriol A, d'Aranda E, Esnault P, Bensalah M, Prunet B, Bordes J, Goutorbe P. | Anaesth Crit Care Pain Med. 2018 Apr;37(2):121-127
Keywords: Intermediate care unit; Management; Sepsis; Septic shock

Original Article

Introduction : While guidelines advocate goal-directed resuscitation based on timed bundles, the management of septic shock (SS) outside an ICU setting has been poorly studied in intermediate care units (IMCU).

Méthode : We reviewed all cases of septic shock patients admitted to our IMCU between January 2013 and June 2014. The characteristics of sepsis, compliance of bundles, and outcomes were collected. The IMCU population was compared with the SS patients admitted to the ICU during the same period. The primary objective was to evaluate the feasibility of care in an IMCU.

Résultats : We treated 59 patients in the IMCU. Forty-three patients (73%) were fully managed in the IMCU and 16 patients (27%) were secondarily transferred to the ICU. In the first 3hours, the compliance to bundles was: blood cultures (95%), plasma lactate concentration (90%), vascular filling volume (1500ml (1000-2000)) and antibiotics (100%). A central venous line and an arterial catheter were inserted in 85% and 98.3% of the cases. At 24h, patients who were transferred to the ICU had higher lactate concentrations than the other patients (1.4±0.7mmol versus 2.9±3.4mmol; P=0.03). A 24 hours-SOFA score>4 was correlated with a transfer in ICU (OR 7,75 (95% CI 2.08-28,81; P=0.002)).

Conclusion : Our work demonstrated the ability to manage SS patients solely in an IMCU. It showed that the SS resuscitation bundle can be successfully implemented outside the ICU. A lack of improvement at the 24th hour is associated with a transfer to the ICU.

Conclusion (proposition de traduction) : Notre travail a démontré la faisabilité de la prise en charge des patients en choc septique exclusivement en IMCU. Il a montré que les soins de réanimation du choc septique peut être mis en œuvre avec succès en dehors de l'unité de soins intensifs.
Un manque d'amélioration à la 24e heure est associé à un transfert à l'USI.

A comparison between intravascular and traditional cooling for inducing and maintaining temperature control in patients following cardiac arrest.
Rosman J, Hentzien M, Dramé M, Roussel V, Just B, Jolly D, Mateu P. | Anaesth Crit Care Pain Med. 2018 Apr;37(2):129-134
Keywords: Cardiac arrest; Intensive care; Mortality; Resuscitation; Temperature control; Therapeutic hypothermia

Original article

Introduction : Therapeutic temperature control has been widely used during the last decade to improve clinical outcomes. We conducted this retrospective observational study to compare traditional cooling with endovascular cooling in post-cardiac arrest comatose survivors and to compare results with current guidelines.

Méthode : All patients admitted to our ICU for cardiac arrest and for whom temperature control was performed were included. Traditional cooling included cold infusions, ice packs and cooling blankets. Endovascular cooling consisted in the insertion of a catheter in which cold fluid circulates in a closed circuit provided by a heat exchanger. Temperature control was started at a target temperature of 32°C to 34°C. Rewarming was performed passively in the traditional group and via computer-assistance in endovascular group. We evaluated the delay prior to and speed of cooling, thermic stability during the maintenance phase and the speed of rewarming.

Résultats : Thirty-four patients were included. The speed of cooling was faster with the endovascular (-0.66±0.35°C/h) compared to the traditional (-0.35±0.38°C/h, P=0.006) technique, with target temperatures reached in 4.0 and 6.0h, respectively (P=0.14). Temperatures were more stable with the endovascular technique (0.03±0.05°C2) than with the traditional technique (0.26±0.16°C2, P<10-4). There were more deviations from the guideline target range in the traditional group (64.7% versus 17.6%, P=0.008). Rewarming was faster in the traditional group (+0.64±0.33°C/h, versus +0.36±0.12°C/h, P=0.01). No significant difference was found concerning mortality or length of stay in the ICU.

Conclusion : Temperature control with a cooling catheter was associated with faster cooling, improved thermic stability in the target range, less overcooling or overheating and slower rewarming in comparison with traditional techniques.

Conclusion (proposition de traduction) : Le contrôle de la température par un cathéter de refroidissement était associé à un refroidissement plus rapide, à une stabilité thermique améliorée dans la plage cible, à un refroidissement ou à une surchauffe moins important et à un réchauffement plus lent par rapport aux techniques traditionnelles.

Short-term effects of low-volume resuscitation with hypertonic saline and hydroxyethylstarch in an experimental model of lung contusion and haemorrhagic shock.
Prunet B, Cordier PY, Prat N, De Bourmont S, Couret D, Lambert D, Michelet P. | Anaesth Crit Care Pain Med. 2018 Apr;37(2):135-140
Keywords: Extravascular lung water; Haemorrhagic shock; Hydroxyethylstarch; Hypertonic saline; Low-volume resuscitation; Lung contusion

Original article

Introduction : This study aimed to assess the short-term respiratory tolerance and haemodynamic efficiency of low-volume resuscitation with hypertonic saline and hydroxyethylstarch (HS/HES) in a pig model of lung contusion and controlled haemorrhagic shock. We hypothesised that a low-volume of HS/HES after haemorrhagic shock did not impact contused lungs in terms of extravascular lung water 3hours after trauma.

Méthode : A lung contusion resulting from blunt chest trauma was induced in 28 anaesthetised female pigs with five bolt-shots to the right thoracic cage, followed by haemorrhagic shock and fluid resuscitation. Pigs were randomly allocated into two groups: fluid resuscitation by 4ml/kg of HS/HES, or fluid resuscitation by 10ml/kg of normal saline (NS). Monitoring was based on transpulmonary thermodilution and a pulmonary artery catheter. After 3h, animals were euthanized to measure extravascular lung water (EVLW) by gravimetry.

Résultats : Blunt chest trauma was followed by a transient collapse and hypoxaemia in both groups. Post-mortem gravimetric assessment demonstrated a significant difference between EVLW in the NS-group (8.1±0.7ml/kg) and in the HS/HES-group (6.2±0.6ml/kg, P=0.038). Based on a pathological EVLW threshold of > 7ml/kg, results indicated that only the NS-group experienced moderate pulmonary oedema, contrary to the HS/HES-group. After haemorrhagic shock, HS/HES infusion enabled the restoration of effective mean arterial pressure and cardiac index. Intrapulmonary shunting increased transiently after fluid resuscitation but there was no significant impairment of oxygenation.

Conclusion : In this pig model of lung contusion, the short-term assessment of fluid resuscitation after haemorrhagic shock with 4ml/kg of HS/HES showed that pulmonary oedema was avoided compared to fluid resuscitation with 10ml/kg of NS.

Conclusion (proposition de traduction) : Dans ce modèle porcin de contusion pulmonaire, l'évaluation à court terme de la réanimation liquidienne après choc hémorragique de 4ml/kg de HS/HES a mis en évidence que l'œdème pulmonaire était évité par rapport à la réanimation liquidienne avec 10ml/kg de solution saline.

Management of severe traumatic brain injury (first 24 hours).
Geeraerts T, and al.. | Anaesth Crit Care Pain Med. 2018 Apr;37(2):171-186
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Editorial : The latest French guidelines for the management in the first 24 hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of intracranial hypertension), an update was required. We would like to highlight the major work done by experts in 1998 and advise readers to refer to it. A large part of the 1998 guidelines remains valid and we present updated recommendations in the present material. These guidelines refer to the early management of severe TBI, i.e. the first 24 hours after injury. Later management (> 24 hrs) and mild and moderate TBI patients have not been taken into consideration. Guidelines for temperature control were not addressed in this document because of the concomitant publication of French guidelines on targeted temperature management in the ICU with a specific focus on brain-injured patients.

Conclusion : After the implementation of the GRADE® method, 32 recommendations were formally developed by the organising committee: 10 were strong (Grade 1 ±), 18 were weak (Grade 2 ±), and 4 were expert opinions because GRADE® methodology was not applicable.
All recommendations were submitted to a reviewing group for a Delphi method assessment. After 2 rounds of voting and evaluation and after various amendments, a strong agreement was reached for 32 (100%) recommendations.

Annales Françaises de Médecine d'Urgence

Allain M, Kuczer V, Longo C, Batard E, Le Conte P. | Ann Fr Med Urgence. 2018 Apr;8(2):75-82
Keywords: Simulation / Formation initiale / Médecine d’urgence / DESC / DES / France

Original article

Introduction : La simulation apparaît aujourd’hui comme un outil indispensable dans l’apprentissage de compétences médicales techniques et non techniques, tout en respectant le principe éthique suivant : « Jamais la première fois sur le patient ». Actuellement, l’intégration de la simulation dans les programmes de formation des internes de médecine d’urgence est disparate : son cadre demeure à définir devant l’ouverture récente du diplôme d’études spécialisée (DES) de médecine d’urgence à l’automne 2017.
Objectif de l’étude : Cette étude a évalué l’utilisation de la simulation en France dans l’enseignement actuel de la médecine d’urgence, afin d’initier une réflexion sur la place que pourrait avoir ce type d’enseignement pour le DES.

Méthode : Il s’agissait d’une étude observationnelle multicentrique. Un questionnaire a été envoyé par e-mail à l’ensemble des responsables universitaires de France impliqués dans l’enseignement de la médecine d’urgence. Les données ont été colligées dans Excel (Microsoft). Elles étaient à la fois quantitatives et qualitatives et concernaient le cadre, la structuration et le contenu de la formation par la simulation.

Résultats : Vingt-cinq facultés de médecine sur 29 ont répondu au questionnaire. Parmi elles, 23 utilisaient la simulation (soit 92 %), dont 22 la simulation haute fidélité et 21 la simulation procédurale. Arrêt cardiorespiratoire (22), état de choc (21), douleur thoracique et tachycardies (20), traumatisé crânien et traumatisé grave (17) étaient les thématiques majoritairement abordées. Les gestes techniques les plus enseignés étaient : intubation (22), intubation difficile (21), ventilation assistée-contrôlée et voie intraosseuse (18). En médiane, la formation comptait entre deux et trois jours de simulation par année de formation. Par ailleurs, dans 12 centres (soit 52 %), les formateurs avaient un temps professionnel dédié, et 15 centres (soit 65 %) bénéficiaient de personnel salarié. Enfin, seulement 12 centres (52 %) estimaient « plutôt » respecter l’adage « Jamais la première fois sur le patient ».

Conclusion : Simulation use in French emergency physician’s initial training is heterogeneous. The main limitation of our study was the absence of response from 4 faculties. Generally, responding coordinators agreed on the main situations and techniques to be taught. As in other countries, promotion of simulation seems to be consensual. However, effective deployment remains difficult due to material investment, formation and availability of staff. This study could provide a basis for the establishment of a national simulation-based training program.

Conclusion (proposition de traduction) : L’utilisation de la simulation dans l’enseignement de la médecine d’urgence est inégale. Les responsables pédagogiques interrogés semblent tomber d’accord quant aux principales thématiques et techniques à aborder. Le développement de la simulation semble souhaité de tous, mais demeure complexe en raison notamment de l’investissement humain et matériel que cela représente. Ces réponses pourraient fournir un axe de réflexion afin d’établir un programme de simulation commun à l’ensemble des facultés.

Cahuzac C, Ta TH, Henaoui A, Laborne FX, Briole N, Porche M, Lamhaut L, Sapir D, Andrianjafy H. | Ann Fr Med Urgence. 2018 Apr;8(2):94-99
Keywords: Syndrome coronarien aigu ST+ / Service d’urgence / délai DIDO (door in-door out) / Réseau de soins

Original article

Introduction : Le délai door in-door out (DIDO) représente la durée de séjour au service d’urgence (SU) des patients pris en charge pour un syndrome coronarien aigu ST+ (SCAST+), avant transfert en centre de cardiologie interventionnelle (CCI). Le DIDO ne devrait pas dépasser 30 minutes. Notre objectif était d’évaluer le DIDO dans le réseau des urgences Sud Île-de-France (RESSIF).

Méthode : Étude épidémiologique, rétrospective, multicentrique comparant le DIDO entre 2014 et 2015 (période 1), puis en 2016 (période 2) dans deux hôpitaux sans CCI, l’hôpital de Longjumeau et l’hôpital d’Arpajon. En 2016 était appliqué dans notre protocole régional SCAST+ le « réflexe électro-oculotéléphonique » (REOT), avec l’objectif de diminuer le DIDO : dès l’électrocardiogramme qualifiant (ECGq), avant tout traitement ou obtention du CCI de transfert, le médecin urgentiste appelle le service d’aide médicale à l’urgence (SAMU) pour l’envoi immédiat d’un service mobile d’urgence et de réanimation (SMUR) secondaire.

Résultats : Entre les deux périodes, le délai DIDO médian n’a pas été modifié significativement (–16 min [4–42] ; p = 0,06). Le délai entre ECGq et appel du SAMU n’était pas significativement différent avant et après application du REOT (15 [8–34] vs 9 min [6–26] ; p = 0,12). Le DIDO était supérieur ou égal à 30 min en période 1, contre 6 % en période 2 (p = 0,11).

Conclusion : The DIDO time was not significantly modified. There was no significant impact of the REET on the DIDO, but our study is underpowered. The REET could be assessed more widely in EDs. Regional network of care involving SAMU, SMUR, ED, and CCU with shared protocols is a prerequisite for the prognosis of STEMI.

Conclusion (proposition de traduction) : Le DIDO du RESSIF n’a pas été significativement modifié. Il n’y a pas eu d’impact significatif du REOT sur le DIDO, mais notre étude manque de puissance. Le REOT pourrait être évalué plus largement dans les SU. Un réseau de soins impliquant les SAMU, SMUR, SU et CCI avec protocoles partagés est essentiel pour le pronostic des SCAST+.

Auzou G, Brunat F, Clot S, Rocher T, Turck J, Maggio L, Bollen Pinto B, Viglino D, Savary D, Belle L. | Ann Fr Med Urgence. 2018 Apr;8(2):89-93
Keywords: Bloc auriculoventriculaire du troisième degré / Infarctus du myocarde / Prise en charge / Entraînement électrosystolique

Original article

Introduction : Les descriptions de l’incidence, de la gravité et des modalités de prise en charge des blocs auriculoventriculaires du troisième degré (BAV3) compliquant la phase aiguë des infarctus du myocarde, avec sus-décalage du segment ST (STEMI), sont rares et anciennes. Par ailleurs, les modalités de prise en charge des STEMI aigus ont beaucoup évolué. Le but de notre étude est d’évaluer l’incidence, de décrire la gravité et les modalités de prise en charge des BAV3 survenant à la phase aiguë des STEMI dans un contexte contemporain.

Méthode : Nous avons réalisé une étude observationnelle rétrospective de la prise en charge des STEMI aigus à partir du registre prospectif des STEMI du Réseau nord alpin des urgences (RENAU) sur les 19 hôpitaux des Alpes du Nord entre 2009 et 2012. Les patients présentant un BAV3 à la phase initiale de leur prise en charge ont été identifiés.

Résultats : Deux mille sept cent neuf patients avec STEMI aigu ont été inclus sur la période d’étude. Cinquante-sept ont présenté un BAV3 (2 %). Cent cinquante-deux des 2 648 patients sans BAV3 (6 %) sont décédés à la phase hospitalière contre 7 des 57 patients (12 %) avec BAV3 (p = 0,047). Parmi les patients en BAV3, un traitement par atropine a été utilisé pour 26 patients et s’est révélé efficace pour (15 %) d’entre eux. L’isoprénaline a été utilisée pour huit patients et a induit une hypotension artérielle pour quatre d’entre eux. Une stimulation ventriculaire droite percutanée a été utilisée pour six patients et a toujours été efficace. Quatorze patients ont été thrombolysés (25 %). Une angioplastie de sauvetage a été nécessaire chez 10 des 14 patients en BAV3 traités par thrombolyse (71 %), comparés aux 325 des 840 patients sans BAV3 traités par thrombolyse (39 % ; p = 0,013).

Conclusion : Most effective prehospital treatment after testing atropine is transthoracic pacing. In the presence of TDAVB, reperfusion should be sought via primary percutaneous intervention due to the high prevalence of rescue interventions post thrombolysis in this group.

Conclusion (proposition de traduction) : L’incidence des BAV3 à la phase aiguë des STEMI est faible. Le BAV3 représente un facteur de sévérité. Les stratégies thérapeutiques sont d’efficacité inégale, avec des effets indésirables induits par l’isoprenaline. La thrombolyse chez ces patients est moins efficace.

Mintandjian A, Mewasing BI, Valentian M, Burggraff E, Passot D, Ray P. | Ann Fr Med Urgence. 2018 Apr;8(2):100-7
Keywords: Membre supérieur / Infirmière organisatrice de l’accueil / Demande anticipée / Radiographie / Urgences / Traumatisme

Original article

Introduction : L’objectif principal de cette étude est de déterminer l’effet d’un protocole de demande anticipée de radiographies par l’infirmier organisateur de l’accueil (IOA) sur le temps de passage des patients au service d’accueil des urgences (SAU).

Méthode : Cette étude monocentrique prospective a été réalisée en deux phases : une phase-avant (de décembre 2016 à janvier 2017) et une phase-après (de mai à juin 2017), où les patients bénéficiaient d’une demande anticipée de radiographie dès l’IOA. Les patients de plus de 18 ans, valides, ayant consulté au SAU pour un traumatisme du membre supérieur (épaule exclue) de moins de 48 heures et présentant au moins deux critères parmi douleur, tuméfaction, déformation ou impotence fonctionnelle étaient inclus.

Résultats : Deux cent treize patients ont répondu aux critères d’inclusion : 112 en phase 1 et 101 en phase 2. Le temps médian de passage global a diminué de manière significative entre la phase 1 et la phase 2 (188 vs 124 min, p < 0,001) ainsi que le temps médian de prise en charge médicale (76 vs 17 min). Plus de 90 % des infirmiers diplômés d’État (IDE) et plus de 75 % des médecins estiment que le protocole a un intérêt pour diminuer le temps de passage. Un tiers des IDE considère que ce protocole entraîne une surcharge de travail pour l’IOA et une surprescription de radiographies.

Conclusion : This study suggests that nurse initiated X-ray protocol in upper limb trauma (shoulder excluded) leads to a significant decrease in length of stay.

Conclusion (proposition de traduction) : Cette étude suggère que l’application d’un protocole de demande anticipée de radiographies par l’IOA chez les patients ayant un traumatisme du membre supérieur (épaule exclue) permet de réduire le temps de passage au SAU.

Pommet S, Claret PG, de La Coussaye JE, Bobbia X. | Ann Fr Med Urgence. 2018 Apr;8(2):113-9
Keywords: Asystole / Cardiac arrest / Echocardiography


Editorial : L’arrêt cardiorespiratoire (ACR) est une situation fréquente pour les structures d’urgences et de réanimation, et l’utilisation de l’échographie y est recommandée par les sociétés savantes. Elle doit impérativement se faire sans augmentation des temps d’interruption du massage cardiaque externe. Après formation, elle permet de détecter rapidement et facilement la présence d’une contractilité myocardique qui est un élément pronostique important pouvant aider dans la décision d’arrêter la RCP. Le recours à des protocoles bien établis avec des équipes entraînées permet d’éviter une interruption prolongée de la RCP. Cependant, aucune étude humaine de grande ampleur n’a permis de décrire de manière fiable pendant l’ACR la sémiologie échographique des causes curables que constituent l’hypovolémie, l’embolie pulmonaire, la tamponnade et le pneumothorax compressif.

Conclusion (proposition de traduction) : Dans l’ACR, l’utilisation de l’échographie est recommandée par les sociétés savantes. Elle doit impérativement se faire sans augmentation des temps d’interruption du MCE. Après formation, elle permet de détecter rapidement et facilement la présence d’une contractilité myocardique qui est un élément pronostique important pouvant aider dans la décision d’arrêter la RCP. Le recours à des protocoles bien établis avec des équipes entraînées permet d’éviter une interruption prolongée de la RCP. L’intérêt de l’échographie dans le diagnostic étiologique de l’ACR nécessite probablement de meilleures compétences échographiques en intégrant l’échographie cardiaque, pleuropulmonaire et abdominale de manière séquentielle comme le propose le protocole SHoC. Aucune étude humaine de grande ampleur n’a permis de décrire de manière fiable, pendant l’ACR, la sémiologie échographique des causes curables que constituent l’hypovolémie, l’EP, la tamponnade et le pneumothorax compressif. Des études prospectives sont donc nécessaires afin de déterminer si les anomalies échographiques constatées chez les patients choqués sont reproductibles dans l’ACR et si l’emploi de l’échographie améliore la morbimortalité.

Cahuzac C, Ta TH, Henaoui A, Laborne FX, Briole N, Porche M, Lamhaut L, Sapir D, Andrianjafy H. | Ann Fr Med Urgence. 2018 Apr;8(2):94-99
Keywords: Syndrome coronarien aigu ST+ / Service d’urgence / délai DIDO (door in-door out) / Réseau de soins

Original article

Introduction : Le délai door in-door out (DIDO) représente la durée de séjour au service d’urgence (SU) des patients pris en charge pour un syndrome coronarien aigu ST+ (SCAST+), avant transfert en centre de cardiologie interventionnelle (CCI). Le DIDO ne devrait pas dépasser 30 minutes. Notre objectif était d’évaluer le DIDO dans le réseau des urgences Sud Île-de-France (RESSIF).

Méthode : Étude épidémiologique, rétrospective, multicentrique comparant le DIDO entre 2014 et 2015 (période 1), puis en 2016 (période 2) dans deux hôpitaux sans CCI, l’hôpital de Longjumeau et l’hôpital d’Arpajon. En 2016 était appliqué dans notre protocole régional SCAST+ le « réflexe électro-oculotéléphonique » (REOT), avec l’objectif de diminuer le DIDO : dès l’électrocardiogramme qualifiant (ECGq), avant tout traitement ou obtention du CCI de transfert, le médecin urgentiste appelle le service d’aide médicale à l’urgence (SAMU) pour l’envoi immédiat d’un service mobile d’urgence et de réanimation (SMUR) secondaire.

Résultats : Entre les deux périodes, le délai DIDO médian n’a pas été modifié significativement (–16 min [4–42] ; p = 0,06). Le délai entre ECGq et appel du SAMU n’était pas significativement différent avant et après application du REOT (15 [8–34] vs 9 min [6–26] ; p = 0,12). Le DIDO était supérieur ou égal à 30 min en période 1, contre 6 % en période 2 (p = 0,11).

Conclusion : The DIDO time was not significantly modified. There was no significant impact of the REET on the DIDO, but our study is underpowered. The REET could be assessed more widely in EDs. Regional network of care involving SAMU, SMUR, ED, and CCU with shared protocols is a prerequisite for the prognosis of STEMI.

Conclusion (proposition de traduction) : Le DIDO du RESSIF n’a pas été significativement modifié. Il n’y a pas eu d’impact significatif du REOT sur le DIDO, mais notre étude manque de puissance. Le REOT pourrait être évalué plus largement dans les SU. Un réseau de soins impliquant les SAMU, SMUR, SU et CCI avec protocoles partagés est essentiel pour le pronostic des SCAST+.

Annals of Emergency Medicine

Diagnostic Accuracy of a New High-Sensitivity Troponin I Assay and Five Accelerated Diagnostic Pathways for Ruling Out Acute Myocardial Infarction and Acute Coronary Syndrome.
Greenslade JH, Carlton EW, Van Hise C, Cho E, Hawkins T, Parsonage WA, Tate J, Ungerer J, Cullen L. | Ann Emerg Med. 2018 Apr;71(4):439-451.e3
Keywords: Aucun


Introduction : This diagnostic accuracy study describes the performance of 5 accelerated chest pain pathways, calculated with the new Beckman's Access high-sensitivity troponin I assay.

Méthode : High-sensitivity troponin I was measured with presentation and 2-hour blood samples in 1,811 patients who presented to an emergency department (ED) in Australia. Patients were classified as being at low risk according to 5 rules: modified accelerated diagnostic protocol to assess patients with chest pain symptoms using troponin as the only biomarker (m-ADAPT), the Emergency Department Assessment of Chest Pain Score (EDACS) pathway, the History, ECG, Age, Risk Factors, and Troponin (HEART) pathway, the No Objective Testing Rule, and the new Vancouver Chest Pain Rule. Endpoints were 30-day acute myocardial infarction and acute coronary syndrome. Measures of diagnostic accuracy for each rule were calculated.

Résultats : Data included 96 patients (5.3%) with acute myocardial infarction and 139 (7.7%) with acute coronary syndrome. The new Vancouver Chest Pain Rule and No Objective Testing Rule had high sensitivity for acute myocardial infarction (100%; 95% confidence interval [CI] 96.2% to 100% for both) and acute coronary syndrome (98.6% [95% CI 94.9% to 99.8%] and 99.3% [95% CI 96.1% to 100%]). The m-ADAPT, EDACS, and HEART pathways also yielded high sensitivity for acute myocardial infarction (96.9% [95% CI 91.1% to 99.4%] for m-ADAPT and 97.9% [95% CI 92.7% to 99.7%] for EDACS and HEART), but lower sensitivity for acute coronary syndrome (≤95.0% for all). The m-ADAPT, EDACS, and HEART rules classified more patients as being at low risk (64.3%, 62.5%, and 49.8%, respectively) than the new Vancouver Chest Pain Rule and No Objective Testing Rule (28.2% and 34.5%, respectively).

Conclusion : In this cohort with a low prevalence of acute myocardial infarction and acute coronary syndrome, using the Beckman's Access high-sensitivity troponin I assay with the new Vancouver Chest Pain Rule or No Objective Testing Rule enabled approximately one third of patients to be safely discharged after 2-hour risk stratification with no further testing. The EDACS, m-ADAPT, or HEART pathway enabled half of ED patients to be rapidly referred for objective testing.

Conclusion (proposition de traduction) : Dans cette cohorte avec une faible prévalence d'infarctus aigu du myocarde et de syndrome coronarien aigu, l'utilisation du dosage de la troponine I à haute sensibilité de Beckman's Access associé au protocole diagnostic clinique de la douleur thoracique de Vancouver a permis à environ un tiers des patients d'être sortant sans risque après deux heures d’évaluation clinique. L’utilisation des protocoles EDACS, m-ADAPT ou HEART a permis à la moitié des patients des urgences d'être rapidement sortant conformément à l'objectif du protocole.

ECG Predictors of Cardiac Arrhythmias in Older Adults With Syncope.
Nishijima DK, Lin AL, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Hollander JE, Nicks BA, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. | Ann Emerg Med. 2018 Apr;71(4):452-461.e3
Keywords: Aucun


Introduction : Cardiac arrhythmia is a life-threatening condition in older adults who present to the emergency department (ED) with syncope. Previous work suggests the initial ED ECG can predict arrhythmia risk; however, specific ECG predictors have been variably specified. Our objective is to identify specific ECG abnormalities predictive of 30-day serious cardiac arrhythmias in older adults presenting to the ED with syncope.

Méthode : We conducted a prospective, observational study at 11 EDs in adults aged 60 years or older who presented with syncope or near syncope. We excluded patients with a serious cardiac arrhythmia diagnosed during the ED evaluation from the primary analysis. The outcome was occurrence of 30-day serous cardiac arrhythmia. The exposure variables were predefined ECG abnormalities. Independent predictors were identified through multivariate logistic regression. The sensitivities and specificities of any predefined ECG abnormality and any ECG abnormality identified on adjusted analysis to predict 30-day serious cardiac arrhythmia were also calculated.

Résultats : After exclusion of 197 patients (5.5%; 95% confidence interval [CI] 4.7% to 6.2%) with serious cardiac arrhythmias in the ED, the study cohort included 3,416 patients. Of these, 104 patients (3.0%; 95% CI 2.5% to 3.7%) had a serious cardiac arrhythmia within 30 days from the index ED visit (median time to diagnosis 2 days [interquartile range 1 to 5 days]). The presence of nonsinus rhythm, multiple premature ventricular conductions, short PR interval, first-degree atrioventricular block, complete left bundle branch block, and Q wave/T wave/ST-segment abnormalities consistent with acute or chronic ischemia on the initial ED ECG increased the risk for a 30-day serious cardiac arrhythmia. This combination of ECG abnormalities had a similar sensitivity in predicting 30-day serious cardiac arrhythmia compared with any ECG abnormality (76.9% [95% CI 67.6% to 84.6%] versus 77.9% [95% CI 68.7% to 85.4%]) and was more specific (55.1% [95% CI 53.4% to 56.8%] versus 46.6% [95% CI 44.9% to 48.3%]).

Conclusion : In older ED adults with syncope, approximately 3% receive a diagnosis of a serious cardiac arrhythmia not recognized on initial ED evaluation. The presence of specific abnormalities on the initial ED ECG increased the risk for 30-day serious cardiac arrhythmias.

Conclusion (proposition de traduction) : Environ 3 % des personnes âgées présentant une syncope ont un diagnostic d'arythmie cardiaque grave non identifié lors de l'évaluation initiale. La présence d'anomalies spécifiques sur l'ECG initial aux urgences a augmenté le risque d'arythmies cardiaques graves à 30 jours.

What Factors Predict Fluid Responsiveness in Hemodynamically Unstable Patients?.
Sharif S, Owen JJ. | Ann Emerg Med. 2018 Apr;71(4):482-484
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Keywords: Aucun

Cardiology/Systematic review snapshot

Méthode : Electronic English-language searches included MEDLINE and EMBASE from 1966 to June 15, 2016. Reference lists of retrieved articles, previous reviews, and physical examination textbooks were also queried.Studies included adult patients in the emergency department or ICU and with hemodynamic instability, defined as refractory hypotension, signs of organ hypoperfusion, or both. Studies with more than 20 patients that evaluated the diagnostic accuracy of elements of the physical examination and physiologic or ultrasonographic parameters for fluid responsiveness were included. Those examining thoracic surgery and severe brain damage were excluded. Fluid responsiveness was defined as an increase in cardiac output after intravenous fluid administration.The Rational Clinical Examination level of evidence and the Quality Assessment of Diagnostic Accuracy Studies Criteria were evaluated; low-quality studies were excluded (Rational Clinical Examination quality level 4 to 5). Meta-analyses were conducted only when more than 3 studies with more than 100 patients were summarized. Results were reported as pooled likelihood ratios (LRs), sensitivity, and specificity.

Résultats : Fifty studies were identified, including 2,260 patients. The most commonly reported cause of hemodynamic instability was sepsis (median 71%; interquartile range 60% to 94%), with a median 66% of patients (interquartile range 50% to 85%) receiving vasopressors. Most findings on physical examination were not predictive, including skin turgor, capillary refill time, jugular venous distention, appearance of mucous membranes, pulmonary auscultation, and presence or absence of leg edema, ascites, and pleural effusions. Response to passive leg raise was predictive of fluid responsiveness when measured by cardiac output (positive LR 11 [95% confidence interval {CI} 7.6 to 17]; negative LR 0.13 [95% CI 0.07 to 0.22]) and pulse pressure (positive LR 3.6 [95% CI 2.5 to 5.4]; negative LR 0.45 [95% CI 0.36 to 0.57]).

Discussion : Despite limited studies with variable inclusion and exclusion criteria, the findings of this systematic review suggest that clinicians should not rely on physical examination findings, including central venous pressure, to determine fluid responsiveness. Cardiac output measurement after passive leg raising is the most accurate predictor of fluid responsiveness. For intubated patients without spontaneous respiratory efforts, respiratory variation in pulse pressure and stroke volume is also useful.

Conclusion : Passive leg raising is useful in predicting fluid responsiveness, whereas other elements of the physical examination have limited predictive value.

Conclusion (proposition de traduction) : L'élévation passive de la jambe est utile pour prédire la réponse au liquide, alors que les autres éléments de l'examen physique ont une valeur prédictive limitée.

Does Administration of Hypertonic Solutions Improve Mortality in Hemorrhagic Shock Compared With Isotonic Solutions?.
Long B, April MD. | Ann Emerg Med. 2018 Apr;71(4):529-531
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Keywords: Aucun


Méthode : Authors searched Cochrane Central Register of Controlled Trials, MEDLINE (through PubMed), and EMBASE from inception through June 2014. Two authors identified eligible studies independently, with studies including adult patients older than 18 years with hemorrhagic shock because of trauma or other causes. Investigators included randomized controlled trials comparing patients receiving hypertonic solutions, sodium chloride 7.5% with dextran 4.2% or 6%, or without versus isotonic solutions in the out-of-hospital, emergency department (ED), or ICU settings. Included studies reported survival as one of the main outcomes, and authors excluded studies involving patients with sepsis. Researchers excluded studies evaluating other concentrations of sodium chloride because of the potential for change in blood pressure and effect on outcome. Authors resolved discrepancies through consensus. Investigators extracted data from each article for setting, study population, intervention (hypertonic solutions or hypertonic saline with dextran), and study outcomes (overall mortality, mortality at 28 days, survival to discharge, complications, and acute respiratory distress syndrome–free survival). Researchers followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for meta-analysis and pooled studies using a random-effects model. Authors reported pooled relative risks with 95% confidence intervals (CIs) for mortality and associated complications. They performed meta-regression to evaluate for sources of heterogeneity and assess treatment effects within subgroups defined by resuscitation fluid type, resuscitation setting, and patient characteristics.

Résultats : Of the 570 identified studies, 12 met inclusion criteria (2,932 patients). Study locations included the United States (8), Brazil (2), the United Kingdom (1), and Australia (1). Settings were out-of-hospital (8), ED (3), and ICU (1). For hypertonic solutions, all 12 studies used 7.5% sodium chloride with or without dextran (4.2% or 6%); 1 study examined hypertonic solutions only, 6 studies examined hypertonic saline with dextran only, and the remaining studies examined both solutions. Control groups used normal saline solution or lactated Ringer’s solution. Patients receiving hypertonic solutions or hypertonic saline with dextran did not display a difference in mortality compared with those receiving isotonic solutions (relative risk 0.96, 95% CI 0.82 to 1.12, and relative risk 0.92, 95% CI 0.80 to 1.06, respectively) (Table). Subgroup analysis similarly revealed no significant effect on mortality.

Discussion : According to this study, hypertonic solutions do not improve mortality in trauma patients with hemorrhagic shock compared with crystalloids, although the original meta-analysis authors stated that hypertonic solutions and hypertonic saline with dextran are feasible resuscitation options in trauma patients with hemorrhagic shock in the out-of-hospital setting. Blood products likely remain the optimal fluid to resuscitate patients in hemorrhagic shock, including tranexamic acid if provided within 3 hours of injury.13 There remains a need for further study of the safety and efficacy of hypertonic solutions in alternative patient populations such as those with head trauma.

Conclusion : Hypertonic solutions offer no survival benefit compared with isotonic solutions in traumatic hemorrhagic shock.

Conclusion (proposition de traduction) : Les solutions hypertoniques n'apportent aucun bénéfice en terme de survie par rapport aux solutions isotoniques dans le choc hémorragique traumatique.

Annals of Intensive Care

There is more to septic shock than arterial hypotension and elevated lactate levels: another appeal to rethink current resuscitation strategies!.
Dünser MW, Dubin A. | Ann Intensive Care. 2018 Apr 27;8(1):55
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Keywords: Aucun


Editorial : Sepsis is an umbrella syndrome created by clinicians to identify patients with an acute infection and a high risk of death. The Sepsis-3 definition group recognized new organ dysfunction as the key indicator determining whether a patient falls into the group with a high risk of death or not.

Conclusion : In light of the missing answers to these fundamental questions of septic shock resuscitation, the current search for the ideal type of fluid, vasopressor, or inotropic agent appears of only minor relevance.

Conclusion (proposition de traduction) : À la lumière des réponses manquantes à ces questions fondamentales sur la réanimation du choc septique, la recherche actuelle devrait réfléchir au type idéal de fluide, de vasopresseur ou d'agent inotrope qui semble peu pertinente.

There is more to septic shock than arterial hypotension and elevated lactate levels: another appeal to rethink current resuscitation strategies!.
Dünser MW, Dubin A. | Ann Intensive Care. 2018 Apr 27;8(1):55
Keywords: Aucun


Editorial : Sepsis is an umbrella syndrome created by clinicians to identify patients with an acute infection and a high risk of death. The Sepsis-3 definition group recognized new organ dysfunction as the key indicator determining whether a patient falls into the group with a high risk of death or not. The same group has redefined septic shock as the combined presence of arterial hypotension [arbitrarily described by a mean arterial pressure (MAP) of 65 mmHg or less] and elevated lactate levels in the absence of hypovolemia. Patients fulfilling these cri- teria were found to have a higher mortality compared to those presenting with sepsis alone.

Conclusion : Independent of pathophysiologic speculations, the results of this study clearly underline that arterial hypotension alone is an inappropriate trigger for vaso-pressor or AVP therapy in critically ill patients (with sepsis)

Conclusion (proposition de traduction) : Indépendamment des spéculations physiopathologiques, les résultats de cette étude soulignent clairement que l'hypotension artérielle seule est un déclencheur inapproprié pour le traitement vasopresseur ou l'arginine vasopressin chez les patients de soins intensifs (avec septicémie).

Mortality and detailed characteristics of pre-ICU qSOFA-negative patients with suspected sepsis: an observational study.
Nakayama I, Izawa J, Mouri H, Kitamura T, Shiotsuka J. | Ann Intensive Care. 2018 Apr 3;8(1):44
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Keywords: Bacteremia; Critical care; Infection; Intensive care unit; Mortality; Sepsis; quick Sequential Organ Failure Assessment (qSOFA) score


Introduction : Recent studies have suggested that quick Sequential Organ Failure Assessment (qSOFA) scores have limited utility in early prognostication in high-mortality populations. The purpose of this study was to investigate the association between pre-ICU qSOFA scores and in-hospital mortality among patients admitted to the ICU with suspected sepsis. This study also aimed to describe detailed clinical characteristics of qSOFA-negative (< 2) patients.

Méthode : This single center, observational study, conducted in a Japanese tertiary care teaching hospital between May 2012 and June 2016, enrolled all consecutive adult patients admitted to the ICU with suspected sepsis. We assessed pre-ICU qSOFA scores with the most abnormal vital signs during the 24-h period before ICU admission. The primary outcome was in-hospital mortality censored at 90 days. We analyzed the association between pre-ICU qSOFA scores and in-hospital mortality.

Résultats : Among 185 ICU patients with suspected sepsis, 14.1% (26/185) of patients remained qSOFA-negative at the time of ICU admission and 29.2% (54/185) of patients died while in hospital. In-hospital mortality was similar between the groups (qSOFA-positive [≥ 2]: 30.2% [48/159] vs qSOFA-negative: 23.1% [6/26], p = 0.642). The Cox proportional hazard regression model revealed that being qSOFA-positive was not significantly associated with in-hospital mortality (adjusted hazard ratio 1.35, 95% confidence interval 0.56-3.22, p = 0.506). Bloodstream infection, immunosuppression, and hematologic malignancy were observed more frequently in qSOFA-negative patients.

Conclusion : Among ICU patients with suspected sepsis, we could not find a strong association between pre-ICU qSOFA scores and in-hospital mortality. Our study suggested high mortality and bacterial diversity in pre-ICU qSOFA-negative patients.

Conclusion (proposition de traduction) : Parmi les patients de l'unité de soins intensifs suspects de sepsis, nous n'avons pas trouvé de lien étroit entre les scores qSOFA pré-soins intensifs et la mortalité hospitalière.
Notre étude a suggéré une mortalité élevée et une diversité bactérienne chez les patients pré-soins intensifs qSOFA-négatifs.


A Multicenter Randomized Trial of a Checklist for Endotracheal Intubation of Critically Ill Adults.
Janz DR, Semler MW, Joffe AM, Casey JD, Lentz RJ, deBoisblanc BP, Khan YA, Santanilla JI, Bentov I, Rice TW; Check-UP Investigators*; Pragmatic Critical Care Research Group. | Chest. 2018 Apr;153(4):816-824
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Keywords: adult; airway management; checklist; critical care; endotracheal; intubation; ventilation

Original research article

Introduction : Hypoxemia and hypotension are common complications during endotracheal intubation of critically ill adults. Verbal performance of a written, preintubation checklist may prevent these complications. We compared a written, verbally performed, preintubation checklist with usual care regarding lowest arterial oxygen saturation or lowest systolic BP experienced by critically ill adults undergoing endotracheal intubation.

Méthode : A multicenter trial in which 262 adults undergoing endotracheal intubation were randomized to a written, verbally performed, preintubation checklist (checklist) or no preintubation checklist (usual care). The coprimary outcomes were lowest arterial oxygen saturation and lowest systolic BP between the time of procedural medication administration and 2 min after endotracheal intubation.

Résultats : The median lowest arterial oxygen saturation was 92% (interquartile range [IQR], 79-98) in the checklist group vs 93% (IQR, 84-100) with usual care (P = .34). The median lowest systolic BP was 112 mm Hg (IQR, 94-133) in the checklist group vs 108 mm Hg (IQR, 90-132) in the usual care group (P = .61). There was no difference between the checklist and usual care in procedure duration (120 vs 118 s; P = .49), number of laryngoscopy attempts (one vs one attempt; P = .42), or severe life-threatening procedural complications (40.8% vs 32.6%; P = .20).

Conclusion : The verbal performance of a written, preprocedure checklist does not increase the lowest arterial oxygen saturation or lowest systolic BP during endotracheal intubation of critically ill adults compared with usual care.

Conclusion (proposition de traduction) : La performance verbale d'une checklist écrite, pré-procédure, n'augmente pas la plus faible saturation artérielle en oxygène ou la plus faible PA systolique lors de l'intubation endotrachéale d'adultes en situation critique par rapport aux soins habituels.


Impact of Healthy Lifestyle Factors on Life Expectancies in the US Population.
Li Y, Pan A, Wang DD, Liu X, Dhana K, Franco OH, Kaptoge S, Di Angelantonio E, Stampfer M, Willett WC, Hu FB. | Circulation. 2018 Apr 30
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Keywords: healthy lifestyle; life expectancy; mortality, premature

Original article

Introduction : Americans have a shorter life expectancy compared with residents of almost all other high-income countries. We aim to estimate the impact of lifestyle factors on premature mortality and life expectancy in the US population.

Méthode : Using data from the Nurses' Health Study (1980-2014; n=78 865) and the Health Professionals Follow-up Study (1986-2014, n=44 354), we defined 5 low-risk lifestyle factors as never smoking, body mass index of 18.5 to 24.9 kg/m2, ≥30 min/d of moderate to vigorous physical activity, moderate alcohol intake, and a high diet quality score (upper 40%), and estimated hazard ratios for the association of total lifestyle score (0-5 scale) with mortality. We used data from the NHANES (National Health and Nutrition Examination Surveys; 2013-2014) to estimate the distribution of the lifestyle score and the US Centers for Disease Control and Prevention WONDER database to derive the agespecific death rates of Americans. We applied the life table method to estimate life expectancy by levels of the lifestyle score.

Résultats : During up to 34 years of follow-up, we documented 42 167 deaths. The multivariable-adjusted hazard ratios for mortality in adults with 5 compared with zero low-risk factors were 0.26 (95% confidence interval [CI], 0.22-0.31) for all-cause mortality, 0.35 (95% CI, 0.27-0.45) for cancer mortality, and 0.18 (95% CI, 0.12-0.26) for cardiovascular disease mortality. The population-attributable risk of nonadherence to 5 low-risk factors was 60.7% (95% CI, 53.6-66.7) for all-cause mortality, 51.7% (95% CI, 37.1-62.9) for cancer mortality, and 71.7% (95% CI, 58.1-81.0) for cardiovascular disease mortality. We estimated that the life expectancy at age 50 years was 29.0 years (95% CI, 28.3-29.8) for women and 25.5 years (95% CI, 24.7-26.2) for men who adopted zero low-risk lifestyle factors. In contrast, for those who adopted all 5 low-risk factors, we projected a life expectancy at age 50 years of 43.1 years (95% CI, 41.3-44.9) for women and 37.6 years (95% CI, 35.8-39.4) for men. The projected life expectancy at age 50 years was on average 14.0 years (95% CI, 11.8-16.2) longer among female Americans with 5 lowrisk factors compared with those with zero low-risk factors; for men, the difference was 12.2 years (95% CI, 10.1-14.2).

Conclusion : Adopting a healthy lifestyle could substantially reduce premature mortality and prolong life expectancy in US adults.

Conclusion (proposition de traduction) : L'adoption d'un mode de vie sain pourrait réduire considérablement la mortalité prématurée et prolonger l'espérance de vie chez les adultes américains.

Commentaire : Les personnes ayant suivi ces cinq habitudes (ne pas fumer, faire 30 minutes d'exercice par jour, avoir une alimentation saine, ne pas boire au-delà d'un verre d'alcool par jour pour les femmes et deux pour les hommes, et avoir un indice de masse corporelle compris entre 18,5 et 24,9 kg/m2) ont 82 % de risques en moins de mourir d’une maladie cardiovasculaire. Les risques de mourir d'un cancer sont également moins grands (65 % en moins).

NT-proBNP (N-Terminal pro-B-Type Natriuretic Peptide)-Guided Therapy in Acute Decompensated Heart Failure: PRIMA II Randomized Controlled Trial (Can NT-ProBNP-Guided Therapy During Hospital Admission for Acute Decompensated Heart Failure Reduce Mortality and Readmissions?).
Stienen S, Salah K, Moons AH, Bakx AL, van Pol P, Kortz RAM, Ferreira JP, Marques I, Schroeder-Tanka JM, Keijer JT, Bayés-Genis A, Tijssen JGP, Pinto YM, Kok WE. | Circulation. 2018 Apr 17;137(16):1671-1683
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Keywords: biomarkers; heart failure; hospitalization; mortality; natriuretic peptide, brain; patient readmission; randomized controlled trial

Original Research Articles

Introduction : The concept of natriuretic peptide guidance has been extensively studied in patients with chronic heart failure (HF), with only limited success. The effect of NT-proBNP (N-terminal probrain natriuretic peptide)-guided therapy in patients with acute decompensated HF using a relative NT-proBNP target has not been investigated. This study aimed to assess whether NT-proBNP-guided therapy of patients with acute decompensated HF using a relative NT-proBNP target would lead to improved outcomes compared with conventional therapy.

Méthode : We conducted a prospective randomized controlled trial to study the impact of in-hospital guidance for acute decompensated HF treatment by a predefined NT-proBNP target (>30% reduction from admission to discharge) versus conventional treatment. Patients with acute decompensated HF with NT-proBNP levels >1700 ng/L were eligible. After achieving clinical stability, 405 patients were randomized to either NT-proBNP-guided or conventional treatment (1:1). The primary end point was dual: a composite of all-cause mortality and HF readmissions in 180 days and the number of days alive out of the hospital in 180 days. Secondary end points were all-cause mortality within 180 days, HF readmissions within 180 days, and a composite of all-cause mortality and HF readmissions within 90 days.

Résultats : Significantly more patients in the NT-proBNP-guided therapy group were discharged with an NT-proBNP reduction of >30% (80% versus 64%, P=0.001). Nonetheless, NT-proBNP-guided therapy did not significantly improve the combined event rate for all-cause mortality and HF readmissions (hazard ratio, 0.96; 95% confidence interval, 0.72-1.37; P=0.99) or the median number of days alive outside of the hospital (178 versus 179 days for NT-proBNP versus conventional patients, P=0.39). Guided therapy also did not significantly improve any of the secondary end points.

Conclusion : The PRIMA II trial (Can NT-ProBNP-Guided Therapy During Hospital Admission for Acute Decompensated Heart Failure Reduce Mortality and Readmissions?) demonstrates that the guidance of HF therapy to reach an NT-proBNP reduction of >30% after clinical stabilization did not improve 6-month outcomes.

Conclusion (proposition de traduction) : L'essai PRIMA II (Can NT-ProBNP-Guided Therapy During Hospital Admission for Acute Decompensated Heart Failure Reduce Mortality and Readmissions ?) démontre que l'orientation de la thérapie de l'insuffisance cardiaque avec pour objectif la réduction des taux de NT-proBNP > à 30 % après stabilisation clinique n'a pas amélioré les résultats sur 6 mois.

Ultrasound for Lower Extremity Deep Venous Thrombosis: Multidisciplinary Recommendations From the Society of Radiologists in Ultrasound Consensus Conference.
Needleman L, Cronan JJ, Lilly MP, Merli GJ, Adhikari S, Hertzberg BS, DeJong MR, Streiff MB, Meissner MH. | Circulation. 2018 Apr 3;137(14):1505-1515
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Keywords: diagnostic imaging; ultrasonography; veins; venous thromboembolism; venous thrombosis

Consensus Report

Editorial : enous ultrasound is the standard imaging test for patients suspected of having acute deep venous thrombosis (DVT). There is variability and disagreement among authoritative groups regarding the necessary components of the test. Some protocols include scanning the entire lower extremity, whereas others recommend scans limited to the thigh and knee supplemented with serial testing. Some protocols use gray-scale ultrasound alone, whereas others include Doppler interrogation. Point-of-care ultrasound is recommended in some settings, and there is heterogeneity of these protocols as well. Heterogeneity of recommendations can lead to errors including incorrect application of guidelines, confusion among requesting physicians, and incorrect follow-up. In October 2016, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to evaluate the current evidence to develop recommendations regarding ultrasound protocols for DVT and the terminology used to communicate results to clinicians. Recommendations were made after open discussion and by unanimous consensus.The panel recommends a comprehensive duplex ultrasound protocol from thigh to ankle with Doppler at selected sites rather than a limited or complete compression-only examination. This protocol is currently performed in many facilities and is achievable with standard ultrasound equipment and personnel. The use of these recommendations will increase the diagnosis of calf DVT and provide better data to explain the presenting symptoms.

Conclusion : The panel recommends a single point-of-care protocol that minimizes underdiagnoses of proximal DVT.The panel recommends the term chronic postthrombotic change to describe the residual material that persists after the acute presentation of DVT to avoid potential overtreatment of prior thrombus.Adoption of a single standardized comprehensive duplex ultrasound and a single point-of-care examination will enhance patient safety and clinicians' confidence.

Conclusion (proposition de traduction) : Le comité recommande un protocole unique au lit du malade qui minimise les sous-diagnostiques de TVP proximale. Le comité recommande le terme de mutation post-thrombotique chronique pour décrire le matériel résiduel qui persiste après la présentation aiguë de la TVP afin d'éviter un éventuel surtraitement du thrombus antérieur. Une échographie duplex complète standardisée et un examen unique au lit du malade amélioreront la sécurité du patient et la confiance des cliniciens.

Critical Care

Ultrasound-assessed diaphragmatic impairment is a predictor of outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease undergoing noninvasive ventilation.
Marchioni A, Castaniere I, Tonelli R, Fantini R, Fontana M, Tabbì L, Viani A, Giaroni F, Ruggieri V, Cerri S, Clini E. | Crit Care. 2018 Apr 27;22(1):109
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Keywords: Diaphragmatic dysfunction; Noninvasive ventilation; Respiratory failure; Transdiaphragmatic pressure; Ultrasound


Introduction : Ultrasound (US) evaluation of diaphragmatic dysfunction (DD) has proved to be a reliable technique in critical care. In this single-center prospective study, we investigated the impact of US-assessed DD on noninvasive ventilation (NIV) failure in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and its correlation with the transdiaphragmatic pressure assessed using the invasive sniff maneuver (Pdi sniff).

Méthode : A population of 75 consecutive patients with AECOPD with hypercapnic acidosis admitted to our respiratory intensive care unit (RICU) were enrolled. Change in diaphragm thickness (ΔTdi) < 20% during tidal volume was the predefined cutoff for identifying DD+/- status. Correlations between ΔTdi < 20% NIV failure and other clinical outcomes were investigated. Correlation between ΔTdi and Pdi sniff values was analyzed in a subset of ten patients.

Résultats : DD+ patients had a higher risk for NIV failure than DD- patients (risk ratio, 4.4; p <  0.001), and this finding was significantly associated with higher RICU, in-hospital, and 90-day mortality rates; longer mechanical ventilation duration; higher tracheostomy rate; and longer RICU stay. Huge increases in NIV failure (HR, 6.2; p < 0.0001) and 90-day mortality (HR, 4.7; p = 0.008) in DD+ patients were found by Kaplan-Meier analysis. ΔTdi highly correlated with Pdi sniff (Pearson's r = 0.81; p = 0.004). ΔTdi < 20% showed better accuracy in predicting NIV failure than baseline pH value and early change in both arterial blood pH and partial pressure of carbon dioxide following NIV start (AUCs 0.84 to DTdi < 20%, 0.51 to pH value at baseline, 0.56 to early change in arterial blood pH following NIV start, and 0.54 to early change in partical pressure of carbon dioxide following NIV start, respectively; p < 0.0001).

Conclusion : Early and noninvasive US assessment of DD during severe AECOPD is reliable and accurate in identifying patients at major risk for NIV failure and worse prognosis.

Conclusion (proposition de traduction) : L'évaluation précoce et non invasive par échographie du dysfonctionnement diaphragmatique au cours des exacerbations aiguës sévères de la maladie pulmonaire obstructive chronique est fiable et précise pour identifier les patients présentant risque majeur d'échec de la VNI et de pronostic plus mauvais.

Reverse shock index multiplied by Glasgow Coma Scale score (rSIG) is a simple measure with high discriminant ability for mortality risk in trauma patients: an analysis of the Japan Trauma Data Bank.
Kimura A, Tanaka N. | Crit Care. 2018 Apr 11;22(1):87
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Keywords: Glasgow Coma Scale score; Heart rate; In-hospital mortality; Japan Trauma Data Bank; Systolic blood pressure


Introduction : The shock index (SI), defined as heart rate (HR) divided by systolic blood pressure (SBP), is reported to be a more sensitive marker of shock than traditional vital signs alone. In previous literature, use of the reverse shock index (rSI), taken as SBP divided by HR, is recommended instead of SI for hospital triage. Among traumatized patients aged > 55 years, SI multiplied by age (SIA) might provide better prediction of early post-injury mortality. Separately, the Glasgow Coma Scale (GCS) score has been shown to be a very strong predictor. When considering these points together, rSI multiplied by GCS score (rSIG) or rSIG divided by age (rSIG/A) could provide even better prediction of in-hospital mortality.

Méthode : This retrospective, multicenter study used data from 168,517 patients registered in the Japan Trauma Data Bank for the period 2006-2015. We calculated areas under receiver operating characteristic curves (AUROCs) to measure the discriminant ability by comparing those of SI (or rSI), SIA, rSIG, and rSIG/A for in-hospital mortality and for 24-h blood transfusion.

Résultats : The highest ROC AUC (AUROC), 0.901(0.894-0.908) for in-hospital mortality in younger patients (aged < 55 years), was seen for rSIG. In older patients (aged ≥ 55 years), the AUROC of rSIG/A, 0.845(0.840-0.850), was highest for in-hospital mortality. However, the difference between rSIG and rSIG/A was slight and did not seem to be clinically important. rSIG also had the highest AUROC of 0.745 (0.741-749) for 24-h blood transfusion.

Conclusion : rSIG ((SBP/HR) × GCS score) is easy to calculate without the need for additional information, charts or equipment, and can be a more reliable triage tool for identifying risk levels in trauma patients.

Conclusion (proposition de traduction) : rSIG ((SBP/HR) × score GCS) est facile à calculer sans avoir besoin d'informations supplémentaires, de graphiques ou d'équipement, et peut être un outil de triage plus fiable pour identifier les niveaux de risque chez les patients traumatisés.

Critical Care Medicine

Oxygen Exposure Resulting in Arterial Oxygen Tensions Above the Protocol Goal Was Associated With Worse Clinical Outcomes in Acute Respiratory Distress Syndrome.
Aggarwal NR, Brower RG, Hager DN, Thompson BT, Netzer G, Shanholtz C, Lagakos A, Checkley W; National Institutes of Health Acute Respiratory Distress Syndrome Network Investigators. | Crit Care Med. 2018 Apr;46(4):517-524
Keywords: Aucun

Clinical Investigations

Introduction : High fractions of inspired oxygen may augment lung damage to exacerbate lung injury in patients with acute respiratory distress syndrome. Participants enrolled in Acute Respiratory Distress Syndrome Network trials had a goal partial pressure of oxygen in arterial blood range of 55-80 mm Hg, yet the effect of oxygen exposure above this arterial oxygen tension range on clinical outcomes is unknown. We sought to determine if oxygen exposure that resulted in a partial pressure of oxygen in arterial blood above goal (> 80 mm Hg) was associated with worse outcomes in patients with acute respiratory distress syndrome.

Méthode : Design: Longitudinal analysis of data collected in these trials.
Setting: Ten clinical trials conducted at Acute Respiratory Distress Syndrome Network hospitals between 1996 and 2013.
Subjects: Critically ill patients with acute respiratory distress syndrome.
Interventions: None.

Résultats : We defined above goal oxygen exposure as the difference between the fraction of inspired oxygen and 0.5 whenever the fraction of inspired oxygen was above 0.5 and when the partial pressure of oxygen in arterial blood was above 80 mm Hg. We then summed above goal oxygen exposures in the first five days to calculate a cumulative above goal oxygen exposure. We determined the effect of a cumulative 5-day above goal oxygen exposure on mortality prior to discharge home at 90 days. Among 2,994 participants (mean age, 51.3 yr; 54% male) with a study-entry partial pressure of oxygen in arterial blood/fraction of inspired oxygen that met acute respiratory distress syndrome criteria, average cumulative above goal oxygen exposure was 0.24 fraction of inspired oxygen-days (interquartile range, 0-0.38). Participants with above goal oxygen exposure were more likely to die (adjusted interquartile range odds ratio, 1.20; 95% CI, 1.11-1.31) and have lower ventilator-free days (adjusted interquartile range mean difference of -0.83; 95% CI, -1.18 to -0.48) and lower hospital-free days (adjusted interquartile range mean difference of -1.38; 95% CI, -2.09 to -0.68). We observed a dose-response relationship between the cumulative above goal oxygen exposure and worsened clinical outcomes for participants with mild, moderate, or severe acute respiratory distress syndrome, suggesting that the observed relationship is not primarily influenced by severity of illness.

Conclusion : Oxygen exposure resulting in arterial oxygen tensions above the protocol goal occurred frequently and was associated with worse clinical outcomes at all levels of acute respiratory distress syndrome severity.

Conclusion (proposition de traduction) : L'exposition à l'oxygène entraînant des pressions artérielles en oxygène au-dessus de l'objectif du protocole s'est produite fréquemment et a été associée à des résultats cliniques plus mauvais à tous les niveaux de gravité du syndrome de détresse respiratoire aiguë.

Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study.
De Jong A, Rolle A, Molinari N, Paugam-Burtz C, Constantin JM, Lefrant JY, Asehnoune K, Jung B, Futier E, Chanques G, Azoulay E, Jaber S. | Crit Care Med. 2018 Apr;46(4):532-539
Keywords: Aucun

Clinical Investigations

Introduction : To determine the prevalence of and risk factors for cardiac arrest during intubation in ICU, as well as the association of ICU intubation-related cardiac arrest with 28-day mortality.

Méthode : Design: Retrospective analysis of prospectively collected data.
Setting: Sixty-four French ICUs.
Patients: Critically ill patients requiring intubation in the ICU.
Interventions: None.

Résultats : During the 1,847 intubation procedures included, 49 cardiac arrests (2.7%) occurred, including 14 without return of spontaneous circulation (28.6%) and 35 with return of spontaneous circulation (71.4%). In multivariate analysis, the main predictors of intubation-related cardiac arrest were arterial hypotension (systolic blood pressure < 90 mm Hg) prior to intubation (odds ratio = 3.406 [1.797-6.454]; p = 0.0002), hypoxemia prior to intubation (odds ratio = 3.991 [2.101-7.583]; p < 0.0001), absence of preoxygenation (odds ratio = 3.584 [1.287-9.985]; p = 0.0146), overweight/obesity (body mass index > 25 kg/m; odds ratio = 2.005 [1.017-3.951]; p = 0.0445), and age more than 75 years old (odds ratio = 2.251 [1.080-4.678]; p = 0.0297). Overall 28-day mortality rate was 31.2% (577/1,847) and was significantly higher in patients who experienced intubation-related cardiac arrest than in noncardiac arrest patients (73.5% vs 30.1%; p < 0.001). After multivariate analysis, intubation-related cardiac arrest was an independent risk factor for 28-day mortality (hazard ratio = 3.9 [2.4-6.3]; p < 0.0001).

Conclusion : ICU intubation-related cardiac arrest occurs in one of 40 procedures with high immediate and 28-day mortality. We identified five independent risk factors for cardiac arrest, three of which are modifiable, possibly to decrease intubation-related cardiac arrest prevalence and 28-day ICU mortality.

Conclusion (proposition de traduction) : Un arrêt cardiaque lié à l'intubation en USI est survenu dans l'une des 40 procédures avec une mortalité immédiate élevée et à 28 jours. Nous avons identifié cinq facteurs de risque indépendants pour les arrêts cardiaques, dont trois sont modifiables, peut-être pour diminuer la prévalence des arrêts cardiaques liés à l'intubation et la mortalité à 28 jours en USI.

Commentaire : Dans l'analyse multivariée, les principaux prédicteurs de l'arrêt cardiaque lié à l'intubation étaient l'hypotension artérielle (pression artérielle systolique < 90 mmHg) avant l'intubation, l'hypoxémie avant l'intubation, l'absence de préoxygénation, la surcharge pondérale/obésité (indice de masse corporelle > 25 kg/m2) et l'âge de plus de 75 ans.

An Interpretable Machine Learning Model for Accurate Prediction of Sepsis in the ICU.
Nemati S, Holder A, Razmi F, Stanley MD, Clifford GD, Buchman TG. | Crit Care Med. 2018 Apr;46(4):547-553
Keywords: Aucun

Clinical Investigations

Introduction : Sepsis is among the leading causes of morbidity, mortality, and cost overruns in critically ill patients. Early intervention with antibiotics improves survival in septic patients. However, no clinically validated system exists for real-time prediction of sepsis onset. We aimed to develop and validate an Artificial Intelligence Sepsis Expert algorithm for early prediction of sepsis.

Méthode : Design: Observational cohort study.
Setting: Academic medical center from January 2013 to December 2015.
Patients: Over 31,000 admissions to the ICUs at two Emory University hospitals (development cohort), in addition to over 52,000 ICU patients from the publicly available Medical Information Mart for Intensive Care-III ICU database (validation cohort). Patients who met the Third International Consensus Definitions for Sepsis (Sepsis-3) prior to or within 4 hours of their ICU admission were excluded, resulting in roughly 27,000 and 42,000 patients within our development and validation cohorts, respectively.
Interventions: None.

Résultats : High-resolution vital signs time series and electronic medical record data were extracted. A set of 65 features (variables) were calculated on hourly basis and passed to the Artificial Intelligence Sepsis Expert algorithm to predict onset of sepsis in the proceeding T hours (where T = 12, 8, 6, or 4). Artificial Intelligence Sepsis Expert was used to predict onset of sepsis in the proceeding T hours and to produce a list of the most significant contributing factors. For the 12-, 8-, 6-, and 4-hour ahead prediction of sepsis, Artificial Intelligence Sepsis Expert achieved area under the receiver operating characteristic in the range of 0.83-0.85. Performance of the Artificial Intelligence Sepsis Expert on the development and validation cohorts was indistinguishable.

Conclusion : Using data available in the ICU in real-time, Artificial Intelligence Sepsis Expert can accurately predict the onset of sepsis in an ICU patient 4-12 hours prior to clinical recognition. A prospective study is necessary to determine the clinical utility of the proposed sepsis prediction model.

Conclusion (proposition de traduction) : En utilisant les données disponibles dans l'unité de soins intensifs en temps réel, l'« Artificial Intelligence Sepsis Expert » peut prédire avec précision l'apparition d'un sepsis chez un patient en réanimation 4 à 12 heures avant la reconnaissance clinique.
Une étude prospective est nécessaire pour déterminer l'utilité clinique du modèle de prévision de la septicémie proposé.

Development and External Validation of an Automated Computer-Aided Risk Score for Predicting Sepsis in Emergency Medical Admissions Using the Patient’s First Electronically Recorded Vital Signs and Blood Test Results.
Faisal M, Scally A, Richardson D, Beatson K, Howes R, Speed K, Mohammed MA. | Crit Care Med. 2018 Apr;46(4):612-618
Keywords: Aucun

Clinical Investigations

Introduction : To develop a logistic regression model to predict the risk of sepsis following emergency medical admission using the patient's first, routinely collected, electronically recorded vital signs and blood test results and to validate this novel computer-aided risk of sepsis model, using data from another hospital.

Méthode : Design: Cross-sectional model development and external validation study reporting the C-statistic based on a validated optimized algorithm to identify sepsis and severe sepsis (including septic shock) from administrative hospital databases using International Classification of Diseases, 10th Edition, codes.
Setting: Two acute hospitals (York Hospital - development data; Northern Lincolnshire and Goole Hospital - external validation data).
Patients: Adult emergency medical admissions discharged over a 24-month period with vital signs and blood test results recorded at admission.
Interventions: None.

Résultats : The prevalence of sepsis and severe sepsis was lower in York Hospital (18.5% = 4,861/2,6247; 5.3% = 1,387/2,6247) than Northern Lincolnshire and Goole Hospital (25.1% = 7,773/30,996; 9.2% = 2,864/30,996). The mortality for sepsis (York Hospital: 14.5% = 704/4,861; Northern Lincolnshire and Goole Hospital: 11.6% = 899/7,773) was lower than the mortality for severe sepsis (York Hospital: 29.0% = 402/1,387; Northern Lincolnshire and Goole Hospital: 21.4% = 612/2,864). The C-statistic for computer-aided risk of sepsis in York Hospital (all sepsis 0.78; sepsis: 0.73; severe sepsis: 0.80) was similar in an external hospital setting (Northern Lincolnshire and Goole Hospital: all sepsis 0.79; sepsis: 0.70; severe sepsis: 0.81). A cutoff value of 0.2 gives reasonable performance.

Conclusion : We have developed a novel, externally validated computer-aided risk of sepsis, with reasonably good performance for estimating the risk of sepsis for emergency medical admissions using the patient's first, electronically recorded, vital signs and blood tests results. Since computer-aided risk of sepsis places no additional data collection burden on clinicians and is automated, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure.

Conclusion (proposition de traduction) : Nous avons développé un nouvel algorithme assisté par ordinateur, validé par des experts externes, du risque de survenu d'une septicémie avec une bonne performance pour les admissions médicales aux urgences en utilisant les premiers signes vitaux enregistrés électroniquement et les résultats des tests sanguins.
Étant donné que le calcul du risque de septicémie assisté par ordinateur n'impose aucun travail supplémentaire de collecte de données aux cliniciens et qu'il est automatisé, il peut maintenant être soigneusement introduit et évalué dans les hôpitaux disposant d'une infrastructure informatique suffisante.

Emergency Medicine Journal (EMJ)

Orthostatic blood pressure recovery patterns in suspected syncope in the emergency department.
van Wijnen VK, Ten Hove D, Gans ROB, Nieuwland W, van Roon AM, Ter Maaten JC, Harms MPM. | Emerg Med J. 2018 Apr;35(4):226-230
DOI:  | Télécharger l'article au format  
Keywords: emergency department; non invasive; vascular-arterial

Short report

Introduction : Orthostasis is a frequent trigger for (pre)syncope but some forms of orthostatic (pre)syncope have a worse prognosis than others. Routine assessment of orthostatic BP in the ED can detect classic orthostatic hypotension, but often misses these other forms of orthostatic (pre)syncope. This study aimed to determine the frequency of abnormal orthostatic BP recovery patterns in patients with (pre)syncope by using continuous non-invasive BP monitoring.

Méthode : We performed a prospective cohort study in suspected patients with (pre)syncope in the ED of a tertiary care teaching hospital between January and August 2014. Orthostatic BP was measured during the active lying-to-standing test with Nexfin, a continuous non-invasive finger arterial pressure measurement device. Orthostatic BP recovery patterns were defined as normal BP recovery, initial orthostatic hypotension, delayed BP recovery, classic orthostatic hypotension and reflex-mediated hypotension.

Résultats : Of 116 patients recruited, measurements in 111 patients (age 63 years, 51% male) were suitable for analysis. Classic orthostatic hypotension was the most prevalent abnormal BP pattern (19%), but only half of the patients received a final diagnosis of orthostatic hypotension. Initial orthostatic hypotension and delayed BP recovery were present in 20% of the patients with (pre)syncope of whom 45% were diagnosed as unexplained syncope. Reflex-mediated hypotension was present in 4% of the patients.

Conclusion : Continuous non-invasive BP measurement can potentially identify more specific and concerning causes of orthostatic (pre)syncope. Correct classification is important because of different short-term and long-term clinical implications.

Conclusion (proposition de traduction) : La mesure continue de la pression artérielle non invasive peut permettre d'identifier des causes plus spécifiques et plus préoccupantes de (pré) syncope orthostatique.
Une classification correcte est importante en raison des différentes implications cliniques à court et à long terme.

Lung ultrasound: a useful tool in the assessment of the dyspnoeic patient in the emergency department. Fact or fiction?.
Wimalasena Y, Kocierz L, Strong D, Watterson J, Burns B. | Emerg Med J. 2018 Apr;35(4):258-266
Keywords: Diagnosis; Dyspnoea; Emergency Department; Lung Consolidation; Lung Ultrasound; POCUS; Pleural Effusion; Pneumothorax; Pulmonary Oedema


Editorial : Patients with respiratory distress present a frequent and challenging dilemma for emergency physicians (EPs). The accurate diagnosis and treatment of the underlying pathology is vitally important in these sick patients to ensure the best outcome and minimise harm from unnecessary treatments. Within the last decade, studies have shown lung ultrasonography (LU) to be valuable in the accurate diagnosis of a variety of lung pathologies, including cardiogenic pulmonary oedema, pleural effusion, pneumothorax, haemothorax and pneumonia. However, despite advances in techniques and the evidence for the use of LU in the diagnosis of respiratory pathology, it remains poorly understood and rarely used by EPs. This clinical review article provides an overview of LU and its relevance as a diagnostic aid to the detection of respiratory pathology in the Emergency Department (ED).

Conclusion : The evidence suggests that LU can be used to accurately diag- nose a range of chest conditions. That accuracy will be depen- dent on training, skill and interpretation knowledge. Much of the evidence should be interpreted with caution given it arises from centres with proven track record and expertise in LU. As more EPs become trained and experienced in US skills, LU will become an additional diagnostic tool; a prototype tricorder for diagnosing critically ill patients presenting with dyspnoea. This will be particularly valuable in prehospital and remote environ- ments where portable and handheld US may be available while conventional CXR is not.

Conclusion (proposition de traduction) : L'étude suggère que l'échographie pulmonaire peut être utilisé pour diagnostiquer avec précision une large gamme de pathologies thoraciques. Cette précision dépendra de la formation, des compétences et des connaissances de l'interprétation. Une grande partie de l'étude doit être interprétée avec prudence, étant donné qu'elle provient de centres ayant fait leurs preuves et possédant une expertise en échographie pulmonaire. Au fur et à mesure que de plus en plus de praticiens seront formés, expérimentés et compétents en échographie, l'échographie pulmonaire deviendra un outil de diagnostic supplémentaire ; un prototype de tricordeur (dispositifs capables de diagnostiquer de manière non-invasive une grande diversité de pathologies) pour le diagnostic de patients de soins intensifs présentant une dyspnée. Cela sera particulièrement utile dans les environnements préhospitaliers et éloignés où les échographies portables et ultra-portables peuvent être disponibles alors que la radiographie du thorax conventionnel ne l'est pas.

Emergency Radiology

Secondary imaging for suspected appendicitis after equivocal ultrasound: time to disposition of MRI compared to CT.
Martin JF, Mathison DJ, Mullan PC, Otero HJ. | Emerg Radiol. 2018 Apr;25(2):161-168
Keywords: Appendicitis; CT; Children; MRI; Ultrasound

Original Article

Introduction : The purpose of this study was to compare MRI to CT as a secondary imaging modality for children age 5 years and older with suspected appendicitis after an equivocal abdominal ultrasound in terms of (1) the time to ED disposition decision, (2) surgery consultation rate, and (3) imaging test accuracy.

Méthode : We retrospectively studied children with suspected appendicitis and equivocal ultrasound results who underwent MR or CT as secondary imaging in a pediatric emergency department over two-consecutive 9-month periods. No oral or intravenous contrast was utilized for MRI. No sedation was utilized for any modality. Time of disposition is the time to admission or discharge order.

Résultats : Twenty-five patients underwent CT and 30 underwent MRI, with no significant difference in the median time from ultrasound to disposition between the CT (5.9 h, IQR 4.5, 8.4) and the MRI (5.9 h, IQR 4.6, 6.9) groups (p = 0.65). Fifteen patients had appendicitis. Of the 40 negative or equivocal studies, surgery was consulted for 79% in the CT and 48% in the MRI group (odds ratio 4.12, 95% CI 1.02-16.67). Diagnostic accuracy was as follows: MRI: sensitivity of 90%, specificity of 97.1%, positive predictive value of 90%, and negative predictive value of 97.1%. Abdominal CT: sensitivity of 88%, specificity of 98.6%, positive predictive value of 95.7%, and negative predictive value of 95.8%.

Conclusion : MRI is a feasible alternative to CT for secondary imaging in acute appendicitis for showing comparable ED throughput metrics and diagnostic accuracy, with added benefits of reduced radiation and avoidance of intravenous contrast.

Conclusion (proposition de traduction) : L'IRM est une alternative possible à la tomodensitométrie pour l'imagerie secondaire dans l'appendicite aiguë pour montrer des paramètres comparables de débit aux urgences et la précision du diagnostic, avec les avantages supplémentaires de diminuer l'irradiation et éviter l'administration de produits de contraste intraveineux.

European Journal of Emergency Medicine

Effect of oxygen therapy on myocardial salvage in ST elevation myocardial infarction: the randomized SOCCER trial.
Khoshnood A, Carlsson M, Akbarzadeh M, Bhiladvala P, Roijer A, Nordlund D, Höglund P, Zughaft D, Todorova L, Mokhtari A, Arheden H, Erlinge D, Ekelund U. | Eur J Emerg Med. 2018 Apr;25(2):78-84
Keywords: Aucun

Original Articles

Introduction : Recent studies suggest that administration of O2 in patients with acute myocardial infarction may have negative effects. With the use of cardiac MRI (CMR), we evaluated the effects of supplemental O2 in patients with ST elevation myocardial infarction (STEMI) accepted for acute percutaneous coronary intervention (PCI).

Méthode : This study was a randomized-controlled trial conducted at two university hospitals in Sweden. Normoxic STEMI patients were randomized in the ambulance to either supplemental O2 (10 l/min) or room air until the conclusion of the PCI. CMR was performed 2-6 days after the inclusion. The primary endpoint was the myocardial salvage index assessed by CMR. The secondary endpoints included infarct size and myocardium at risk.

Résultats : At inclusion, the O2 (n=46) and air (n=49) patient groups had similar patient characteristics. There were no significant differences in myocardial salvage index [53.9±25.1 vs. 49.3±24.0%; 95% confidence interval (CI): -5.4 to 14.6], myocardium at risk (31.9±10.0% of the left ventricle in the O2 group vs. 30.0±11.8% in the air group; 95% CI: -2.6 to 6.3), or infarct size (15.6±10.4% of the left ventricle vs. 16.0±11.0%; 95% CI: -4.7 to 4.1).

Conclusion : In STEMI patients undergoing acute PCI, we found no effect of high-flow oxygen compared with room air on the size of ischemia before PCI, myocardial salvage, or the resulting infarct size. These results support the safety of withholding supplemental oxygen in normoxic STEMI patients.

Conclusion (proposition de traduction) : Chez les patients ayant présenté un infarctus du myocarde avec sus-décalage ST, nous n'avons trouvé aucun effet de l'oxygène à haut débit comparé à l'air ambiant sur la taille de l'ischémie avant l'intervention coronarienne percutanée, la récupération myocardique ou la taille de l'infarctus. Ces résultats confirment la sécurité de l'apport limité d'oxygène supplémentaire chez les patients normoxique présentant un infarctus du myocarde avec sus-décalage ST.

Commentaire : En contradiction avec les résultats de l'essai AVOID : Stub D and al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015 Jun 16;131(24):2143-50  .
L'essai multicentrique AVOID incluait 638 patients randomisés avec notamment une évaluation de la taille de l'infarctus à 6 mois (critère secondaire d'évaluation) contrairement à l'étude suédoise de Khoshnood.

Lactate - Arterial and Venous Agreement in Sepsis: a prospective observational study.
Datta D, Grahamslaw J, Gray AJ, Graham C, Walker CA. | Eur J Emerg Med. 2018 Apr;25(2):85-91
Keywords: Aucun

Original Articles

Introduction : Sepsis is a common condition in the emergency department (ED). Lactate measurement is an important part of management: arterial lactate (A-LACT) measurement is the gold standard. There is increasing use of peripheral venous lactate (PV-LACT); however, there is little research supporting the interchangeability of the two measures.If PV-LACT has good agreement with A-LACT, it would significantly reduce patient discomfort and the risks of arterial sampling for a large group of acutely unwell patients, while allowing faster and wider screening, with potential reduced costs to the healthcare system.
OBJECTIVE: The aim of this study is to determine the agreement between PV-LACT and A-LACT in septic patients attending the ED.

Méthode : We carried out a prospective observational cohort study of 304 consented patients presenting with sepsis to a single UK NHS ED (110 000 adult attendances annually) taking paired PV-LACT and A-LACT. Bland-Altman analysis was carried out to determine agreement. Receiver operating characteristic curves and 2×2 tables were constructed to explore the predictive value of PV-LACT for A-LACT.

Résultats : The mean difference (PV-LACT-A-LACT) is 0.4 mmol/l [95% confidence interval (CI): 0.37-0.45], with 95% limits of agreement from -0.4 (95% CI: -0.45 to -0.32) to 1.2 (95% CI: 1.14-1.27). A PV-LACT of at least 2 mmol/l predicts an A-LACT of at least 2 with 100% sensitivity (95% CI: 89-100%) and 83% specificity (95% CI: 77-87%).

Conclusion : This study is the largest comparing the two measurements, and shows good clinical agreement. We recommend using PV-LACT in the routine screening of septic patients. A PV-LACT less than 2 mmol/l is predictive of an A-LACT less than 2 mmol/l.

Conclusion (proposition de traduction) : Cette étude est la plus importante comparant les deux méthodes de mesures, et montre une bonne concordance clinique. Nous recommandons d'utiliser le taux de lactate veineux périphérique pour le dépistage de routine des patients septiques.
Un taux de lactate veineux périphérique inférieur à 2 mmol/l est prédictif d'un taux de lactate artériel inférieur à 2 mmol/l.

Agreement between arterial and venous lactate in emergency department patients: a prospective study of 157 consecutive patients.
Valli V, Philippon AL, Devilliers C, Bloom B, Hausfater P, Riou B, Freund Y. | Eur J Emerg Med. 2018 Apr;25(2):92-96
Keywords: Aucun

Original Articles

Introduction : In the emergency department (ED), lactate is routinely used for risk stratification. Whether venous or arterial lactate measured on blood gas is interchangeable is not known. We hypothesized that venous lactate can be used instead of arterial lactate for the evaluation of acute patients in the ED.

Méthode : This was a prospective single-center study. All patients requiring a lactate measurement were enrolled and we simultaneously drew arterial and venous blood. We followed up all patients to hospital discharge. Our primary aim was to evaluate agreements between the two measurements using Bland and Altman plots with the report of bias (mean difference) and limits of agreements. We also aimed to determine the rate of misclassification (defined as one measurement<1.8 mmol/l and the other>2.2). Our secondary aim was to evaluate their respective prognostic value to predict in-hospital death or admission in the ICU longer than 72 h.

Résultats : The mean age of the 132 analyzed patients was 62 years (SD: 18 years), and 59% were men. The mean difference (bias) between arterial and venous lactate was -0.6 mmol/l (limits of agreement: -1.7 to 0.6 mmol/l). The rate of misclassification was 8% (95% confidence interval: 3-2%). Both methods present similar performances for the prediction of poor outcomes, with an area under the receiving operator characteristic curves of 0.67 for both. Results were similar when focused only on septic patients.

Conclusion : Venous and arterial lactates do not agree well, and there is a high misclassification rate. Venous lactate does not appear to be interchangeable with arterial sampling.

Conclusion (proposition de traduction) : Les taux de lactates veineux et artériels ne concordent pas bien, et il y a un taux élevé d'erreur de classification. Le lactate veineux ne semble pas être interchangeable avec l'échantillonnage artériel.

Commentaire : Etude française qui contre-dit l'article de Datta D. and al. Lactate - Arterial and Venous Agreement in Sepsis: a prospective observational study. Eur J Emerg Med. 2018 Apr;25(2):85-91.   dans le même numéro.

Characteristics, treatment and outcomes for all emergency department patients fulfilling criteria for septic shock: a prospective observational study.
Williams JM, Greenslade JH, Dymond CA, Chu K, Brown AFT, Lipman J. | Eur J Emerg Med. 2018 Apr;25(2):97-104
Keywords: Aucun

Original article

Introduction : Most published data on emergency department (ED) patients with septic shock have been generated from studies examining the effect of early protocolised resuscitation in selected cohorts. Consequently, these data do not generally represent patients falling outside trial inclusion criteria or judged unsuitable for aggressive treatment. Our aim was to determine the characteristics, treatment and outcomes for all ED patients fulfilling the criteria for septic shock.

Méthode : Septic shock patients were identified from a prospective database of consecutive ED patients admitted with infection. Descriptive data were compared with those from previous studies and associations between ED processes of care and mortality were determined.

Résultats : A total of 399 septic shock patients were identified, with a 30-day mortality of 19.5%. The median ED length of stay was 9.2 h. Rates of vasopressor use (22.6%) and ICU admission (37.3%) were low. Subgroups fulfilling the lactate criteria alone, hypotension criteria alone and both criteria represented distinct shock phenotypes with increasing severity of illness and mortality. Mortality for patients with limitations to treatment determined in the ED was 65.6% and 6.1% for those without limitations. Greater volumes of intravenous fluid and early vasopressor therapy for appropriate patients were associated with survival.

Conclusion : Median length of stay over 9 hours may have enhanced identification of patients with limitations to treatment and fluid responders, reducing invasive therapies and ICU admissions. Distinct shock phenotypes were apparent, with implications for revision of septic shock definitions and future trial design. Liberal fluids and early vasopressor use in appropriate patients were associated with survival.

Conclusion (proposition de traduction) : La durée médiane d'un séjour de plus de 9 heures peut avoir amélioré l'identification des patients ne répondant pas au traitement et au remplissage par cristalloïdes, ce qui réduit les thérapies invasives et les admissions en unité de soins intensifs. Des phénotypes de choc distincts étaient apparents, avec des implications pour la révision des définitions du choc septique et la conception de l'essai futur.
L'utilisation large d'un remplissage par cristalloïdes et de vasopresseurs précocement chez les patients appropriés étaient associés à la survie.

Is severe hypercalcemia immediately life-threatening?.
Guimard C, Batard E, Lavainne F, Trewick D. | Eur J Emerg Med. 2018 Apr;25(2):110-113
Keywords: Aucun

Original article

Introduction : Severe hypercalcemia is often considered an emergency because of a potential risk of cardiac arrest or coma. However, there is little evidence to support this. The aim of our study was to assess whether severe hypercalcemia (Ca>4 mmol/l or 16 mg/dl) was associated with immediately life-threatening cardiac arrhythmias or neurological complications in patients admitted to the Emergency Department (ED).

Méthode : A retrospective observational study was carried out over a 5-year period (2008-2012). Eligible patients were admitted to the Adult Emergency Department of Nantes University Hospital and had a calcium concentration in excess of 4 mmol/l. There were no exclusion criteria. The primary outcome was the number of life-threatening cardiac arrhythmias and/or neurological complications during the stay in the ED. The secondary outcomes were correlation between calcium concentrations/ECG QTc intervals and mortality.

Résultats : A total of 126 204 adult patients had calcium concentrations measured. Thirty one (0.025%) patients had severe hypercalcemia as defined in our study. The median calcium concentration was 4.3 mmol/l (Q1, 4.2; Q3, 4.7) and the median albumin-adjusted calcium concentration was 4.3 mmol/l (Q1, 4.1; Q3, 4.7). No patient presented with a life-threatening cardiac event during stay in the ED. The median ED stay was 7 h 32 min. One patient presented with a coma of multifactorial origin. There was no correlation between calcemia and QTc intervals (P=0.60). Mortality at 1 year was 55% (17 patients).

Conclusion : We found no cases of immediately life-threatening cardiac arrhythmias or neurological complications associated with hypercalcemia above 4 mmol/l over a 5-year period in a large tertiary ED.

Conclusion (proposition de traduction) : Nous n'avons trouvé aucun cas d'arythmie cardiaque ou de complication neurologique immédiatement mortelle associée à une hypercalcémie supérieure à 4 mmol/l sur une période de 5 ans dans un service d'urgence tertiaire.

Physician-provided prehospital critical care, effect on patient physiology dynamics and on-scene time.
Reid BO, Rehn M, Uleberg O, Krüger A. | Eur J Emerg Med. 2018 Apr;25(2):114-119
Keywords: Aucun

Original articles

Introduction : Improved physiologic status can be seen as a surrogate measure of improved outcome and a field-friendly prognostic model such as the Mainz Emergency Evaluation Score (MEES) could quantify the effect on physiological response. We aim to examine the dynamic physiological profile as measured by this score on patients managed by physician-manned helicopter emergency medical services and how this profile was related to on-scene time expenditure and critical care interventions.

Méthode : Data including patient characteristics, physiological data, and description of diagnostic and therapeutic interventions were prospectively collected over two 14-day periods, summer and winter, at six participating Norwegian bases. The MEES score was utilized to examine the difference between a score measured at first patient contact (MEES 1) and end-of-care (MEES 2).

Résultats : A total of 240 primary missions with patient-on-scene form the basis of the study. In total, 43% were considered severely ill or injured, of whom 59% were medical patients. Twenty-nine percent were severely deranged physiologically. The most common advanced procedure performed was advanced airway management (15%), followed by defibrillation (8.8%). Using MEES as an indicator, 1% deteriorated under care, whereas 66% remained unchanged and 33% showed an improvement in their physiological status. With increasing on-scene time, fewer patients deteriorated and a greater proportion of patients improved.

Conclusion : Restoring deranged physiology remains a mantra for all critical care practitioners. We have shown that this is also possible in the prehospital context, even when prolonging on-scene time, and after initiating advanced procedures.

Conclusion (proposition de traduction) : La restauration de la physiologie atteinte demeure un mantra pour tous les praticiens en soins intensifs. Nous avons montré que cela est également possible dans le contexte préhospitalier, même en prolongeant le temps passé sur les lieux, et après avoir initié des procédures avancées.

Intensive Care Medicine

Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: a randomized multicenter study.
Daubin C, Valette X, Thiollière F, Mira JP, Hazera P, Annane D, Labbe V, Floccard B, Fournel F, Terzi N, Du Cheyron D, Parienti JJ; BPCTrea Study Group. | Intensive Care Med. 2018 Apr;44(4):428-437
DOI:  | Télécharger l'article au format  
Keywords: Antibiotic stewardship; Chronic obstructive pulmonary disease; Community-acquired pneumonia; Procalcitonin; Respiratory tract infection; Viral infection

Seven-Day Profile Publication

Introduction : To compare the efficacy of an antibiotic protocol guided by serum procalcitonin (PCT) with that of standard antibiotic therapy in severe acute exacerbations of COPD (AECOPDs) admitted to the intensive care unit (ICU).

Méthode : We conducted a multicenter, randomized trial in France. Patients experiencing severe AECOPDs were assigned to groups whose antibiotic therapy was guided by (1) a 5-day PCT algorithm with predefined cutoff values for the initiation or stoppage of antibiotics (PCT group) or (2) standard guidelines (control group). The primary endpoint was 3-month mortality. The predefined noninferiority margin was 12%.

Résultats : A total of 302 patients were randomized into the PCT (n = 151) and control (n = 151) groups. Thirty patients (20%) in the PCT group and 21 patients (14%) in the control group died within 3 months of admission (adjusted difference, 6.6%; 90% CI - 0.3 to 13.5%). Among patients without antibiotic therapy at baseline (n = 119), the use of PCT significantly increased 3-month mortality [19/61 (31%) vs. 7/58 (12%), p = 0.015]. The in-ICU and in-hospital antibiotic exposure durations, were similar between the PCT and control group (5.2 ± 6.5 days in the PCT group vs. 5.4 ± 4.4 days in the control group, p = 0.85 and 7.9 ± 8 days in the PCT group vs. 7.7 ± 5.7 days in the control group, p = 0.75, respectively).

Conclusion : The PCT group failed to demonstrate non-inferiority with respect to 3-month mortality and failed to reduce in-ICU and in-hospital antibiotic exposure in AECOPDs admitted to the ICU.

Conclusion (proposition de traduction) : Le groupe PCT n'a pas démontré de non-infériorité en ce qui concerne la mortalité à 3 mois et n'a pas réussi à réduire l'exposition aux antibiotiques en USI et à l'hôpital lors d'exacerbations aiguës de BPCO admises en USI.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Une valeur initiale basse de PCT ne semble pas autoriser la non-administration d’antibiotique lors d’une exacerbation aigue de BPCO conduisant à une admission en réanimation  . Rédigé par le Dr Olivier Leroy.

Internal and Emergency Medicine

Mild troponin elevation in patients admitted to the emergency department with atrial fibrillation: 30-day post-discharge prognostic significance.
Augusto J, Borges Santos M, Roque D, Faria D, Urzal J, Morais J, Gil V, Morais C. | Intern Emerg Med. 2018 Apr;13(3):333-341
Keywords: Atrial fibrillation; Emergency department; Prognosis; Troponin I


Introduction : Patients with atrial fibrillation (AF) often undergo troponin (Tn) testing in the emergency department (ED), but the clinical significance of mildly elevated values remains unclear. We evaluated short-term 30-day post-discharge outcomes in AF patients according to troponin levels.

Méthode : Out of 2181 AF patients evaluated in the ED (June 2014 to June 2015), we included consecutive admitted patients. Patients were grouped into those with normal Tn values (≤ 0.05 ng/mL), mild elevations (> 0.05-0.5 ng/mL, 10× URL) and marked elevations (> 0.5 ng/mL). Outcomes included acute coronary syndrome (ACS), revascularization, all-cause mortality and combined end point; the secondary outcome was ischemic stroke.

Résultats : A total of 348 patients (90.9%) had Tn testing, which was associated with longer in-hospital stay (median 2.04 vs. 0.74 days in unmeasured Tn, p = 0.014); 37.1% did not have clinical suspicion of ACS. Mild Tn elevation occurred in 19.0% and 6.3% had markedly elevated values. Compared to normal values, mild elevations had higher absolute incidence, without statistical significance, of ACS (1.5 vs. 0.0%, p = 0.202), revascularization (1.5 vs. 0.0%, p = 0.202), all-cause mortality (12.1 vs. 6.9%, p = 0.200), combined end point (13.3 vs. 6.9%, p = 0.084) or ischemic stroke (4.5 vs. 2.3%, p = 0.394).

Conclusion : Tn testing is routine in admitted AF patients, even without suspicion of ACS, and is associated with prolonged stay. Mild Tn elevation is associated with a nonsignificant trend toward higher adverse events. Larger-scale studies are needed to evaluate the cost-effectiveness of Tn testing for prognosis in admitted AF patients, as this prolongs stay and has unclear impact on patient management.

Conclusion (proposition de traduction) : Le dosage de la troponine est systématique chez les patients admis pour FA, même sans suspicion de SCA, et est associé à un séjour prolongé. L'élévation légère de la troponine est associée à une tendance non significative vers des événements indésirables plus élevés.
Des études à plus grande échelle sont nécessaires pour évaluer le rapport coût-efficacité du test de la troponine pour le pronostic chez les patients admis pour FA, car cela prolonge le séjour et a un impact imprécis sur la prise en charge du patient.

SOFA score in septic patients: incremental prognostic value over age, comorbidities, and parameters of sepsis severity.
Ng PCY, Long BJ, Davis WT, Sessions DJ, Koyfman A. | Intern Emerg Med. 2018 Apr;13(3):405-412
Keywords: Lactate; Organ dysfunction scores; Prognostic scores; Sepsis; Vital signs


Introduction : Several widely used scoring systems for septic patients have been validated in an ICU setting, and may not be appropriate for other settings like Emergency Departments (ED) or High-Dependency Units (HDU), where a relevant number of these patients are managed. The purpose of this study is to find reliable tools for prognostic assessment of septic patients managed in an ED-HDU.

Méthode : In 742 patients diagnosed with sepsis/severe sepsis/septic shock, not-intubated, admitted in ED between June 2008 and April 2016, SOFA, qSOFA, PIRO, MEWS, Charlson Comorbidity Index, MEDS, and APACHE II were calculated at ED admission (T0); SOFA and MEWS were also calculated after 24 h of ED-High-Dependency Unit stay (T1). Discrimination and incremental prognostic value of SOFA score over demographic data and parameters of sepsis severity were tested. Primary outcome is 28-day mortality.

Résultats : Twenty-eight day mortality rate is 31%. The different scores show a modest-to-moderate discrimination (T0 SOFA 0.695; T1 SOFA 0.741; qSOFA 0.625; T0 MEWS 0.662; T1 MEWS 0.729; PIRO: 0.646; APACHE II 0.756; Charlson Comorbidity Index 0.596; MEDS 0.674, all p < 0.001). At a multivariate stepwise Cox analysis, including age, Charlson Comorbidity Index, MEWS, and lactates, SOFA shows an incremental prognostic ability both at T0 (RR 1.165, IC 95% 1.009-1.224, p < 0.0001) and T1 (RR 1.168, IC 95% 1.104-1.234, p < 0.0001).

Conclusion : SOFA score shows a moderate prognostic stratification ability, and demonstrates an incremental prognostic value over the previous medical conditions and clinical parameters in septic patients.

Conclusion (proposition de traduction) : Le score SOFA montre une capacité de stratification pronostique modérée, et montre une valeur pronostique incrémentale sur les conditions médicales précédentes et les paramètres cliniques chez les patients septiques.

Predictors of good neurologic outcome after resuscitation beyond 30 min in out-of-hospital cardiac arrest patients undergoing therapeutic hypothermia.
Ahn S, Lee BK, Youn CS, Kim YJ, Sohn CH, Seo DW, Kim WY. | Intern Emerg Med. 2018 Apr;13(3):413-419
Keywords: Out-of-hospital cardiac arrest; Outcomes; Resuscitation; Targeted temperature management


Introduction : Neurologically intact survival after cardiac arrest is possible even after prolonged resuscitation efforts. However, the factors associated with good neurologic outcome in these patients remain unknown. This study identifies predictors associated with good neurologic outcome after resuscitation beyond 30 min in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM).

Méthode : This multicenter, registry-based, retrospective cohort study conducted in 24 hospitals across South Korea between 2007 and 2012 includes adult (≥18 years) non-traumatic OHCA patients with prolonged (>30 min) downtime who underwent TTM treatment. Good neurologic outcomes were defined as cerebral performance category scores of ≤2.

Résultats : Of the 930 comatose adult cardiac arrest patients treated with TTM, 423 patients with prolonged downtime were included. A total of 76 (18.0%) had good neurologic outcome. Multivariable analysis reveal that age <65 years (OR 7.91, 95% CI 3.18-19.68), initial shockable rhythm (OR 6.31, 95% CI 3.40-11.74), and witnessed arrest (OR 3.81, 95% CI 1.73-8.45) are associated with good neurologic outcome. The sensitivity and specificity for good neurologic outcome in patients with age <65 years, shockable rhythm, and witnessed arrest are 90.8% and 41.2, 67.6 and 79.5%, and 81.6 and 41.2%, respectively.

Conclusion : In prolonged cardiac arrest patients, initial shockable rhythm, age <65 years, or witnessed arrest are predictors for neurologic intact survival.

Conclusion (proposition de traduction) : Chez les patients en arrêt cardiaque prolongé, le rythme initial choquable, l'âge < à 65 ans ou l'arrêt devant témoin sont des critères prédictifs de la survie neurologique de bonne qualité.

A simplified diagnostic algorithm for the management of suspected pulmonary embolism: the YEARS study.
Manzoni M, Reggiani M; GrAM (Gruppo di Autoformazione Metodologica). | Intern Emerg Med. 2018 Apr;13(3):429-431
Keywords: Aucun


Editorial : The significant clinical burden of venous thromboembolism (VTE) is expressed by its high rate of mortality and mor- bidity: sudden death is the clinical presentation in almost 25% of patients with pulmonary embolism (PE), and about 15% of patients with a PE dies within 3 months, about half of them because of the direct consequences of the PE. The estimated annual incidence rates of overall VTE range from 104 to 183 per 100,000 person-years in Europe, with the higher rate observed in older people. The clinical picture of PE is non-specific: consequently, when PE is suspected, a computed tomography pulmonary angiography (CTPA) is generally performed to confirm or exclude the diagnosis, owing to its high diagnostic accuracy. However, considering the risk of radiation exposure, of contrast-induced nephropa- thy and the elevated costs, the number of performed CTPA should be restricted. Therefore, diagnostic algorithms have been introduced and validated, with the aim of safely exclud- ing VTE and limiting the number of unnecessary CTPA examination. These algorithms usually combine clinical scores for VTE with the interpretation of high-sensitivity D-dimer concentrations. In 2013, another study proposed an interpretative key for D-dimer concentration that is the age- adjusted D-dimer (cut-off value = age × 10 μg/L).

Conclusion : The YEARS study group proposed a new diagnostic algorithm for suspected PE, aiming to safely reduce the number of unnecessary CTPA examinations.

Conclusion (proposition de traduction) : Le groupe d'étude YEARS a proposé un nouvel algorithme de diagnostic pour la soupirions d'embolie pulmonaire, visant à réduire en toute sécurité le nombre d'examens scanographiques inutiles.

Commentaire : Voir l'article de van der Hulle T. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017 Jul 15;390(10091):289-297.  

International Journal of Antimicrobial Agents

Higher versus standard amikacin single dose in emergency department patients with severe sepsis and septic shock: a randomised controlled trial.
De Winter S, Wauters J, Meersseman W, Verhaegen J, Van Wijngaerden E, Peetermans W, Annaert P, Verelst S, Spriet I. | Int J Antimicrob Agents. 2018 Apr;51(4):562-570
Keywords: Aminoglycosides; Emergency department; Pharmacodynamics; Pharmacokinetics; Sepsis; Septic shock

Original article

Editorial : Recent studies suggest that intensive care unit patients treated with amikacin frequently do not attain the desired pharmacokinetic/pharmacodynamic (PK/PD) target, i.e. peak amikacin concentration (Cpeak) to minimum inhibitory concentration (MIC) ratio of ≥8, when a single dose of 15 mg/kg is used. No data are available for patients admitted to the emergency department (ED). The aim of this prospective randomised controlled study was to determine PK/PD target attainment in ED patients presenting with severe sepsis or septic shock treated with 15 mg/kg versus 25 mg/kg amikacin. Patients were randomly assigned to receive amikacin 25 mg/kg or 15 mg/kg. Amikacin Cpeak values were determined. The primary outcome was target attainment defined as Cpeak/MIC ≥ 8 both using EUCAST susceptibility breakpoints and actually documented MICs as denominator. A total of 104 patients were included. The EUCAST-based target was attained in 76% vs. 40% of patients assigned to the 25 mg/kg vs. 15 mg/kg dose groups (P <0.0001). Target attainment using actual MICs (median of 2 mg/L, documented in 48 isolated Gram-negative pathogens) was achieved in 95% vs. 94% of patients in the 25 mg/kg vs. 15 mg/kg dose groups (P = 0.969). Risk factors associated with PK/PD target failure were identified in the multivariable analysis. At least 25 mg/kg amikacin as a single dose should be used in ED patients with severe sepsis and septic shock to attain the EUCAST-based PK/PD target. However, when using local epidemiology as denominator, 15 mg/kg appears to be sufficient.

Introduction : Les aminosides sont fréquemment associés avec les bêtalactamines pour le traitement initial des patients en sepsis sévère ou en état de choc. Les 2 paramètres PK/PD témoins de leur efficacité antibactérienne et clinique sont Cmax/CMI et ASC/CMI. Il est recommandé d’obtenir une Cmax/CMI > 8 et une ASC/CMI > 70. Pour les patients de réanimation, il est usuel de préconiser une dose d’amikacine de 25mg/kg pour atteindre ces objectifs pharmacocinétiques. La pertinence d’une telle dose chez les patients se présentant dans un service d’urgence pour un sepsis sévère ou un choc septique est inconnue, raison de ce travail.

Méthode : Etude prospective, randomisée, menée dans un hôpital Belge pendant une période de 18 mois (01/2013 – 8/2014). Les patients en état de sepsis sévère ou d’état de choc étaient randomisés pour recevoir soit 15 soit 25/mg/kg (poids total) d’amikacine avec des doses maximales respectives de 1,2 et 2 g. Les dosages du taux sérique avaient lieu à H+1, H+6 et H+24 après le début de l’administration (durée 30 minutes).

Résultats : Parmi les 100 patients inclus, 50 ont été analysés dans chaque groupe.Les valeurs de Cmax ont été de 58,0 (46,8–69,6) et de 90,6 mg/l (71,7–105,3) dans les groupes 15 et 25/mg/kg, respectivement.En prenant pour référence une CMI de 8mg/l pour les entérobactéries et le P. aeruginosa (normes EUCAST), la valeur cible de Cmax/CMI > 8 n’a été atteinte que pour 40% des patients recevant 15 mg/kg vs. 76% des patients recevant 25 mg/kg (p<0,0001).Toutefois, la CMI médiane des pathogènes isolés étant de 2mg/l, la valeur cible a été atteinte pour respectivement 94 vs. 95% des patients. Aucune différence d’atteinte rénale n’a été observée entre les 2 groupes.

Conclusion (proposition de traduction) : Les auteurs concluent qu’une dose d’amikacine de 15mg/kg paraît suffisante pour la prise en charge des patients en sepsis sévère ou choc septique dans les structures d’urgence.

Commentaire : – 24 Avril 2018, L’utilisation d’une dose unique d’amikacine de 15 mg/kg semble suffisante pour la prise en charge des patients en sepsis sévère ou choc septique aux urgences   : Cette étude démontre que les doses d’aminosides doivent être adaptées aux CMI potentielles des germes causals. Celles-ci varient bien évidemment selon le lieu d’acquisition de l’agent causal. Toutefois, faut-il rentrer dans de telles distinctions dès lors que l’administration de l’aminoside est peu fréquente (100 patients en 18 mois) et se fait en dose quasiment unique ?

International Journal of Emergency Medicine

Prompting with electronic checklist improves clinician performance in medical emergencies: a high-fidelity simulation study.
Sevilla-Berrios R, SO'Horo JC, Schmickl CN, Erdogan A, Chen X, Garcia Arguello LY, Dong Y, Kilickaya O, Pickering B, Kashyap R, Gajic O. | Int J Emerg Med. 2018 Apr 27;11(1):26
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original Research

Introduction : Inefficient processes of care delivery during acute resuscitation can compromise the "Golden Hour," the time when quick interventions can rapidly determine the course of the patient's outcome. Checklists have been shown to be an effective tool for standardizing care models. We developed a novel electronic tool, the Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN) to facilitate standardized evaluation and treatment approach for acutely decompensating patients. The checklist was enforced by the use of a "prompter," a team member separate from the leader who records and reviews pertinent CERTAIN algorithms and verbalizes these to the team. Our hypothesis was that the CERTAIN model, with the use of the tool and a prompter, can improve clinician performance and satisfaction in the evaluation of acute decompensating patients in a simulated environment.

Méthode : Volunteer clinicians with valid adult cardiac life support (ACLS) certification were invited to test the CERTAIN model in a high-fidelity simulation center. The first session was used to establish a baseline evaluation in a standard clinical resuscitation scenario. Each subject then underwent online training before returning to a simulation center for a live didactic lecture, software knowledge assessment, and practice scenarios. Each subject was then evaluated on a scenario with a similar content to the baseline. All subjects took a post-experience satisfaction survey. Video recordings of the pre-and post-test sessions were evaluated using a validated method by two blinded reviewers.

Résultats : Eighteen clinicians completed baseline and post-education sessions. CERTAIN prompting was associated with reduced omissions of critical tasks (46 to 32%, p < 0.01) and 12 out of 14 general assessment tasks were completed in a more timely manner. The post-test survey indicated that 72% subjects felt better prepared during an emergency scenario using the CERTAIN model and 85% would want to be treated with the CERTAIN if they were critically ill.

Conclusion : Prompting with electronic checklist improves clinicians' performance and satisfaction when dealing with medical emergencies in high-fidelity simulation environment.

Conclusion (proposition de traduction) : L'utilisation d'une checklist électronique améliore la performance et la satisfaction des cliniciens lorsqu'ils sont confrontés à des urgences médicales dans un environnement de simulation haute fidélité.

Approach to undifferentiated dyspnea in emergency department: aids in rapid clinical decision-making.
Guttikonda SNR, Vadapalli K. | Int J Emerg Med. 2018 Apr 4;11(1):21
Keywords: Diagnostic strategy; Dyspnea; Emergency department; Multiorgan USG; Resource limited setting

Original research

Introduction : Diagnosis and management of patients presenting with acute dyspnea is one of the major challenges for physicians in emergency department (ED). A correct diagnosis is frequently delayed and difficult to ascertain, and clinical uncertainty is common, explaining the need for rapid diagnosis and a management plan. The primary aim of our study is to assess a diagnostic strategy using multiorgan point of care ultrasonography (USG) to differentiate patients presenting with acute dyspnea to ED into different diagnostic categories for timely management in a resource-limited setting.

Méthode : This is a prospective cohort study which assessed the diagnostic performance of a strategy in evaluating patients presenting with undifferentiated dyspnea as primary predominant complaint to ED. Focused multiorgan USG which includes cardiac USG for left ventricle systolic function, right ventricle enlargement, and pericardial effusion, inferior vena cava (IVC) diameter and collapsibility, lung USG to identify various patterns (acute interstitial syndrome, pneumothorax, pleural effusion, consolidation, etc.) and renal USG to assess kidney size and echotexture was performed. Later, patients were grouped into one of ten clinical syndromes defined in the study based on USG and clinical patterns. Emergency diagnosis was compared with final hospital diagnosis to assess the accuracy of this strategy.

Résultats : Concordance between ED diagnosis of dyspnea using the diagnostic strategy proposed in the study with final hospital diagnosis was high with agreement in 88% of patients (Kappa statistic = .805, p = .000) which is statistically significant. The most common diagnosis was acute decompensated heart failure (ADHF). Sensitivity and specificity of the diagnostic strategy used in this study to identify ADHF was 97.3 and 93.3%, respectively. On multivariate analysis, jugular venous distension, fever and cough, ejection fraction (by eyeball method), dilated IVC, absent to decreased lung sliding showed independent association in predicting cardiac and non-cardiac diagnosis.

Conclusion : The present study concludes that integrating focused multiorgan USG by lung-cardiac-IVC and renal ultrasound into routine clinical evaluation of patients with dyspnea has a higher accuracy for differentiating causes of dyspnea in emergency department. This strategy can be adopted even in resource limited setting.

Conclusion (proposition de traduction) : Cette étude conclut que l'intégration d'une exploration multi-organe par une échographie au lit du malade de la veine pulmonaire-cardiaque inférieure et des reins dans l'évaluation clinique systématique des patients présentant une dyspnée a une plus grande précision pour différencier les étiologies des dyspnées dans les services d'urgence. Cette stratégie peut être adoptée même dans un contexte de ressources limitées.

Journal of Antimicrobial Chemotherapy

Are infection specialists recommending short antibiotic treatment durations? An ESCMID international cross-sectional survey.
Macheda G, Macheda G, Dyar OJ, Luc A, Beovic B, Béraud G, Castan B, Gauzit R, Lesprit P, Tattevin P, Thilly N, Pulcini C; ESGAP and SPILF. | J Antimicrob Chemother. 2018 Apr 1;73(4):1084-1090
Keywords: Aucun


Introduction : To evaluate the current practice and the willingness to shorten the duration of antibiotic therapy among infection specialists.

Méthode : Infection specialists giving at least weekly advice on antibiotic prescriptions were invited to participate in an online cross-sectional survey between September and December 2016. The questionnaire included 15 clinical vignettes corresponding to common clinical cases with favourable outcomes; part A asked about the antibiotic treatment duration they would usually advise to prescribers and part B asked about the shortest duration they were willing to recommend.

Résultats : We included 866 participants, mostly clinical microbiologists (22.8%, 197/863) or infectious diseases specialists (58.7%, 507/863), members of an antibiotic stewardship team in 73% (624/854) of the cases, coming from 58 countries on all continents. Thirty-six percent of participants (271/749) already advised short durations of antibiotic therapy (compared with the literature) to prescribers for more than half of the vignettes and 47% (312/662) chose shorter durations in part B compared with part A for more than half of the vignettes. Twenty-two percent (192/861) of the participants declared that their regional/national guidelines expressed durations of antibiotic therapy for a specific clinical situation as a fixed duration as opposed to a range and in the multivariable analysis this was associated with respondents advising short durations for more than half of the vignettes (adjusted OR 1.5, P = 0.02).

Conclusion : The majority of infection specialists currently do not advise the shortest possible duration of antibiotic therapy to prescribers. Promoting short durations among these experts is urgently needed.

Conclusion (proposition de traduction) : Actuellement, la majorité des infectiologues ne conseillent pas aux prescripteurs la durée la plus courte possible d'antibiothérapie.
La promotion de courtes durées parmi ces experts est urgente.

Journal of Critical Care

Noninvasive ventilation failure in pneumonia patients ≥65years old: The role of cough strength.
Hong Y, Duan J, Bai L, Han X, Huang S, Guo S. | J Crit Care. 2018 Apr;44:149-153
Keywords: Cough strength; Noninvasive ventilation; Pneumonia

Original research article

Introduction : To explore the association between cough strength and outcomes in elderly patients who received noninvasive ventilation (NIV) due to acute respiratory failure caused by pneumonia.

Méthode : We enrolled patients ≥65years old with acute respiratory failure caused by pneumonia. Just before NIV treatment, cough strength was assessed on a cough-strength scale graded from 0 to 5. Patients graded 0-2 were defined as having no/weak coughs and those graded 3-5 were defined as having moderate/strong coughs.

Résultats : We enrolled 349 patients in this study. The prevalence of no/weak cough was 24% (84/349). Moderate/strong cough patients had lower NIV failure (92/265 [34.7%] vs. 67/84 [79.8%], p<0.01) and lower hospital mortality (85/265 [32.1%] vs. 60/84 [71.4%], p<0.01) than no/weak cough patients. In multivariate logistic regression analysis, we also found that no/weak cough was an independent risk factor for NIV failure (odds ratio=13.83, 95% confidence interval: 6.01-31.81) and death in hospital (odds ratio=4.41, 95% confidence interval: 2.49-7.81).

Conclusion : In pneumonia patients ≥65years old, no/weak cough is associated with NIV failure and death in hospital. NIV must be used only with caution in no/weak cough patients.

Conclusion (proposition de traduction) : Che les patients ≥ 65 ans présentant une pneumonie, la présence d'une toux faible ou absente est associé à l'échec de la VNI et au risque de décès à l'hôpital. La VNI doit être utilisé seulement avec la prudence chez les patients qui présentent une toux faible ou absente.

A modified Montpellier protocol for intubating intensive care unit patients is associated with an increase in first-pass intubation success and fewer complications.
Corl KA, Dado C, Agarwal A, Azab N, Amass T, Marks SJ, Levy MM, Merchant RC, Aliotta J. | J Crit Care. 2018 Apr;44:191-195
Keywords: First-pass success; Intensive care unit; Intubation; Intubation complications; Montpellier protocol

Original research article

Introduction : The Montpellier protocol for intubating patients in the intensive care unit (ICU) is associated with a decrease in intubation-related complications. We sought to determine if implementation of a simplified version of the Montpellier protocol that removed selected components and allowed for a variety of pre-oxygenation modalities increased first-pass intubation success and reduced intubation-related complications.

Méthode : A prospective pre/post-comparison of a modified Montpellier protocol in two medical and one medical/surgical/cardiac ICU within a hospital system. The modified eight-point protocol included: fluid administration, ordering sedation, two intubation trained providers, pre-oxygenation with non-invasive positive pressure ventilation, nasal high flow cannula or non-rebreather mask, rapid sequence intubation, capnography, sedation administration, and vasopressors for shock.

Résultats : Patient characteristics and indications for intubation were similar for the 275 intubations in the control (137) and intervention (138) periods. In the intervention vs. control periods, the modified Montpellier protocol was associated with a significant 16.2% [95% CI: 5.1-30.0%] increase in first-pass intubation success and a 12.6% [95% CI: 1.2-23.6%] reduction in all intubation-related complications.

Conclusion : A simplified version of the Montpellier intubation protocol for intubating ICU patients was associated with an improvement in first-pass intubation success rates and a reduction in the rate of intubation-related complications.

Conclusion (proposition de traduction) : La version simplifiée du protocole de Montpellier pour l'intubation en USI a été associée à une amélioration du succès de la première tentative d'intubation et à une réduction du taux de complications liées à l'intubation.

Commentaire : Voir l'article de De Jong A and al. en 2014 dans Crit Care. 2014; 18(2): 209  

Measurement of respiratory rate by multiple raters in a clinical setting is unreliable: A cross-sectional simulation study.
Brabrand M, Hallas P, Folkestad L, Lautrup-Larsen CH, Brodersen JB. | J Crit Care. 2018 Apr;44:404-406
Keywords: Aucun

Original research article

Introduction : To evaluate the inter-observer reliability of nurses assessing respiratory rate.

Méthode : We presented seven minimum 60-seconds long videos of thoraces of non-identifiable patients breathing to experienced nurses from several Danish emergency departments. Two videos were assessed by 50 raters while five were reviewed by eight. The videos were shown using an online system that also recorded the counted respiratory rate.

Résultats : A total of 140 nurses participated with a median of 15years' experience. The range of counted respiratory rate was minimum 10 on each video. For videos evaluated by eight nurses, average Inter Class Coefficient (ICC) was 0.662 (0.000-0.960) and individual ICC 0.197 (0.000-0.750). For the two case-videos analyzed by 50 nurses, average ICC was 0.0 (0.000-0.991) and individual ICC 0.0 (0.000-0.677).

Conclusion : We found a wide variation in measurements of RR with both few and many observers assessing exactly the same patients.

Conclusion (proposition de traduction) : Nous avons trouvé d'importantes variations dans les mesures de la fréquence respiratoire tant avec peu qu'avec beaucoup d'opérateurs évaluant exactement les mêmes patients.

The impact of sustained new-onset atrial fibrillation on mortality and stroke incidence in critically ill patients: A retrospective cohort study.
Yoshida T, Uchino S, Yokota T, Fujii T, Uezono S, Takinami M. | J Crit Care. 2018 Apr;44:267-272
Keywords: AF at 6h after onset; AF duration; Critically ill patients; Poor outcomes; Sustained new-onset AF

Original research article

Introduction : The purpose of the study is to evaluate the impact of sustained new-onset AF on mortality and the incidence of stroke in critically ill non-cardiac surgery patients.

Méthode : This was a retrospective cohort study of non-cardiac surgery patients with new-onset AF conducted in a general intensive care unit. We compared patients remaining in AF with those restored to sinus rhythm (SR) at 6h after the onset of AF and conducted multivariable logistic regression analysis for in-hospital mortality. We also examined the impact of the cumulative time of AF duration in the first 48h on hospital outcomes.

Résultats : New-onset AF occurred in 151 of 1718 patients (9%). Patients with sustained AF after 6h (34% of 151 patients included) experienced greater in-hospital mortality than patients with SR at 6h (37% vs. 20%, p=0.033). Multivariable logistic regression analysis confirmed the association between AF at 6h and in-hospital mortality (adjusted odds ratio, 3.14; 95% confidence intervals, 1.28-7.69; p=0.012). Patients with longer AF duration had greater in-hospital mortality (p=0.043) and in-hospital ischemic stroke incidence (p=0.041).

Conclusion : Sustained new-onset AF is associated with poor outcomes.

Conclusion (proposition de traduction) : Une FA d'apparition nouvelle soutenue est associée à de mauvais résultats.

Predictive accuracy of medical transport information for in-hospital mortality.
Reimer AP, Dalton JE. | J Crit Care. 2018 Apr;44:238-242
Keywords: Aucun

Original research article

Editorial : Interhospital transfer patients present several challenges when attempting to include and analyze data to either refine current risk prediction models, or build a clinical decision support system capable of using real-time data.

Conclusion : We found that common transport variables did not in isolation, or in combination with APACHE-IV variables add to predictive accuracy of transferred patients post-transport mortality. Future work should focus on the pre-transfer hospitalization and identifying factors that predict which patients require earlier transfer to higher levels of care.

Conclusion (proposition de traduction) : Nous avons constaté que les variables de transport communes n'ont pas fait dans l'isolement, ou dans la combinaison avec les variables APACHES-IV ajoutent à l'exactitude prophétique de mortalité de post-transport de patients transférée. Le travail futur devrait se concentrer sur l'hospitalisation de pré-transfert et les facteurs s'identifiant qui prédisent quels patients exigent le plus premier transfert aux niveaux supérieurs de soin.

La Revue Sage-Femme

El Ayoubi F, Comte F. | La Revue Sage-Femme. 2018 April;17(2):54-62
Keywords: Vegetarian diets; Vegan diets; Pregnancy; Lactation; Consequences; Nutritional deficiencies


Introduction : Identifier les conséquences des régimes végétariens et végétaliens pendant la grossesse et la lactation, sur la femme enceinte, le fœtus, le nouveau-né et le nourrisson. Répertorier les carences alimentaires provoquées par ces différents régimes pendant la grossesse et la lactation.

Méthode : Recherche bibliographique entre 1981 et 2015 sur les bases de données Pubmed et Cochrane Library et recherche de proche en proche à partir de la bibliographie des articles.

Résultats : La carence alimentaire la plus fréquemment identifiée pendant la grossesse et la lactation chez les femmes végétariennes et végétaliennes est la carence en vitamine B12, sachant qu’il existe également d’autres carences potentielles : carences en zinc, fer, calcium et protéines. Ces différentes carences ont de nombreuses et importantes conséquences maternelles, fœtales, néonatales et infantiles, notamment anémies, retards de croissance intra-utérins, altérations de la croissance staturo-pondérale, troubles neurologiques, retards mentaux à long-terme, etc.

Conclusion : Given the serious consequences of these regimens during pregnancy and lactation on maternal, fetal, neonatal and infant health, it would seem advisable to set up an early and systematic detection of these dietary practices from the first months of pregnancy and on the other hand a supplementation adapted to the various potential deficiencies. In this respect, the role of the midwife is important because of its proximity to pregnant women, nursing mothers and newborns.

Conclusion (proposition de traduction) : Étant donné la gravité des conséquences que peuvent entraîner ces régimes pendant la grossesse et la lactation sur la santé maternelle, fœtale, néonatale et infantile, il semblerait judicieux de mettre en place, d’une part, un dépistage précoce et systématique de ces pratiques alimentaires dès les premiers mois de la grossesse et, d’autre part, une supplémentation adaptée aux différentes carences potentielles. À cet égard, le rôle de la sage-femme est important du fait de sa proximité avec les femmes enceintes, les femmes allaitantes et les nouveau-nés.

de Souza A, Minebois H, Luc A, Choserot M, Bertholdt C, Morel O, Callec R. | La Revue Sage-Femme. 2018 April;17(2):78-86
Keywords: Stained-amniotic fluid; Neonatal acidosis; Abnormal fetal heart

Travail original

Introduction : Déterminer si la présence d’un liquide amniotique (LA) teinté ou méconial est corrélée à un risque accru d’acidose métabolique néonatale sévère.

Méthode : Dans une étude rétrospective de type cas-témoin réalisée dans une maternité de type 3 du 1er janvier au 31 décembre 2014, toutes les patientes ayant accouché à un terme ≥ 37SA d’un fœtus singleton eutrophe en présentation céphalique et pour lesquelles un LA teinté ou méconial a été mis en évidence ont été incluses. Les caractéristiques maternelles, les complications obstétricales et néonatales ont été comparées en fonction de la couleur du LA.

Résultats : Au total, 302 patientes dans le groupe LA « anormal » (198 « LA méconial » et 104 « LA teinté ») vs. 302 patientes dans le groupe LA clair ont été incluses. Aucune différence significative sur le taux d’acidose néonatale sévère entre les 2 groupes n’a été retrouvée. La fréquence des anomalies du rythme cardiaque fœtal était augmentée en cas de LA méconial (11,3 % vs. 31,7 %, p < 0,0001). Le critère composite associant pH artériel ombilical < 7,0 ± excès de bases ≥ 12 mmol/L ± score d’Apgar à 5 min < 7, était plus fréquent en cas de LA méconial (4,0 % vs. 12,5 %, p = 0,0018).

Conclusion : The occurrence of severe neonatal metabolic acidosis was not more frequent in case of stained or meconial amniotic fluid, but with an increase in the use of fetal scalp pH and cesaerian deliveries when the fluid was meconial.

Conclusion (proposition de traduction) : La survenue d’une acidose métabolique néonatale sévère n’était pas plus fréquente en cas de mise en évidence d’un liquide amniotique teinté ou méconial, au prix d’une majoration du recours au pH au scalp et à la césarienne lorsque le liquide était méconial.


Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis.
Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ, Neary JD, Alhazzani W. | Lancet. 2018 Apr 28;391(10131):1693-1705
Keywords: Aucun


Introduction : Supplemental oxygen is often administered liberally to acutely ill adults, but the credibility of the evidence for this practice is unclear. We systematically reviewed the efficacy and safety of liberal versus conservative oxygen therapy in acutely ill adults.

Méthode : In the Improving Oxygen Therapy in Acute-illness (IOTA) systematic review and meta-analysis, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, HealthSTAR, LILACS, PapersFirst, and the WHO International Clinical Trials Registry from inception to Oct 25, 2017, for randomised controlled trials comparing liberal and conservative oxygen therapy in acutely ill adults (aged ≥18 years). Studies limited to patients with chronic respiratory diseases or psychiatric disease, patients on extracorporeal life support, or patients treated with hyperbaric oxygen therapy or elective surgery were excluded. We screened studies and extracted summary estimates independently and in duplicate. We also extracted individual patient-level data from survival curves. The main outcomes were mortality (in-hospital, at 30 days, and at longest follow-up) and morbidity (disability at longest follow-up, risk of hospital-acquired pneumonia, any hospital-acquired infection, and length of hospital stay) assessed by random-effects meta-analyses. We assessed quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO, number CRD42017065697.

Résultats : 25 randomised controlled trials enrolled 16 037 patients with sepsis, critical illness, stroke, trauma, myocardial infarction, or cardiac arrest, and patients who had emergency surgery. Compared with a conservative oxygen strategy, a liberal oxygen strategy (median baseline saturation of peripheral oxygen [SpO2] across trials, 96% [range 94-99%, IQR 96-98]) increased mortality in-hospital (relative risk [RR] 1·21, 95% CI 1·03-1·43, I2=0%, high quality), at 30 days (RR 1·14, 95% CI 1·01-1·29, I2=0%, high quality), and at longest follow-up (RR 1·10, 95% CI 1·00-1·20, I2=0%, high quality). Morbidity outcomes were similar between groups. Findings were robust to trial sequential, subgroup, and sensitivity analyses.

Conclusion : In acutely ill adults, high-quality evidence shows that liberal oxygen therapy increases mortality without improving other patient-important outcomes. Supplemental oxygen might become unfavourable above an SpO2 range of 94-96%. These results support the conservative administration of oxygen therapy.

Conclusion (proposition de traduction) : Chez les adultes de soins intensifs, des données probantes de haute qualité montrent que la stratégie d'oxygénothérapie libérale augmente la mortalité sans améliorer les autres résultats importants pour les patients. L'oxygène supplémentaire pourrait devenir défavorable au-dessus d'une plage de SpO2 de 94-96 %. Ces résultats sont en faveur la stratégie d'administration conservatrice de l'oxygéne.

Commentaire : Retrouvez l'analyse de la SRLF de l'article de Panwar R and al. : Conservative versus Liberal Oxygenation Targets for Mechanically Ventilated Patients. A Pilot Multicenter Randomized Controlled Trial. Am J Respir Crit Care Med. 2016 Jan 1; 193(1):43-5. (  .

Médecine & Droit

Hamelin PL, Arzalier JJ. | Médecine & Droit. 2018 April;2018(149):39-46
Keywords: Aucun

Exercice professionnel

Introduction : Les demandes de soins non programmés sans caractère urgent et relevant de la permanence des soins ambulatoire (PDSA) sont régulées par un médecin régulateur chargé d’identifier la demande et d’orienter le patient. Nous nous sommes attachés à rechercher les facteurs de risques de contentieux en régulation médicale de la PDSA par l’analyse des plaintes et des lettres de réclamation.

Méthode : Nous avons inclus les affaires relevant de la PDSA au SAMU du Var qui ont été suivies d’une plainte ou d’une réclamation entre le 1er janvier 2004 et le 31 décembre 2010. Nous avons analysé les dossiers de régulation médicale, les enregistrements téléphoniques, les lettres de réclamation, les rapports d’expertise et les jugements.

Résultats : Sur les 342 400 affaires traitées par les régulateurs de la PDSA, dix-huit ont fait l’objet d’une demande d’explication et dix d’une plainte ou d’une demande indemnitaire. En proportion, les réclamations et les plaintes touchent principalement les affaires gérées en nuit profonde. L’activité en régulation par elle-même ne constitue donc pas un facteur important de contentieux. Par contre, les trois affaires marquées par un désaccord de l’appelant vis-à-vis de la décision médicale se sont soldées par le décès du patient. La non-adhésion du requérant à la décision doit amener le régulateur à réévaluer la gravité de la situation. Les propos tenus par le médecin doivent rester empathiques à défaut de quoi il risque de se les voir reprocher par l’expert ou le juge.

Conclusion : The prevention of fatigue is important. The malfunctions of the medical regulation center must be declared by staff to prevent and anticipate litigations. Moreover, that should help to improve procedures and individual practices. Finally, we enhanced the involvement of the managers during legal procedures in order to explain to the judge the specific difficulties of medical regulation.

Conclusion (proposition de traduction) : La prise en compte du facteur humain et de la fatigue en régulation est essentielle. Le signalement interne des dysfonctionnements liés à la régulation permettrait l’anticipation et la prévention des contentieux et servirait de base aux revues de morbi-mortalité et aux actions de formation continue. L’implication personnelle du responsable de service lors des phases d’instruction ou de jugement est utile afin de faire comprendre les difficultés spécifiques de la régulation.

Emergency contraception.
Taboulet F | Médecine & Droit. 2018 April;2018(149):31-38
Keywords: Aucun

Droit et médicament

Editorial : Avoiding the use of abortion by minors is the aim that has been pursued since 2000 through the facilitated access of young girls to emergency contraception : breaking numerous rules relative to health security and to Social Security, the dispensation is done anonymously and free of charge. However, the analysis shows that the three postulates from which this policy was built – satisfactory benefit/risk ratio of emergency contraception, safety of repeated medication and real efficiency to reduce numbers of unwanted pregnancies and abortion – are not validated. In addition, there are some indications that this policy is not devoid of adverse effects.

Conclusion (proposition de traduction) : L’objectif d’éviter le recours des mineures à l’IVG est poursuivi depuis l’an 2000 par la mise en place d’un accès facilité des jeunes filles aux médicaments de contraception d’urgence (MCU) : dérogeant aux règles usuelles de sécurité sanitaire et de sécurité sociale, la dispensation est réalisée à titre anonyme et gratuit. Or, l’analyse montre que les trois postulats à partir desquels cette politique s’est construite – rapport bénéfice/risque des MCU satisfaisant, innocuité des prises à répétition, c’est-à-dire hors AMM, et réelle efficacité à réduire les nombres de grossesses non désirées et d’IVG – ne sont pas validés, et qu’en outre, le dispositif ne serait pas dénué d’effets pervers.

Pediatric Emergency Care

The Use of a Triage-Based Protocol for Oral Rehydration in a Pediatric Emergency Department.
Hendrickson MA, Zaremba J, Wey AR, Gaillard PR, Kharbanda AB. | Pediatr Emerg Care. 2018 Apr;34(4):227-232
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original Articles

Introduction : Guidelines recommend oral rehydration therapy (ORT) and avoidance of laboratory tests and intravenous fluids for mild to moderate dehydration in children with gastroenteritis; oral ondansetron has been shown to be an effective adjunct.
OBJECTIVES: The aim of this study was to determine if a triage-based, nurse-initiated protocol for early provision of ondansetron and ORT could safely improve the care of pediatric emergency department (ED) patients with symptoms of gastroenteritis.

Méthode : This study evaluated a protocol prompting triage nurses to assess dehydration in gastroenteritis patients and initiate ondansetron and ORT if indicated. Otherwise well patients aged 6 months to 5 years with symptoms of gastroenteritis were eligible. Prospective postintervention data were compared with retrospective, preintervention control subjects.

Résultats : One hundred twenty-eight (81 postintervention and 47 preintervention) patients were analyzed; average age was 2.1 years. Ondansetron use increased from 36% to 75% (P < 0.001). Time to ondansetron decreased from 60 minutes to 30 minutes (P = 0.004). Documented ORT increased from 51% to 100% (P < 0.001). Blood testing decreased from 37% to 21% (P = 0.007); intravenous fluid decreased from 23% to 9% (P = 0.03). Fifty-two percent of postintervention patients were discharged with prescriptions for ondansetron. There were no significant changes in ED length of stay, admissions, or unscheduled return to care.

Conclusion : A triage nurse-initiated protocol for early use of oral ondansetron and ORT in children with evidence of gastroenteritis is associated with increased and earlier use of ondansetron and ORT and decreased use of IV fluids and blood testing without lengthening ED stays or increasing rates of admission or unscheduled return to care.

Conclusion (proposition de traduction) : Un protocole de triage initié par l'infirmière pour l'utilisation précoce de l'ondansétron oral et du SRO chez les enfants présentant des signes de gastro-entérite est associé à une utilisation accrue et plus précoce de l'ondansétron et du SRO et à une utilisation réduite des liquides IV et des analyses sanguines sans allonger les séjours aux urgences ou augmenter les taux d'admission ou de retour non programmé aux soins.

Auricular Acupuncture for the Treatment of Pediatric Migraines in the Emergency Department.
Graff DM, McDonald MJ. | Pediatr Emerg Care. 2018 Apr;34(4):258-262
Keywords: Aucun

Original Articles

Introduction : Headache remains a frequent complaint for children presenting to a pediatric emergency department (ED). Typical treatments include oral or intravenous medications, but do not always relieve pain. An alternative intervention is auricular acupuncture. It has been shown to be effective in the treatment of migraines in adults. The objective of this study was to evaluate the utility and adverse effects of auricular acupuncture in the treatment of pediatric migraines in the ED.

Méthode : This was a prospective, interventional, cohort study of patients 8 to 18 years of age. Efficacious ear points were located by needle contact or electrical point finder with attention to 2 migraine lines on the ear. ASP gold semipermanent ear needles were placed in the efficacious points and patients were monitored for 15 minutes. The primary outcome was the change in preintervention and postintervention pain scores using a numerical self-reported pain visual analog scale (VAS).

Résultats : Nineteen patients elected to enroll in the study. The mean change in the VAS scores was both clinically and statistically significant at 7.03 (interquartile range, 6-8.5) with a P value of less than 0.001. Two patients elected to withdraw from the study secondary to incomplete resolution of migraine pain despite improvement in VAS scores. There were no known adverse events.

Conclusion : With all subjects showing improvement or resolution of migraine headache, this pilot study introduces an alternative intervention to pediatric migraine management. Further studies are needed to evaluate the duration of symptom resolution and comparative effectiveness; auricular acupuncture seems to be a valid alternative.

Conclusion (proposition de traduction) : Avec toutes les études montrant une amélioration ou une résolution des céphalées migraineuses, cette étude pilote introduit une intervention alternative à la prise en charge pédiatrique de la migraine. D'autres études sont nécessaires pour évaluer la durée de la résolution des symptômes et l'efficacité comparative ; l'acupuncture auriculaire semble être une alternative valable.

Prehospital Management of Pediatric Hanging.
Rehn M, Davies G, Foster E, Lockey DJ. | Pediatr Emerg Care. 2018 Apr;34(4):263-266
Keywords: Aucun

Original articles

Introduction : Hanging may inflict laryngotracheal injuries and increase the potential for difficult airway management. We describe the management of pediatric hangings attended by an urban physician-led prehospital trauma service to provide information on a clinical situation encountered infrequently by most acute care clinicians.

Méthode : Retrospective trauma registry-based observational study of all children younger than 16 years attended with hanging as mechanism of injury in the period between 2000 and 2014.

Résultats : Twenty-three thousand one hundred thirty patients were attended; 2415 (10%) of which were children. Of these, 32 cases (<1%) were pediatric hanging (1 case excluded due to missing data). There were 22 (71%) boys and 9 (29%) girls. Median age was 13 years. There was suicidal intent in 23 (74%) cases, and in 8 (26%) cases, hanging was accidental. There were 17 (55%) deaths, of which 14 (82%) were suicides.The doctor-paramedic team intubated 25 (80%) patients, with a 100% success rate. One (3%) patient was managed with a supraglottic airway device, and 5 (16%) patients did not require any advanced airway management.

Conclusion : Pediatric hanging is rare, but has a high mortality rate. Attempted suicide is the leading cause of hangings in children and preventive measures should target psychiatric morbidity. Despite concerns about airway edema or laryngeal injury, experienced doctor-paramedic teams had no failed airway attempts.

Conclusion (proposition de traduction) : La pendaison en pédiatrie est rare, mais le taux de mortalité est élevé. La tentative de suicide est la principale cause de pendaison chez les enfants et les mesures préventives devraient cibler la morbidité psychiatrique. Malgré les préoccupations au sujet de l'œdème des voies respiratoires ou des lésions laryngées, les équipes expérimentées de médecins et d'ambulanciers paramédicaux n'ont pas échoué dans leurs tentatives de prise en charge des voies respiratoires.

Outcomes After Pediatric Out-of-Hospital Cardiopulmonary Interventions.
Lo JY, Tani LY, Christensen M, Sheng X, Clawson J, Menon SC. | Pediatr Emerg Care. 2018 Apr;34(4):267-272
Keywords: Aucun

Original articles

Introduction : The aim of the study was to evaluate outcomes after pediatric out-of-hospital cardiopulmonary interventions (CPIs) by emergency medical services (EMS).

Méthode : Children (age, ≤18 years) who received CPI by EMS from 2001 to 2008 were identified from the Utah Department of Health. Cardiopulmonary intervention was defined as oxygenation, ventilation or CPR, and transport to a hospital by EMS. Univariate and multivariable regression analyses evaluated associations between potential predictors and outcomes (death and new neurologic dysfunction).

Résultats : A total of 464 patients (58% male) received EMS attention. For the 71% patients (327) who were alive on EMS arrival, 63% (205) received CPI without CPR. Of note, 6% (12) of these patients died after arrival to the hospital and new neurologic dysfunction was diagnosed in 6% (13). Among the 12 patients who died, 50% (6) were younger than 1 year.On multivariable regression analysis, factors associated with increased risk of death before and in-hospital are the following: age younger than 1 year (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.17-0.39), shorter EMS transport time (OR, 0.94; 95% CI, 0.89-0.99), and longer EMS dispatch time (OR, 1.23; 95% CI, 1.08-1.40). Factors associated with increased risk of new neurologic dysfunction are the following: lack of pulse (OR, 0.14; 95% CI, 0.04-0.53), requiring CPR (OR, 6.15; 95% CI, 1.48-25.6), and CPR duration (OR, 1.20; 95% CI, 1.05-1.37).

Conclusion : Age younger than 1 year, shorter transport time, and longer dispatch time were associated with increased risk of death. Being pulseless upon discovery and receiving CPR were associated with new neurologic dysfunction. Maximizing EMS transport interventions for patients younger than 1 year requiring CPI may improve patient outcomes.

Conclusion (proposition de traduction) : L'âge inférieur à un an, le temps de transport plus court et le délai de transfert plus long étaient associés à un risque accru de décès. Le fait d'être sans pouls au moment de la découverte et de recevoir une RCP était associé à un nouveau dysfonctionnement neurologique.
Maximiser les interventions de transport des intervenants pré-hospitaliers pour les enfants de moins d'un an nécessitant une réanimation cardio-pulmonaire peut améliorer le devenir des patients.

Prehospital and Disaster Medicine

Arrêtez le saignement : L'effet de l'éducation sur le contrôle des hémorragies sur la volonté des profanes d'intervenir lors d'une urgence médicale traumatique.
Ross EM, Redman TT, Mapp JG, Brown DJ, Tanaka K, Cooley CW, Kharod CU, Wampler DA. | Prehosp Disaster Med. 2018 Apr;33(2):127-132
Keywords: CAT Combat Action Tourniquet; CPR cardiopulmonary resuscitation; RMT Ratcheting Medical Tourniquet; SWAT-T Stretch Wrap and Tuck Tourniquet; hemorrhage control training; stop the bleed; tourniquet training

Original Research

Introduction : The "Stop the Bleed" campaign advocates for non-medical personnel to be trained in basic hemorrhage control. However, it is not clear what type of education or the duration of instruction needed to meet that requirement. The objective of this study was to determine the impact of a brief hemorrhage control educational curriculum on the willingness of laypersons to respond during a traumatic emergency.

Méthode : This "Stop the Bleed" education initiative was conducted by the University of Texas Health San Antonio Office of the Medical Director (San Antonio, Texas USA) between September 2016 and March 2017. Individuals with formal medical certification were excluded from this analysis. Trainers used a pre-event questionnaire to assess participants knowledge and attitudes about tourniquets and responding to traumatic emergencies. Each training course included an individual evaluation of tourniquet placement, 20 minutes of didactic instruction on hemorrhage control techniques, and hands-on instruction with tourniquet application on both adult and child mannequins. The primary outcome in this study was the willingness to use a tourniquet in response to a traumatic medical emergency.

Résultats : Of 236 participants, 218 met the eligibility criteria. When initially asked if they would use a tourniquet in real life, 64.2% (140/218) responded "Yes." Following training, 95.6% (194/203) of participants responded that they would use a tourniquet in real life. When participants were asked about their comfort level with using a tourniquet in real life, there was a statistically significant improvement between their initial response and their response post training (2.5 versus 4.0, based on 5-point Likert scale; P<.001).

Conclusion : In this hemorrhage control education study, it was found that a short educational intervention can improve laypersons' self-efficacy and reported willingness to use a tourniquet in an emergency. Identified barriers to act should be addressed when designing future hemorrhage control public health education campaigns. Community education should continue to be a priority of the "Stop the Bleed" campaign.

Conclusion (proposition de traduction) : Dans cette étude sur l'éducation sur le contrôle des hémorragies, on a constaté qu'une intervention éducative de courte durée peut améliorer l'auto-efficacité des profanes et leur volonté d'utiliser un garrot en cas d'urgence. Les obstacles à l'action identifiés devraient être abordés lors de la conception de futures campagnes d'éducation en santé publique sur le contrôle des hémorragies. L'éducation communautaire doit rester une priorité de la campagne « Stop the Bleed ».

Is Distance to the Nearest Registered Public Automated Defibrillator Associated with the Probability of Bystander Shock for Victims of Out-of-Hospital Cardiac Arrest?.
Neves Briard J, de Montigny L, Ross D, de Champlain F, Segal E. | Prehosp Disaster Med. 2018 Apr;33(2):153-159
Keywords: AED automated external defibrillator; CPR cardiopulmonary resuscitation; EMS Emergency Medical Services; OHCA out-of-hospital cardiac arrest; PAED public automated external defibrillator; ROSC return of spontaneous circulation; automated external defibrillator; out-of-hospital cardiac arrest; public access defibrillation

Original Research

Introduction : Introduction Rapid access to defibrillation is a key element in the management of out-of-hospital cardiac arrests (OHCAs). Public automated external defibrillators (PAEDs) are becoming increasingly available, but little information exists regarding the relation between the proximity to the arrest and their usage in urban areas.

Méthode : This study is a retrospective, observational, cross-sectional analysis of non-traumatic OHCA during a 24-month period in the greater Montreal area (Quebec, Canada). Using logistic regression, bystander shock odds are described with regards to distance from the OHCA scene to the nearest PAED, adjusted for prehospital care arrival delay and time of day, and stratifying for type of location.

Résultats : Out of a total of 2,443 OHCA victims identified, 77 (3%) received bystander PAED shock, 622 (26%) occurred out-of-home, and 743 (30%) occurred during business hours. When controlling for time (business hours versus other hours) and minimum response delay for prehospital care arrival, a marginal negative association was found between bystander shock and distance to the nearest PAED in logged meters (aOR=0.80; CI, 0.64-0.99) for out-of-home cardiac arrests. No significant association was found between distance and bystander shock for at-home arrests. Out-of-home victims had significantly higher odds of receiving bystander shock up to 175 meters of distance to a PAED inclusively (aOR=2.52; CI, 1.07-5.89).

Conclusion : For out-of-home cardiac arrests, proximity to a PAED was associated with bystander shock in the greater Montreal area. Strategies aiming to increase accessibility and use of these life-saving devices could further expand this advantage by assisting bystanders in rapidly locating nearby PAEDs.

Conclusion (proposition de traduction) : Pour les arrêts cardiaques hors du domicile, la proximité d'un défibrillateur public externe automatisé a été associée à un choc par les témoins dans la grande région de Montréal. Les stratégies visant à accroître l'accessibilité et l'utilisation de ces dispositifs de sauvetage pourraient accroître cet avantage en aidant les témoins à localiser rapidement les défibrillateurs externes automatisés publics à proximité.

The Association between Cardiopulmonary Resuscitation in Out-of-Hospital Settings and Chest Injuries: A Retrospective Observational Study.
Takayama W, Koguchi H, Endo A, Otomo Y. | Prehosp Disaster Med. 2018 Apr;33(2):171-175
Keywords: AHA American Heart Association; CPR cardiopulmonary resuscitation; CT computed tomography; ECC Emergency Cardiovascular Care; OHCA out-of-hospital cardiac arrest; ROSC return of spontaneous circulation; cardiopulmonary resuscitation; chest compressions; chest injury; out-of-hospital cardiac arrest

Original Research

Introduction : The aim of this study was to assess the risk of cardiopulmonary resuscitation (CPR) performed in out-of-hospital settings for chest injuries in patients with out-of-hospital cardiac arrest (OHCA).

Méthode : This retrospective, observational study was conducted in an emergency critical care medical center in Japan. Non-traumatic OHCA patients transferred to the hospital from April 2013 through August 2016 were analyzed. The outcome was defined by chest injuries related to CPR, which is composite of rib fractures, sternal fractures, and pneumothoraces. A multivariate logistic regression analysis was performed to assess the independent risk factors for chest injuries related to CPR. The threshold of out-of-hospital CPR duration that increased risk of chest injuries was also assessed.

Résultats : A total of 472 patients were identified, of whom 233 patients sustained chest injuries. The multivariate logistic regression model showed that the independent risk factors for chest injuries were age and out-of-hospital CPR duration (age: AOR=1.06 [95% CI, 1.04 to 1.07]; out-of-hospital CPR duration: AOR=1.03 [95% CI, 1.01 to 1.05]). In-hospital CPR duration was not an independent risk factor for chest injuries. When the duration of out-of-hospital CPR extended over 15 minutes, the likelihood of chest injuries increased; however, this association was not statistically significant.

Conclusion : Long duration of out-of-hospital CPR was an independent risk factor for chest injuries, possibly due to the difficulty of maintaining adequate quality of CPR. Further investigations to assess the efficacy of alternative CPR devices are expected in cases requiring long transportation times.

Conclusion (proposition de traduction) : Une RCP de longue durée en extra-hospitalier était un facteur de risque indépendant pour les blessures du thorax, peut-être en raison de la difficulté à maintenir une qualité adéquate de la RCP. D'autres études visant à évaluer l'efficacité d'autres appareils de RCP sont prévues dans les cas nécessitant de longs délais de transport.

Prehospital Emergency Care

Prehospital End-tidal Carbon Dioxide Predicts Mortality in Trauma Patients.
Childress K, Arnold K, Hunter C, Ralls G, Papa L, Silvestri S. | Prehosp Emerg Care. 2018 Mar-Apr;22(2):170-174
Keywords: capnography; end-tidal carbon dioxide; prehospital; trauma; vital signs


Introduction : End-tidal carbon dioxide (EtCO2) measurement has been shown to have prognostic value in acute trauma.
OBJECTIVE: Evaluate the association of prehospital EtCO2 and in-hospital mortality in trauma patients and to assess its prognostic value when compared to traditional vital signs.

Méthode : Retrospective, cross-sectional study of patients transported by a single EMS agency to a level one trauma center. We evaluated initial out-of-hospital vital signs documented by EMS personnel including EtCO2, respiratory rate (RR), systolic BP (SBP), diastolic BP (DBP), pulse (P), and oxygen saturation (O2) and hospital data. The main outcome measure was mortality.

Résultats : 135 trauma patients were included; 9 (7%) did not survive. The mean age of patients was 40 (SD17) [Range 16-89], 97 (72%) were male, 76 (56%) were admitted to the hospital and 15 (11%) went to the ICU. The mean EtCO2 level was 18 mmHg (95%CI 9-28) [Range 5-41] in non-survivors compared to 34 mmHg (95%CI 32-35) [Range 11-51] in survivors. The area under the ROC curve (AUC) for EtCO2 in predicting mortality was 0.84 (0.67-1.00) (p = 0.001), RR was 0.82 (0.63-1.00), SBP was 0.72 (0.49-0.96), DBP was 0.72 (0.47-0.97), pulse was 0.51 (0.26-0.76), and O2 was 0.64 (0.37-0.91). Cut-off values at 30 mmHg yielded sensitivity = 89% (51-99), specificity = 68% (59-76), PPV = 13% (6-24) and NPV = 99% (93-100) for predicting mortality. There was no correlation between RR and EtCO2 (correlation 0.16; p = 0.06).

Conclusion : We found an inverse association between prehospital EtCO2 and mortality. This has implications for improving triage and assisting EMS in directing patients to an appropriate trauma center.

Conclusion (proposition de traduction) : Nous avons trouvé une association inverse entre EtCO2 préhospitalier et la mortalité. Cela a des répercussions sur l'amélioration du triage et sur l'aide aux SMU pour diriger les patients vers un centre de traumatologie approprié.

Prehospital Pain Management: Disparity By Age and Race.
Hewes HA, Dai M, Mann NC, Baca T, Taillac P. | Prehosp Emerg Care. 2018 Mar-Apr;22(2):189-197
Keywords: Pain; pain assessment; pediatrics; race


Introduction : Historically, pain management in the prehospital setting, specifically pediatric pain management, has been inadequate despite many EMS (emergency medical services) transports related to traumatic injury with pain noted as a symptom. The National Emergency Services Information System (NEMSIS) database offers the largest national repository of prehospital data, and can be used to assess current patterns of EMS pain management across the country.
OBJECTIVES: To analyze prehospital management of pain using NEMSIS data, and to assess if variables such as patient age and/or race/ethnicity are associated with disparity in pain treatment.

Méthode : A retrospective descriptive study over a three-year period (2012-2014) of the NEMSIS database for patients evaluated for three potentially painful medical impressions (fracture, burn, penetrating injury) to assess the presence of documented pain as a symptom, and if patients received treatment with analgesic medications. Results were analyzed according to type of pain medication given, age categories, and race/ethnicity of the patients.
MAIN OUTCOMES: Percentage of EMS transports documenting the three painful impressions that had pain documented as a symptom, received any of the six pain medications, and the disparity in documentation and treatment by age and race/ethnicity.

Résultats : There were 276,925 EMS records in the NEMSIS database that met inclusion criteria. Pain was listed as a primary or associated symptom for 29.5% of patients, and the youngest children (0-3 years) were least likely to have pain documented as a symptom (14.6%). Only 15.6% of all activations documented the receipt of prehospital pain medications. Children (<15 years) received pain medication 14.8% [95% CI 14.33, 15.34] of the time versus adults (≥15 years) 15.6% [95% CI 15.48, 15.76, p = 0.004]. Morphine and fentanyl were the most commonly administered medications to all age groups. Black patients were less likely to receive pain medication than other racial groups.

Conclusion : Documentation of pain as a symptom and pain treatment continue to be infrequent in the prehospital setting in all age groups, especially young children. There appears to be a racial disparity with Black patients less often treated with analgesics. The broad incorporation of national NEMSIS data suggests that these inadequacies are a widespread challenge deserving further attention.

Conclusion (proposition de traduction) : La recherche d'une douleur en tant que symptôme et son traitement continue d'être peu fréquente en milieu préhospitalier dans tous les groupes d'âge, en particulier chez les jeunes enfants. Il semble y avoir une disparité raciale avec les patients noirs moins souvent traités avec des analgésiques. L'intégration générale des données nationales du NEMSIS (National Emergency Services Information System  ) suggère que ces insuffisances constituent un défi généralisé méritant une attention accrue.

Gains of Continuing Resuscitation in Refractory Out-of-hospital Cardiac Arrest: A Model-based Analysis to Identify Deaths Due to Intra-arrest Prognostication.
Grunau B, Puyat J, Wong H, Scheuermeyer FX, Reynolds JC, Kawano T, Singer J, Dick W, Christenson J. | Prehosp Emerg Care. 2018 Mar-Apr;22(2):198-207
Keywords: cardiac arrest; cardiopulmonary resuscitation; prognostication


Introduction : Prognostication bias, in which a clinician predicts a negative outcome and terminates resuscitation (TR) thereby ensuring a poor outcome, is a rarely identified limitation of out-of-hospital cardiac arrest (OHCA) research. We sought to estimate the number of deaths due to intra-arrest prognostication in a cohort of OHCA's, and use this data to estimate the incremental benefit of continuing resuscitation.

Méthode : This study examined a cohort of consecutive non-traumatic EMS-treated OHCAs from a provincial ambulance service, between 2007 and 2011 inclusive. We used Cox and logistic regression modeling, adjusting for Utstein covariates, to estimate the probability of ROSC, survival, and favorable neurological outcomes as a function of resuscitation time, and applied these models to estimate the number of missed survivors in those who had TR (prior to 20, 30, or 40 minutes). We determined the time juncture at which (1) the likelihood of survival fell below 1%, and (2) the proportion of survivors who had achieved ROSC exceeded 99%.

Résultats : Of 5674 adult EMS-treated cases, 46% achieved ROSC, and 12% survived. The median time of TR was 27.0 minutes (IQR 19.0-35.0). Continuing resuscitation until 40 minutes yielded an estimated 17 additional survivors (95% CI 13-21), 10 (95% CI 7-13) with favorable neurological outcomes. The probability of survival of those in refractory arrest decreased below 1% at 28 minutes (95% CI 24-30 minutes). At 36 minutes (95% CI 34-38 minutes) >99% of survivors had achieved ROSC.

Conclusion : We identified possible deaths due to intra-arrest prognostication. Resuscitation should be continued for a minimum of 30 minutes in all patients, however for those with initial shockable rhythms 40 minutes appears to be warranted. Interventional trials and observational studies should standardize or adjust for duration of resuscitation prior to TR.

Conclusion (proposition de traduction) : Nous avons identifié des décès possibles dus au pronostic pendant l'arrêt. La réanimation doit être poursuivie pendant au moins 30 minutes chez tous les patients, cependant pour ceux qui ont des rythmes choquables initiaux, 40 minutes semblent être justifiées.
Les essais interventionnels et les études observationnelles devraient normaliser ou ajuster la durée de la réanimation avant la décision d'arrêt des soins.

Sternal Route More Effective than Tibial Route for Intraosseous Amiodarone Administration in a Swine Model of Ventricular Fibrillation.
Burgert JM, Martinez A, O'Sullivan M, Blouin D, Long A, Johnson AD. | Prehosp Emerg Care. 2018 Mar-Apr;22(2):266-275
Keywords: Amiodarone; bone marrow; intraosseous infusions; resuscitation; ventricular fibrillation


Introduction : The pharmacokinetics of IO administered lipid soluble amiodarone during ventricular fibrillation (VF) with ongoing CPR are unknown. This study measured mean plasma concentration over 5 minutes, maximum plasma concentration (Cmax), and time to maximum concentration (Tmax) of amiodarone administered by the sternal IO (SIO), tibial IO (TIO), and IV routes in a swine model of VF with ongoing CPR.

Méthode : Twenty-one Yorkshire-cross swine were randomly assigned to three groups: SIO, TIO, and IV. Ventricular fibrillation was induced under general anesthesia. After 4 minutes in VF, 300 mg amiodarone was administered as indicated by group assignment. Serial blood specimens collected at 30, 60, 90, 120, 150, 180, 240, and 300 seconds were analyzed using high performance liquid chromatography with tandem mass spectrometry.

Résultats : The mean plasma concentration of IV amiodarone over 5 minutes was significantly higher than the TIO group at 60 seconds (P = 0.02) and 90 seconds (P = 0.017) post-injection. No significant differences in Cmax between the groups were found (P <0.05). The Tmax of amiodarone was significantly shorter in the SIO (99 secs) and IV (86 secs) groups compared to the TIO group (215 secs); P = 0.002 and P = 0.002, respectively.

Conclusion : The SIO and IV routes of amiodarone administration were comparable. The TIO group took nearly three times longer to reach Tmax than the SIO and IV groups, likely indicating depot of lipid-soluble amiodarone in adipose-rich tibial yellow bone marrow. The SIO route was more effective than the TIO route for amiodarone delivery in a swine model of VF with ongoing CPR. Further investigations are necessary to determine if the kinetic differences found between the SIO and TIO routes in this study affect survival of VF in humans.

Conclusion (proposition de traduction) : Les voies d'administration d'amiodarone intra-osseuse sternale et IV étaient comparables. Le groupe intra-osseuse tibial a pris presque trois fois plus de temps pour atteindre Tmax que les groupes intra-osseuse sternale et IV, ce qui indique probablement un dépôt d'amiodarone liposoluble dans la moelle osseuse tibiale jaune riche en adipose. La voie intra-osseuse sternale était plus efficace que la voie intra-osseuse tibial pour l'administration d'amiodarone dans un modèle de FV porcine avec RCP en cours. D'autres investigations sont nécessaires pour déterminer si les différences cinétiques trouvées entre les voies intra-osseuse sternale et intra-osseuse tibial dans cette étude affectent la survie de la FV chez l'homme.

Development and Prospective Federal State-Wide Evaluation of a Device for Height-Based Dose Recommendations in Prehospital Pediatric Emergencies: A Simple Tool to Prevent Most Severe Drug Errors.
Kaufmann J, Roth B, Engelhardt T, Lechleuthner A, Laschat M, Hadamitzky C, Wappler F, Hellmich M. | Prehosp Emerg Care. 2018 Mar-Apr;22(2):252-259
Keywords: medication errors; pediatrics; prehospital emergency care


Introduction : Drug dosing errors pose a particular threat to children in prehospital emergency care. With the Pediatric emergency ruler (PaedER), we developed a simple height-based dose recommendation system and evaluated its effectiveness in a pre-post interventional trial as the Ethics Committee disapproved randomization due to the expected positive effect of the PaedER on outcome.

Méthode : Pre-interventional data were retrospectively retrieved from the electronic records and medical protocols of the Cologne Emergency Medical Service over a two-year period prior to the introduction of the PaedER. Post-interventional data were collected prospectively over a six-year period in a federal state-wide open trial. The administered doses of either intravenous or intraosseous fentanyl, midazolam, ketamine or epinephrine were recorded. Primary outcome measure was the number and severity of drug dose deviation from recommended dose (DRD) based on the patient's weight.

Résultats : Fifty-nine pre-interventional and 91 post-interventional prehospital drug administrations in children were analyzed. The rate of DRD > 300% overall medications were 22.0% in the pre- and 2.2% in the post-interventional group (p < 0.001). All administrations of epinephrine occurred excessive (DRD > 300%) in pre-interventional and none in post-interventional patients (p < 0.001).

Conclusion : The use of the PaedER resulted in a 90% reduction of medication errors (95% CI: 57% to 98%; p < 0.001) and prevented all potentially life-threatening errors associated with epinephrine administration. There is an urgent need to increase the safety of emergency drug dosing in children during emergencies. A simple height-based system can support health care providers and helps to avoid life-threatening medication errors.

Conclusion (proposition de traduction) : L'utilisation du PaedER a permis une réduction de 90 % des erreurs médicamenteuses (IC à 95 %: 57 % à 98 %, p <0,001) et a empêché toutes les erreurs potentiellement fatales associées à l'administration d'épinéphrine.
Il y a un besoin urgent d'augmenter la sécurité du dosage de médicament d'urgence chez les enfants aux urgences. Un système basé sur la taille simple peut aider les intervenant de santé et aider à éviter les erreurs de médication potentiellement mortelles.

Analysis of Prehospital Scene Times and Interventions on Mortality Outcomes in a National Cohort of Penetrating and Blunt Trauma Patients.
Ruelas OS, Tschautscher CF, Lohse CM, Sztajnkrycer MD. | Prehosp Emerg Care. 2018 Apr 4:1-7
Keywords: blunt; mortality; penetrating; scene time; trauma

Original Articles

Introduction : Recent studies have suggested improved outcomes in victims of penetrating trauma managed with shorter prehospital times and limited interventions. The purpose of the current study was to perform an outcome analysis of patients transported following penetrating and blunt traumatic injuries.

Méthode : We performed a descriptive retrospective analysis of the 2014 National Emergency Medical Services Information System (NEMSIS) public release research data set for patients presenting after acute traumatic injury.

Résultats : A total of 2,018,141 patient encounters met criteria, of which 3.9% were penetrating trauma. Prehospital cardiac arrest occurred in 0.5% blunt and 4.2% penetrating trauma patients. Emergency department (ED) mortality was higher in penetrating than blunt trauma patients (4.1% vs. 0.8%). Scene times were 18.1 ± 36.5 minutes for blunt and 16.0 ± 45.3 minutes for penetrating trauma. Mean scene time for blunt trauma patients who died in the ED was 24.9 ± 58.0 minutes compared with 18.8 ± 38.5 minutes for those admitted; for penetrating trauma, scene times were 17.9 ± 23.5 and 13.4 ± 11.6 minutes, respectively. Mean number of procedures performed for blunt trauma patients who died in the ED was 6.5 ± 4.3 compared with 3.1 ± 2.3 for those who survived until admission; for penetrating trauma, the numbers of procedures performed were 5.7 ± 3.4 and 2.6 ± 2.0, respectively.

Conclusion : Although less frequent than blunt trauma, penetrating trauma is associated with significantly higher prehospital and ED mortality. Increased scene time and number of procedures was associated with greater mortality for both blunt and penetrating trauma. Further study is required to better understand any causal relationships between prehospital times and interventions and patient outcomes.

Conclusion (proposition de traduction) : Bien qu'ils soient moins fréquents que les traumatismes contondants, les traumatismes pénétrants sont associés à une mortalité préhospitalière et aux urgences beaucoup plus élevée. L'augmentation de la durée sur intervention et du nombre d'interventions était associée à une plus grande mortalité pour les traumatismes contondants et pénétrants. D'autres études sont nécessaires pour mieux comprendre toute relation de cause à effet entre les temps préhospitaliers et les interventions et les résultats pour les patients.


Regional cerebral oxygen saturation during cardiopulmonary resuscitation as a predictor of return of spontaneous circulation and favourable neurological outcome - A review of the current literature.
Schnaubelt S, Sulzgruber P, Menger J, Skhirtladze-Dworschak K, Sterz F, Dworschak M. | Resuscitation. 2018 Apr;125:39-47
Keywords: CPC; Clinical decision-making; Cutoff-values; NIRS; Prognostication; ROSC; Regional cerebral oxygen saturation; Resuscitation; Surviva


Introduction : Regional cerebral oxygen saturation (rSO2) can be measured non-invasively even at no- or low-flow states. It thus allows assessment of brain oxygenation during CPR. Certain rSO2 values had been associated with return of spontaneous circulation (ROSC) and neurological outcome in the past. Clear-cut thresholds for the prediction of beneficial outcome, however, are still lacking.

Méthode : We conducted a database search to extract all available investigations on rSO2 measurement during CPR. Mean, median, and ΔrSO2 values were either taken from the studies or calculated. Thresholds for the outcome "ROSC" and "neurological outcome" were sought.

Résultats : We retrieved 26 publications for the final review. The averaged mean rSO2 for patients achieving ROSC was 41 ± 12% vs. 30 ± 12% for non-ROSC (p = .009). ROSC was not observed when mean rSO2 remained <26%. In ROSC patients, ΔrSO2 was 22 ± 16% vs. 7 ± 10% in non-ROSC patients (p = .009). A rSO2 threshold of 36% predicted ROSC with a sensitivity of 67% and specificity of 69% while ΔrSO2 of 7% showed a sensitivity of 100% and a specificity of 86% (AUC = 0.733 and 0.893, respectively). Mean rSO2 of 47 ± 11% was associated with favourable and 38 ± 12% with poor neurological outcome. There was, however, a great overlap between groups due to scarce data.

Conclusion : Higher rSO2 consistently correlated with increased rates of ROSC. The discriminatory power of rSO2 to prognosticate favourable neurological outcome remains unclear. Measuring rSO2 during CPR could potentially facilitate clinical decision-making.

Conclusion (proposition de traduction) : Une saturation cérébrale régionale en oxygène plus élevée était en corrélation systématique avec des taux plus important de retour à une activité cardiaque spontanée (RACS). Le pouvoir discriminant de la saturation cérébrale régionale en oxygène pour pronostiquer le résultat neurologique favorable n'est pas clairement établi.
La mesure de la saturation cérébrale régionale en oxygène pendant CPP pourrait potentiellement faciliter la prise de décision clinique.

Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest.
Cournoyer A, Notebaert É, de Montigny L, Ross D, Cossette S, Londei-Leduc L, Iseppon M, Lamarche Y, Sokoloff C, Potter BJ, Vadeboncoeur A, Larose D, Morris J, Daoust R, Chauny JM, Piette É, Paquet J, Cavayas YA, de Champlain F, Segal E, Albert M, Guertin MC, Denault A. | Resuscitation. 2018 Apr;125:28-33
Keywords: Out-of-hospital cardiac arrest; Percutaneous-coronary intervention; Prehospital systems; Survival to discharge

Clinical Papers

Introduction : Patients suffering from out-of-hospital cardiac arrest (OHCA) are frequently transported to the closest hospital. Percutaneous coronary intervention (PCI) is often indicated following OHCA. This study's primary objective was to determine the association between being transported to a PCI-capable hospital and survival to discharge for patients with OHCA. The additional delay to hospital arrival which could offset a potential increase in survival associated with being transported to a PCI-capable center was also evaluated.

Méthode : This study used a registry of OHCA in Montreal, Canada. Adult patients transported to a hospital following a non-traumatic OHCA were included. Hospitals were dichotomized based on whether PCI was available on-site or not. The effect of hospital type on survival to discharge was assessed using a multivariable logistic regression. The added prehospital delay which could offset the increase in survival associated with being transported to a PCI-capable center was calculated using that regression.

Résultats : A total of 4922 patients were included, of whom 2389 (48%) were transported to a PCI-capable hospital and 2533 (52%) to a non-PCI-capable hospital. There was an association between being transported to a PCI-capable center and survival to discharge (adjusted odds ratio = 1.60 [95% confidence interval 1.25-2.05], p < .001). Increasing the delay from call to hospital arrival by 14.0 min would offset the potential benefit of being transported to a PCI-capable center.

Conclusion : It could be advantageous to redirect patients suffering from OHCA patients to PCI-capable centers if the resulting expected delay is of less than 14 min.

Conclusion (proposition de traduction) : Il pourrait être intéressant de rediriger les patients après un arrêt cardiaque extrahospitalier vers un établissement pouvant pratiquer une intervention coronarienne percutanée si le retard induit pour l'admission dans ce centre est inférieur à 14 min.

Initial electrical frequency predicts survival and neurological outcome in out of hospital cardiac arrest patients with pulseless electrical activity.
Weiser C, Poppe M, Sterz F, Herkner H, Clodi C, Schriefl C, Warenits A, Vossen M, Schwameis M, Nürnberger A, Spiel A. | Resuscitation. 2018 Apr;125:34-38
Keywords: Non-shockable; OOHCA; Outcome; PEA; Prognosis; Pulseless electrical activity; Resuscitation; Survival

Clinical papers

Introduction : Outcome is generally poor in out of hospital cardiac arrests (OHCA) with initial non-shockable rhythms. Termination of resuscitation rules facilitate early prognostication at the scene to cease resuscitation attempts in futile situations and to proceed advanced life support in promising conditions. As pulseless electrical activity (PEA) is present as first rhythm in every 4th OHCA we were interested if the initial electrical frequency in PEA predicts survival.

Méthode : All patients >18 years of age with non-traumatic OHCA and PEA as first rhythm between August 2013 and August 2015 from the Vienna Cardiac Arrest Registry were included in this retrospective observational study. Defibrillator and epidemiological data from the emergency medical system as survival data were processed considering the initial electrical activity in PEA and 30 days survival.

Résultats : Out of 2149 OHCA patients, a total of 504 PEA patients were eligible for analyses. These patients were stratified into 4 groups according the initial electrical frequency in PEA: 10-24/min, 25-39/min, 40-59/min, >60/min. Compared to a frequency >60/min all other subgroups were associated with higher mortality especially those with an initial electrical frequency 10-24 (adjusted OR 0.56 (0.39-0.79) p = .001 for each category chance). QRS duration in PEA did not influence outcome. Patients in the >60/min group showed a 30-days-survival rate of 22% and a good neurological outcome in 15% of all patients - comparable to shockable cardiac arrest rhythms.

Conclusion : Regardless of other resuscitation factors, higher initial electrical frequency in PEA is associated with increased odds of survival and good neurological outcome.

Conclusion (proposition de traduction) : Sans tenir compte d'autres facteurs de réanimation, la fréquence électrique initiale la plus haute dans l'activité électrique sans pouls est associée à une probabilité augmentée de survie et de bon résultat neurologique.


Time From Imaging to Endovascular Reperfusion Predicts Outcome in Acute Stroke.
Tsai JP, Mlynash M, Christensen S, Kemp S, Kim S, Mishra NK, Federau C, Nogueira RG, Jovin TG, Devlin TG, Akhtar N, Yavagal DR, Bammer R, Straka M, Zaharchuk G, Marks MP, Albers GW, Lansberg MG; CRISP Investigators. | Stroke. 2018 Apr;49(4):952-957
DOI:  | Télécharger l'article au format  
Keywords: cerebral revascularization; perfusion imaging; reperfusion; stroke; thrombectomy

Original contributions

Introduction : This study aims to describe the relationship between computed tomographic (CT) perfusion (CTP)-to-reperfusion time and clinical and radiological outcomes, in a cohort of patients who achieve successful reperfusion for acute ischemic stroke.

Méthode : We included data from the CRISP (Computed Tomographic Perfusion to Predict Response in Ischemic Stroke Project) in which all patients underwent a baseline CTP scan before endovascular therapy. Patients were included if they had a mismatch on their baseline CTP scan and achieved successful endovascular reperfusion. Patients with mismatch were categorized into target mismatch and malignant mismatch profiles, according to the volume of their Tmax >10s lesion volume (target mismatch, <100 mL; malignant mismatch, >100 mL). We investigated the impact of CTP-to-reperfusion times on probability of achieving functional independence (modified Rankin Scale, 0-2) at day 90 and radiographic outcomes at day 5.

Résultats : Of 156 included patients, 108 (59%) had the target mismatch profile, and 48 (26%) had the malignant mismatch profile. In patients with the target mismatch profile, CTP-to-reperfusion time showed no association with functional independence (P=0.84), whereas in patients with malignant mismatch profile, CTP-to-reperfusion time was strongly associated with lower probability of functional independence (odds ratio, 0.08; P=0.003). Compared with patients with target mismatch, those with the malignant mismatch profile had significantly more infarct growth (90 [49-166] versus 43 [18-81] mL; P=0.006) and larger final infarct volumes (110 [61-155] versus 48 [21-99] mL; P=0.001).

Conclusion : Compared with target mismatch patients, those with the malignant profile experience faster infarct growth and a steeper decline in the odds of functional independence, with longer delays between baseline imaging and reperfusion. However, this does not exclude the possibility of treatment benefit in patients with a malignant profile.

Conclusion (proposition de traduction) : Comparativement aux patients présentant une cible de non-appariement, ceux dont le profil malin connaît une croissance plus rapide de l'infarctus et une diminution plus marquée des chances d'indépendance fonctionnelle, avec des délais plus longs entre l'imagerie de base et la reperfusion. Toutefois, cela n'exclut pas la possibilité de bénéficier d'un traitement chez les patients présentant un profil malin.

Commentaire : Voir l'article de Jean-Marc Olivot sur le profil malin dans Sang Thrombose Vaisseaux 2012;24(10):460-4  , Rôle de l’imagerie cérébrale dans l’extension des indications de thrombolyse de l’infarctus cérébral

Atrial Cardiopathy and the Risk of Ischemic Stroke in the CHS (Cardiovascular Health Study).
Kamel H, Bartz TM, Elkind MSV, Okin PM, Thacker EL, Patton KK, Stein PK, deFilippi CR, Gottesman RF, Heckbert SR, Kronmal RA, Soliman EZ, Longstreth WT Jr.. | Stroke. 2018 Apr;49(4):980-986
DOI:  | Télécharger l'article au format  
Keywords: adult; atrial fibrillation; cardiomyopathies; risk factors; thromboembolism

Original contributions

Introduction : Emerging evidence suggests that an underlying atrial cardiopathy may result in thromboembolism before atrial fibrillation (AF) develops. We examined the association between various markers of atrial cardiopathy and the risk of ischemic stroke.

Méthode : The CHS (Cardiovascular Health Study) prospectively enrolled community-dwelling adults ≥65 years of age. For this study, we excluded participants diagnosed with stroke or AF before baseline. Exposures were several markers of atrial cardiopathy: baseline P-wave terminal force in ECG lead V1, left atrial dimension on echocardiogram, and N terminal pro B type natriuretic peptide (NT-proBNP), as well as incident AF. Incident AF was ascertained from 12-lead electrocardiograms at annual study visits for the first decade after study enrollment and from inpatient and outpatient Medicare data throughout follow-up. The primary outcome was incident ischemic stroke. We used Cox proportional hazards models that included all 4 atrial cardiopathy markers along with adjustment for demographic characteristics and established vascular risk factors.

Résultats : Among 3723 participants who were free of stroke and AF at baseline and who had data on all atrial cardiopathy markers, 585 participants (15.7%) experienced an incident ischemic stroke during a median 12.9 years of follow-up. When all atrial cardiopathy markers were combined in 1 Cox model, we found significant associations with stroke for P-wave terminal force in ECG lead V1 (hazard ratio per 1000 μV*ms 1.04; 95% confidence interval, 1.001-1.08), log-transformed NT-proBNP (hazard ratio per doubling of NT-proBNP, 1.09; 95% confidence interval, 1.03-1.16), and incident AF (hazard ratio, 2.04; 95% confidence interval, 1.67-2.48) but not left atrial dimension (hazard ratio per cm, 0.96; 95% confidence interval, 0.84-1.10).

Conclusion : In addition to clinically apparent AF, other evidence of abnormal atrial substrate is associated with subsequent ischemic stroke. This finding is consistent with the hypothesis that thromboembolism from the left atrium may occur in the setting of several different manifestations of atrial disease.

Conclusion (proposition de traduction) : A côté de la fibrillation atriale cliniquement évidente, d'autres preuves de substrats auriculaires anormaux sont associés à un accident vasculaire cérébral ischémique ultérieur. Cette constatation concorde avec l'hypothèse selon laquelle une thromboembolie de l'oreillette gauche pourrait survenir lors de plusieurs manifestations différentes de la maladie auriculaire.

Commentaire : Le substrat de la FA est le plus souvent fait d’un enchevêtrement d’altérations de la structure et de la physiologie des oreillettes, réalisant une véritable myopathie atriale qui contribue au caractère récidivant et chronique de l’arythmie.

The American Journal of Emergency Medicine

Ultrasound assisted evaluation of chest pain in the emergency department.
Colony MD, Edwards F, Kellogg D. | Am J Emerg Med. 2018 Apr;36(4):533-539
Keywords: Aucun

Original Contribution

Editorial : Chest pain is a commonly encountered emergency department complaint, with a broad differential including several life-threatening possible conditions. Ultrasound-assisted evaluation can potentially be used to rapidly and accurately arrive at the correct diagnosis. We propose an organized, ultrasound assisted evaluation of the patient with chest pain using a combination of ultrasound, echocardiography and clinical parameters. Basic echo techniques which can be mastered by residents in a short time are used plus standardized clinical questions and examination. Information is kept on a checklist. We hypothesize that this will result in a quicker, more accurate evaluation of chest pain in the ED leading to timely treatment and disposition of the patient, less provider anxiety, a reduction in the number of diagnostic errors, and the removal of false assumptions from the diagnostic process.

Conclusion : This article proposes a ten-minute evaluation which includes exam of the heart, lungs, ascend- ing aorta and aortic arch, plus clinical questions about GI symptoms, emotional symptoms and the presence or absence of pain during thoracic palpation or movement. An exam conducted in such a manner, is much more likely to lead to the correct diagnosis, uncover causes of chest pain which are non-cardiac, and unmask potentially lethal conditions such as massive PE or aortic dissection. A need exists to conduct a large scale study to verify the usefulness of such an exam and to determine the feasibility of teaching this exam to Emergency Medicine providers.

Conclusion (proposition de traduction) : Cet article propose une évaluation de dix minutes qui comprend l'examen cardiaque, pulmonaire, de l'aorte ascendante et de la crosse de l'aorte, ainsi que des questions cliniques sur les symptômes digestifs, les symptômes émotionnels et la présence ou l'absence de douleur pendant la palpation ou le mouvement thoracique. Un examen effectué de cette manière est beaucoup plus susceptible d'aboutir à un diagnostic correct, de découvrir les causes de douleurs thoraciques qui ne sont pas cardiaques et de démasquer les affections potentiellement mortelles comme l'EP massive ou la dissection aortique.
Il est nécessaire de mener une étude à grande échelle pour vérifier l'utilité d'un tel examen et pour déterminer la faisabilité d'enseigner cet examen aux urgentistes.

Association between seatbelt sign and internal injuries in the contemporary airbag era: A retrospective cohort study.
Glover JM, Waychoff MF, Casmaer M, April MD, Hunter CJ, Trexler ST, Blackbourne LH. | Am J Emerg Med. 2018 Apr;36(4):545-550
Keywords: Air bags; Injury; Motor vehicle crashes, traffic; Seatbelts; Trauma

Original Contribution

Introduction : Literature predating routine availability of airbags reported an association between seatbelt signs and internal injuries. We measured this association among patients involved in motor vehicle crashes (MVCs) with airbag deployment.

Méthode : We conducted a retrospective cohort study by chart review of all MVC patients presenting to our Emergency Department (ED) during 1 January 2008-30 September 2015. We included all adult MVC patients in the driver or front passenger seats with both shoulder and lap seatbelts and airbag deployment. Two trained chart abstractors recorded data regarding restraints and airbag deployment. We obtained all other data via electronic medical record abstraction including demographics, injuries, and survival. We compared the prevalence of cervicothoracic and intra-abdominopelvic injuries between patients with a documented seatbelt sign versus no seatbelt sign using a logistic regression model.

Résultats : Of 1379 MVC patients, 350 met inclusion criteria. Of these, 138 (39.4%) had a seatbelt sign. The prevalence of cervicothoracic injury was higher among subjects with a documented seatbelt sign (54.3% versus 42.9%, p=0.036) Seatbelt sign predicted cervicothoracic injury with a positive likelihood ratio of 1.3 (95% CI 1.0-1.7) and negative likelihood ratio of 0.8 (95% CI 0.7-1.0). The odds ratio of cervicothoracic injury among patients with a seatbelt sign versus no seatbelt sign was 1.58 (95% confidence interval 1.02-2.46) in the logistic regression model. There was no association between seatbelt sign and intra-abdominopelvic injury (p=0.418).

Conclusion : In the setting of airbag deployment, there is an association between seatbelt sign and cervicothoracic injury but not intra-abdominopelvic injury.

Conclusion (proposition de traduction) : Dans le cadre du déploiement des airbags, il existe une association entre le signe de la ceinture de sécurité et une lésion cervico-thoracique, mais pas une lésion intra-abdominopelvienne.

Prevalence of pulmonary embolism in patients presenting with syncope. A systematic review and meta-analysis.
Oqab Z, Ganshorn H, Sheldon R. | Am J Emerg Med. 2018 Apr;36(4):551-555
Keywords: Emergency department; Hospitalized; Prevalence; Pulmonary embolism; Syncope

Original Contribution

Introduction : Syncope is a common clinical presentation and establishing an etiology is often challenging. Pulmonary embolism (PE) has been thought to be an uncommon cause but a recent report suggested otherwise.
OBJECTIVE: To establish the prevalence of PE in patients presenting with syncope to the emergency department (ED) and in hospitalized patients.

Méthode : We systematically searched Medline, CINAHL, EMBASE, LILACS and Web of Science with relevant keywords and MeSH headings for syncope and PE. Inclusion criteria were patients presenting with syncope to ED or hospitalized due to syncope, and etiologies including PE.

Résultats : Of 1329 titles and abstracts, 12 (other than Prandoni et al.) met inclusion criteria. Nine studies included 6608 ED patients and 3 included 975 hospitalized patients. The mean age was 62 (95% CI 54-69) for ED patients and 67 (95% CI 64-70) for hospitalized. The pooled estimate of PE prevalence in ED syncope patients was 0.8% (95% CI 0.5-1.3%, I2=0%). The pooled estimate of PE prevalence in hospitalized patients was 1.0% (95% CI 0.5-1.9%, I2=0). In contrast, the prevalence of PE in Prandoni et al. were 3.8% and 17.3% for ED and hospitalized patients respectively, both significantly higher than in other relevant studies (p<0.0001).

Conclusion : The estimated prevalence of PE in patients presenting with syncope is low. The Prandoni et al. estimates are significantly higher, suggesting a possible site effect, accrual bias, or investigation strategy. These and the prognostic impact of higher PE prevalence require understanding before changes in practice.

Conclusion (proposition de traduction) : La prévalence estimée de l'EP chez les patients présentant une syncope est faible. Les estimations de Prandoni et coll. sont beaucoup plus élevées, ce qui suggère un effet de site possible, un biais de recrutement ou une stratégie d'enquête. Ces facteurs et l'impact pronostique d'une prévalence plus élevée de l'EP doivent être compris avant que des changements ne soient apportés à la pratique.

Blood pressure variability as an indicator of sepsis severity in adult emergency department patients.
Nouriel JE, Millis SR, Ottolini J, Wilburn JM, Sherwin RL, Paxton JH. | Am J Emerg Med. 2018 Apr;36(4):560-566
Keywords: Fluid resuscitation; Hemodynamic monitoring; Sepsis

Original Contribution

Introduction : Quantify the correlation between blood pressure variability (BPV) and markers of illness severity: serum lactate (LAC) or Sequential Organ Failure Assessment (SOFA) scores.

Méthode : We performed a secondary analysis of data from a prospective, observational study evaluating fluid resuscitation on adult, septic, ED patients. Vital signs and fluid infusion volumes were recorded every 15min during the 3h following ED arrival. BPV was assessed via average real variability (ARV): the average of the absolute differences between consecutive BP measurements. ARV was calculated for the time periods before and after 3 fluid infusion milestones: 10-, 20-, and 30-mL/kg total body weight (TBW). Spearman's rho correlation coefficient analysis was utilized. A p-value<0.05 was considered statistically significant.

Résultats : Forty patients were included. Mean fluid infusion was 33.7mL/kg TBW (SD 22.1). All patients received fluid infusion≥10mL/kg TBW, 25 patients received fluid infusion>20mL/kg TBW, and 16 patients received fluid infusion>30mL/kg TBW. Mean initial LAC was 4.0mmol/L (SD 3.2). Mean repeat LAC was 3.1mmol/L (SD 3.2), obtained an average of 6.6h (SD 5.3) later. Mean SOFA score was 7.0 (SD 4.4). BPV correlated with both follow-up LAC (r=0.564; p=0.023) and SOFA score (r=0.544; p=0.024) among the cohort that received a fluid infusion>20-mL/kg TBW.

Conclusion : With the finding of a positive correlation between BPV and markers of illness severity (LAC and SOFA scores), this pilot study introduces BPV analysis as a real-time, non-invasive tool for continuous sepsis monitoring in the ED.

Conclusion (proposition de traduction) : Avec la découverte d'une corrélation positive entre le variation de pression artérielle et les marqueurs de la gravité de la maladie (scores LAC et SOFA), cette étude pilote présente l'analyse de la variation de pression artérielle comme outil non invasif en temps réel pour la surveillance continue de la septicémie aux urgences.

Accuracy of bedside point of care testing in critical emergency department patients.
McIntosh BW, Vasek J, Taylor M, Le Blanc D, Thode HC, Singer AJ. | Am J Emerg Med. 2018 Apr;36(4):567-570
Keywords: Accuracy; Emergency department; Point-of-care testing

Original Contribution

Introduction : Point-of-care (POC) testing reduces laboratory turn-around having the potential to improve timely diagnosis and management. We compared the accuracy of nurse performed POC and core laboratory testing and determined whether deviations between the two were clinically meaningful.

Méthode : We performed a prospective, observational study on a convenience sample of 50 critical care ED patients in whom a POC chemistry and hematocrit was ordered. Blood samples were divided into 2 aliquots; one sample was tested by the treating nurse using a handheld POC device and the other sample was tested in the core laboratory. Paired comparisons of test results were performed using Pearson's correlation coefficients, Lin concordance coefficients, and Bland Altman plots.

Résultats : Mean patient age was 67, 50% were male, 82% were admitted. Pearson's correlation and Lin concordance coefficients were excellent (0.84-1.00) for all 8 analytes. Mean (95%CI) paired differences between POC and core laboratory measurements were Na+ 0.30 (-0.22 to 0.82) mmol/L, K+-0.12 (-0.14 to - 0.09) mmol/L, Cl- 2.10 (1.41 to 2.78) mmol/L, TCO2-1.68 (-2.06 to -1.30) mmol/L, glucose 2.46 (1.46 to 3.46) mg/dL, BUN, 1.69 (0.95 to 2.42) mg/dL, creatinine 0.13 (0.08 to 0.17) mg/dL, and hematocrit -0.39 (-0.93 to 0.15) %. In 3 of 400 measurements, the difference between POC and core lab exceeded the maximal clinically acceptable deviation based on physician surveys.

Conclusion : Bedside POC by ED nurses is reliable and accurate and does not deviate significantly from core laboratory testing by trained technicians.

Conclusion (proposition de traduction) : Les tests effectués au chevet du patient par du personnel infirmier des urgences est fiable et précis et ne s'écarte pas de façon significative des tests de laboratoire de base effectués par des techniciens qualifiés.

Validation of the (Troponin-only) Manchester ACS decision aid with a contemporary cardiac troponin I assay.
Va Den Berg P, Burrows G, Lewis P, Carley S, Body R. | Am J Emerg Med. 2018 Apr;36(4):602-607
Keywords: Acute coronary syndromes; Cardiac troponin; Clinical decision rules; Sensitivity and specificity

Original Contribution

Introduction : The Manchester Acute Coronary Syndromes (MACS) decision aid can 'rules in' and 'rule out' acute coronary syndromes (ACS) by combining a patient's symptoms with the results of a single blood test taken at the time of arrival in the Emergency Department (ED). The original model (MACS) included two biomarkers: high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (h-FABP). A refined model without h-FABP was found to have comparable sensitivity but greater specificity. We sought to validate MACS and T-MACS using the contemporary Siemens Advia Centaur cardiac troponin I assay to increase usability in practice.

Méthode : This is a secondary analysis from prospective diagnostic cohort study at Stepping Hill Hospital, United Kingdom. Patients presenting with chest pain of suspected cardiac nature warranting rule out for ACS were included. All patients underwent hs-cTnT testing at least 12h after peak symptoms. The primary outcome was a diagnosis of ACS, defined as either prevalent acute myocardial infarction (AMI) or incident major adverse cardiac events (death, AMI or coronary revascularization) within 30days.

Résultats : Of 405 included patients, 76 (18.8%) had ACS. MACS and T-MACS had similar C-statistics (0.94 for each, p=0.36) and sensitivity (difference 1.3%, 95% CI -1.3 to 3.9%, p=1.00) but T-MACS had significantly greater specificity (difference 16.7%, 95% CI 14.6-18.9%, p<0.0001). T-MACS and MACS would have allowed 36.3% and 22.5% patients to be immediately discharged respectively. Of patients classified as 'very low risk', none had ACS when MACS was used compared to one (0.7%) with T-MACS.

Conclusion : Both MACS and T-MACS effectively ruled out ACS even with a contemporary troponin I assay and could be used to reduce unnecessary hospital admissions.

Conclusion (proposition de traduction) : Les scores Manchester Acute Coronary Syndromes et troponine T Manchester Acute Coronary a effectivement exclu les syndromes coronaires aigus même avec un dosage contemporain de la troponine I et pourrait être utilisé pour réduire les hospitalisations inutiles.

Blood pressure variability as an indicator of sepsis severity in adult emergency department patients.
Nouriel JE, Millis SR, Ottolini J, Wilburn JM, Sherwin RL, Paxton JH. | Am J Emerg Med. 2018 Apr;36(4):560-566
Keywords: Fluid resuscitation; Hemodynamic monitoring; Sepsis

Original Contribution

Introduction : Quantify the correlation between blood pressure variability (BPV) and markers of illness severity: serum lactate (LAC) or Sequential Organ Failure Assessment (SOFA) scores.

Méthode : We performed a secondary analysis of data from a prospective, observational study evaluating fluid resuscitation on adult, septic, ED patients. Vital signs and fluid infusion volumes were recorded every 15min during the 3h following ED arrival. BPV was assessed via average real variability (ARV): the average of the absolute differences between consecutive BP measurements. ARV was calculated for the time periods before and after 3 fluid infusion milestones: 10-, 20-, and 30-mL/kg total body weight (TBW). Spearman's rho correlation coefficient analysis was utilized. A p-value<0.05 was considered statistically significant.

Résultats : Forty patients were included. Mean fluid infusion was 33.7mL/kg TBW (SD 22.1). All patients received fluid infusion≥10mL/kg TBW, 25 patients received fluid infusion>20mL/kg TBW, and 16 patients received fluid infusion>30mL/kg TBW. Mean initial LAC was 4.0mmol/L (SD 3.2). Mean repeat LAC was 3.1mmol/L (SD 3.2), obtained an average of 6.6h (SD 5.3) later. Mean SOFA score was 7.0 (SD 4.4). BPV correlated with both follow-up LAC (r=0.564; p=0.023) and SOFA score (r=0.544; p=0.024) among the cohort that received a fluid infusion>20-mL/kg TBW.

Conclusion : With the finding of a positive correlation between BPV and markers of illness severity (LAC and SOFA scores), this pilot study introduces BPV analysis as a real-time, non-invasive tool for continuous sepsis monitoring in the ED.

Conclusion (proposition de traduction) : Avec la découverte d'une corrélation positive entre la variabilité de la pression artérielle et les marqueurs de la gravité de la maladie (scores LAC et SOFA), cette étude pilote introduit l'analyse de la variabilité de la pression artérielle en tant qu'outil non invasif en temps réel pour la surveillance continue de la septicémie aux urgences.

Stair-related injuries treated in United States emergency departments.
Blazewick DH, Chounthirath T, Hodges NL, Collins CL, Smith GA. | Am J Emerg Med. 2018 Apr;36(4):608-614
Keywords: Emergency department; Injury; National Electronic Injury Surveillance System; Stairs; Stairways

Original Contribution

Introduction : To investigate the characteristics of stair-related injuries among individuals of all ages and estimate national injury frequencies and rates using a representative sample of patients treated in United States emergency departments.

Méthode : Data from the National Electronic Injury Surveillance System were analyzed for patients treated for stair-related injuries in United States emergency departments from 1990 through 2012.

Résultats : An estimated 24,760,843 patients were treated in emergency departments for a stair-related injury during the 23-year study period, averaging 1,076,558 patients annually, or 37.8 injuries per 10,000 United States residents. The annual rate of stair-related injuries decreased by 12.6% (p<0.001) during 1990-1996, followed by an increase of 24.0% (p<0.001) during 1996-2012. Although the highest injury rates occurred among younger children and older adults, the majority (67.2%) of emergency department visits for stair-related injuries was by individuals 11-60years old. Most patients were female (62.4%), who also had a higher injury rate (46.5 vs. 29.1 per 10,000) than males. Sprains and strains (32.3%), soft tissue injuries (23.8%), and fractures (19.3%) were the most common types of injury. The body regions most frequently injured were the lower extremities (42.1%) and head/neck (21.6%). Patients ≤10years old experienced more head/neck injuries. Older adult patients more frequently sustained fractures than younger age groups.

Conclusion : Stairs are a common source of injury among individuals of all ages and the frequency and rate of stair-related injuries are increasing. This underscores the need for increased prevention efforts, particularly those related to stair design and construction.

Conclusion (proposition de traduction) : Les escaliers sont une source fréquente de blessures chez les personnes de tous âges, et la fréquence et le taux de blessures liées aux escaliers augmentent. Cela souligne la nécessité d'accroître les efforts de prévention, en particulier ceux liés à la conception et à la construction des escaliers.

Choice of resuscitative fluids and mortality in emergency department patients with sepsis.
Sethi M, Owyang CG, Meyers C, Parekh R, Shah KH, Manini AF. | Am J Emerg Med. 2018 Apr;36(4):625-629
Keywords: Fluids; Mortality; Resuscitation; Sepsis

Original research

Introduction : Balanced resuscitative fluids (BF) have been associated with decreased incidence of hyperchloremic metabolic acidosis in sepsis. We hypothesized that higher proportions of BF during resuscitation would thus be associated with improved mortality in Emergency Department (ED) patients with sepsis.

Méthode : This was a retrospective chart review of adult ED patients who presented with sepsis to a large, urban teaching hospital over one year. The choice of resuscitation fluid in the first 2days of hospitalization was defined as either normal saline (NS) or balanced fluids (BF; Lactated Ringer's or Isolyte). The primary study outcome was in-hospital mortality, which was analyzed with multivariable logistic regression based on the proportion of BF received during the initial ED resuscitation.

Résultats : Of 149 patients screened, 33 were excluded, leaving 115 for analysis, of whom 18 died (16% overall mortality). Sixty-one (53%) patients received BF and NS, 6 (5%) patients received BF exclusively, while 48 (42%) patients received NS only. The mean number of liters administered was 5.4, and the mean percentage of BF administered was 29%. In univariate analysis, a higher proportion of BF was associated with lower odds of mortality (OR 0.973 [95% CI 0.961-0.986], p=0.00003). This association held true in multivariable models controlling for comorbidities and admission lactate level.

Conclusion : We found that the proportion of BF during the initial ED resuscitation in septic patients was associated with a significant reduction in mortality. This association provides the necessary rationale for future randomized clinical trials of BF resuscitation in sepsis.

Conclusion (proposition de traduction) : Nous avons constaté que la proportion de cristalloïdes balancés pendant la réanimation initiale aux urgences chez les patients septiques était associée à une réduction significative de la mortalité. Cette association fournit la justification nécessaire pour les essais cliniques randomisés futurs de la réanimation par les cristalloïdes balancés en cas de septicémie.

Commentaire : Plusieurs études sont en faveur des cristalloïdes balancés pour le remplissage dans les états de choc.
La SFAR propose, sur son site, la lecture du document suivant  Faut-il utiliser des solutés balancés ?  , par le Professeur Carole ICHAI.
La SRLF mentionne l'utilisation des cristalloïdes balancés ou du sérum salé pour l’expansion volémique des patients en sepsis ou choc septique (recommandation faible, niveau de preuve faible) dans : Recommandations internationales sur la prise en charge du sepsis et du choc septique : du neuf en 2016.

Is pulseless electrical activity a reason to refuse cardiopulmonary resuscitation with ECMO support?.
Pabst D, Brehm CE. | Am J Emerg Med. 2018 Apr;36(4):637-640
Keywords: ECMO; ECPR; Outcome; PEA; Survival

Original research

Introduction : Cardiopulmonary resuscitation with ECMO support (ECPR) has shown to improve outcome in patients after cardiac arrest under resuscitation. Most current recommendations for ECPR do not include patients with a non-shockable rhythm such as PEA and asystole.
AIM: The aim of this study was to investigate the outcome of 3 patient groups separated by initial rhythm at time of ECMO placement during CPR: asystole, PEA and shockable rhythm.

Méthode : We made a retrospective single-center study of adults who underwent ECPR for in-hospital cardiac arrest between June 2008 and January 2017. Outcome and survival were identified in 3 groups of patients regarding to the heart rhythm at the time decision for ECMO support was made: 1. patients with asystole, 2. patients with pulseless electrical activity, 3. patients with a shockable rhythm.

Résultats : 63 patients underwent ECPR in the mentioned time frame. Five patients were excluded due to incomplete data. Under the 58 included patients the number of cases for asystole, PEA, shockable rhythm was 7, 21 and 30 respectively. The means of CPR-time in these groups were 37, 41 and 37min. Survival to discharge was 0.0%, 23.8% and 40.0% respectively (p=0.09). All survivors to discharge had a good neurological outcome, defined as cerebral performance category 1or 2.

Conclusion : Survival to discharge in patients with pulseless electrical activity as initial rhythm at the time of decision for Cardiopulmonary resuscitation with ECMO is 23.8% while no patients with asystole as initial rhythm survived discharge. Patients with pulseless electrical activity should be carefully considered for Cardiopulmonary resuscitation with ECMO.

Conclusion (proposition de traduction) : La survie au congé chez les patients ayant une activité électrique sans pouls comme rythme initial au moment de la décision de réanimation cardio-pulmonaire avec ECMO est de 23,8 %, tandis qu'aucun patient ayant une asystolie comme rythme initial n'a survécu au congé. Les patients dont l'activité électrique est sans pouls doivent être soigneusement examinés en vue d'une réanimation cardiopulmonaire avec ECMO.

Comparison of bronchodilator administration with vibrating mesh nebulizer and standard jet nebulizer in the emergency department.
Dunne RB, Shortt S. | Am J Emerg Med. 2018 Apr;36(4):641-646
Keywords: Adapter; Aerosol; Jet nebulizer; Mesh; Vibrating mesh

Original research

Introduction : Projects comparing bronchodilator response by aerosol devices in the ED are limited. Evidence suggests that the vibrating mesh nebulizer (VMN) provides 5-fold greater aerosol delivery to the lung as compared to a jet nebulizer (JN). The aim of this project was to evaluate a new nebulizer deployed in an Emergency Department.

Méthode : A quality improvement evaluation using a prospectively identified data set from the electronic medical record comparing all ED patients receiving aerosolized bronchodilators with the JN during September 2015 to those receiving aerosolized bronchodilators with the VMN during October 2015.

Résultats : 1594 records were extracted, 879 patients received bronchodilators via JN and 715 patients via the VMN. Admission rates in the VMN group were 28.1% and in the JN group at 41.4%. The total albuterol dose administered was significantly lower in the VMN group compared to the JN (p<0.001). No patient in the VMN group required >5mg albuterol to control symptoms (85% of the VMN group received only 2.5mg) whereas dosing in the JN group was higher in some patients (with 47% receiving only 2.5mg). The use of VMN was also associated with a 13% (37min) reduction in median length of stay in the ED.

Conclusion : The VMN was associated with fewer admissions to the hospital, shorter length of stay in the ED and a reduction in albuterol dose. The device type was a predictor of discharge, disposition and amount of drug used. Randomized controlled studies are needed to corroborate these findings.

Conclusion (proposition de traduction) : Le nébuliseur à mailles vibratoires était associé à moins d'admissions à l'hôpital, à une durée de séjour plus courte aux urgences et à une réduction de la dose d'albutérol. Le type d'instrument était un prédicteur de la nébulisation, de la biodisponibilité et de la quantité de médicament utilisée. Des études randomisées et contrôlées sont nécessaires pour corroborer ces résultats.

Effect of platelet-lymphocyte ratio and lactate levels obtained on mortality with sepsis and septic shock.
Biyikli E, Kayipmaz AE2, Kavalci C. | Am J Emerg Med. 2018 Apr;36(4):647-650
Keywords: Emergency treatment; Infection; Severe sepsis

Original research

Introduction : Sepsis is a potentially fatal condition with high treatment costs, and is especially common among the elderly population. The emergency management of septic patients has gained importance.
OBJECTIVE: Herein, we investigated the effect of admission lactate levels and the platelet-lymphocyte ratio (PLR) on the 30-day mortality among patients older than 65years who were diagnosed with sepsis and septic shock according to the qSOFA criteria at our hospital's emergency department.

Méthode : This observational study was conducted retrospectively. We obtained information regarding patients' demographic characteristics, comorbid conditions, hemodynamic parameters at admission, initial treatment needs at the emergency department.

Résultats : 131 patients received a diagnosis of sepsis and septic shock at our emergency department in two years. Among these, 45% (n=59) of the patients died within 30days of admission. Forty (30.5%) patients required mechanical ventilation. There was a significant difference between the survival and non-survival groups with regard to systolic and diastolic blood pressures (p=0.013 and 0.045, respectively). There were significant differences between the two groups with respect to the Glasgow Coma Scale score (p<0.001) and BUN levels (p<0.001). The mortality status according to qSOFA scores was revealed a significant difference between the two groups (p<0.001).

Conclusion : Our results showed that the patients who died within 30days of admission and those who did not had comparable PLR and lactate levels (p=0.821 and 0.120, respectively). We opine that serial lactate measurements would be more useful than a single admission lactate measurement for the prediction of mortality.

Conclusion (proposition de traduction) : Nos résultats ont montré que les patients décédés dans les 30 jours suivant l'admission étaient ceux qui n'avaient pas un rapport plaquettaire-lymphocyte et des taux de lactate comparables (p=0,821 et 0,120, respectivement). Nous pensons que des mesures sérielles du lactate seraient plus utiles qu'une mesure du lactate à admission unique pour la prédiction de la mortalité.

The Cardiac Arrest Sonographic Assessment (CASA) exam - A standardized approach to the use of ultrasound in PEA.
Gardner KF, Clattenburg EJ, Wroe P, Singh A, Mantuani D, Nagdev A. | Am J Emerg Med. 2018 Apr;36(4):729-731
Keywords: Cardiopulmonary resuscitation; Point-of-care ultrasound


Editorial : Emergency physicians (EPs) have started integrating point-of-careultrasound (POCUS) into the evaluation of patients with cardiac arrest to identify reversible causes of pulseless electrical activity (PEA) and it is now recommended by the AHA. However, POCUS prolongs CPR pauseswhich negatively impacts survival. While POCUS protocols for cardiac arrest have been suggested, they are too complex and cumbersome. Here we present an evidence based, three step protocol that is simple, rapid, and allows the EP to quickly and accurately identify reversible causes of PEA while minimizing CPR interruptions.

Conclusion : POCUS is a powerful tool for assessing reversible causes of cardiac arrest. However, it must be utilized in a protocolized, efficient manner so as to not do harm. The CASA examassesses for the highest yield reversible causes of PEA that can be visualizedwith ultrasound,while limiting POCUS's negative impact. It is our hope that the utilization of the CASA examwill limit prolonged CPR pauses and improve diagnostic accuracy.

Conclusion (proposition de traduction) : L'échographie au lit du patient est un outil puissant pour évaluer les causes réversibles d'arrêt cardiaque. Cependant, il doit être utilisé d'une manière protocolisée et efficace afin de ne pas nuire à la RCP. L'examen CASA permet d'évaluer les causes réversibles les plus probables de dissociation électromécanique dans l'ACR qui peuvent être visualisées par ultrasons, tout en limitant l'impact négatif de l'échographie au lit du patient. Nous espérons que l'utilisation de l'examen CASA limitera les pauses prolongées de RCP et améliorera l'exactitude du diagnostic.

The Journal of Emergency Medicine

A Novel Difficult-Airway Prediction Tool for Emergency Airway Management: Validation of the HEAVEN Criteria in a Large Air Medical Cohort.
Kuzmack E, Inglis T, Olvera D, Wolfe A, Seng K, Davis D. | J Emerg Med. 2018 Apr;54(4):395-401
Keywords: airway management; difficult airway; emergency; intubation; prediction tool; rapid sequence intubation

Original contribution

Introduction : Difficult-airway prediction tools help identify optimal airway techniques, but were derived in elective surgery patients and may not be applicable to emergency rapid sequence intubation (RSI). The HEAVEN criteria (Hypoxemia, Extremes of size, Anatomic abnormalities, Vomit/blood/fluid, Exsanguination, Neck mobility issues) may be more relevant to emergency RSI patients.
OBJECTIVE: To validate the HEAVEN criteria for difficult-airway prediction in emergency RSI using a large air medical cohort.

Méthode : This was a retrospective analysis using a large air medical airway registry using data from 160 bases over a 1-year period. Standard test characteristics (sensitivity, specificity, positive predictive value, negative predictive value [NPV]) for the HEAVEN criteria were calculated for overall intubation success, first-attempt success, and first-attempt success without desaturation. In addition, multivariable logistic regression was used to quantify the independent association between each of the HEAVEN criteria, as well as the total number of criteria present and intubation success after adjusting for age, gender, and clinical category (burn, medical, trauma, nontraumatic shock).

Résultats : A total of 2419 patients undergoing air medical RSI were included. Excellent NPV was observed (97% for each of the HEAVEN criteria except "Exsanguination," which had an NPV of 87% but specificity of 99%). First-attempt success was lower for each of the HEAVEN criteria, with an inverse relationship observed between total HEAVEN criteria and intubation success (first-attempt success with no criteria = 94% and with 5 + criteria = 43%). Multivariable logistic regression revealed independent associations between each of the HEAVEN criteria, as well as total number of criteria and intubation success.

Conclusion : The HEAVEN criteria seem to be a useful tool to predict difficult airways in emergency RSI.

Conclusion (proposition de traduction) : Les critères HEAVEN semblent être un outil utile pour prédire le risque d'intubation difficile dans l'intubation en séquence rapide en urgence.

Predictor of Isolated Trauma in Head: A New Simple Predictor for Survival of Isolated Traumatic Brain Injury.
Lee SH1, Lim D2, Kim DH1, Kim SC2, Kim TY1, K, Lim D, Kim DH, Kim SC, Kim TY, Kang C, Jeong JH, Park YJ, Lee SB, Kim RB. | J Emerg Med. 2018 Apr;54(4):427-434
Keywords: emergency department; prognosis; survival probability; traumatic brain injury

Original contribution

Introduction : Mortality prediction in patients with brain trauma during initial management in the emergency department (ED) is essential for creating the foundation for a better prognosis.
OBJECTIVE: This study aimed to create a simple and useful survival predictive model for patients with isolated blunt traumatic brain injury that is easily available in the ED.

Méthode : This is a retrospective study based on the trauma registry data of an academic teaching hospital. The inclusion criteria were age ≥ 15 years, blunt and not penetrating mechanism of injury, and Abbreviated Injury Scale (AIS) scores between 1 and 6 for head and 0 for all other body parts. The primary outcome was 30-day survival probability. Internal and external validation was performed.

Résultats : After univariate logistic regression analysis based on the derivation cohort, the final Predictor of Isolated Trauma in Head (PITH) model for survival prediction of isolated traumatic brain injury included Glasgow Coma Scale (GCS), age, and coded AIS of the head. In the validation cohort, the area under the curve of the PITH score was 0.970 (p < 0.0001; 95% confidence interval 0.960-0.978). Sensitivity and specificity were 95% and 81.7% at the cutoff value of 0.9 (probability of survival 90%), respectively.

Conclusion : The PITH model performed better than the GCS; Revised Trauma Score; and mechanism of injury, GCS, age, and arterial pressure. It will be a useful triage method for isolated traumatic brain injury in the early phase of management.

Conclusion (proposition de traduction) : Le modèle PITH a donné de meilleurs résultats que le Glasgow, le Revised Trauma Score et le mécanisme de la blessure, le Glasgow, l'âge et la pression artérielle.
Il semble être une méthode de triage utile pour les traumatismes crâniens isolés dans la phase initiale de la prise en charge.

Approach to the Agitated Emergency Department Patient.
Gottlieb M, Long B, Koyfman A. | J Emerg Med. 2018 Apr;54(4):447-457
Keywords: agitation; antipsychotic; benzodiazepine; control; delirium; ketamine; physical restraint; psychosis

Original research article

Introduction : Acute agitation is a common occurrence in the emergency department (ED) that requires rapid assessment and management.

Méthode : This review provides an evidence-based summary of the current ED evaluation and management of acute agitation.

Discussion : Acute agitation is an increasingly common presentation to the ED and has a broad differential diagnosis including metabolic, neurologic, infectious, toxicologic, and psychiatric etiologies. Missed diagnosis of a dangerous etiology of the patient's agitation may result in severe morbidity and mortality. Assessment and management of the agitated patient should occur concurrently. Focused history and physical examination are recommended, though control of the patient's agitation may be required. All patients should receive a point-of-care glucose test, with additional testing depending upon the specific patient presentation. Initial management should involve verbal de-escalation techniques, followed by pharmacologic interventions, with physical restraints reserved as a last resort. Pharmacologic options include first-generation antipsychotics, second-generation antipsychotics, benzodiazepines, and ketamine. Finally, the management of pediatric, pregnant, and elderly patients warrants special consideration.

Conclusion : Acute agitation is an important presentation that requires prompt recognition and treatment. A focused and thorough examination coupled with appropriate management strategies can assist emergency clinicians to safely and effectively manage these patients.

Conclusion (proposition de traduction) : L'agitation aiguë est un motif de recours fréquent qui nécessite une reconnaissance et un traitement rapides. Un examen ciblé et approfondi associé à des stratégies de prise en charge appropriées peut aider les cliniciens des urgences à gérer efficacement et en toute sécurité ces patients.

The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma.
Bores SA, Pajerowski W, Carr BG, Holena D, Meisel ZF, Mechem CC, Band RA. | J Emerg Med. 2018 Apr;54(4):487-499.e6
Keywords: prehospital care; resuscitation

Original research article

Introduction : The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care.
OBJECTIVE: We sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality.

Méthode : We conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered.

Résultats : There were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score-predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47-1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96-1.08).

Conclusion : We found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma.

Conclusion (proposition de traduction) : Nous n'avons trouvé aucune différence significative en ce qui concerne la mortalité ou le temps d'appel des EMS entre les patientes qui ont reçu ou non une intraveineuse préhospitalière pour un traumatisme pénétrant.

The Journal of Trauma and Acute Care Surgery

Speed is not everything: Identifying patients who may benefit from helicopter transport despite faster ground transport.
Chen X, Gestring ML, Rosengart MR, Billiar TR, Peitzman AB, Sperry JL, Brown JB. | J Trauma Acute Care Surg. 2018 Apr;84(4):549-557
Keywords: Aucun

AAST 2017 Podium Paper

Introduction : Helicopter emergency medical services (HEMS) have demonstrated survival benefits over ground emergency medical services (GEMS) for trauma patient transport. While HEMS speed is often-cited, factors such as provider experience and level of care may also play a role. Our objective was to identify patient groups that may benefit from HEMS even when prehospital time for helicopter utilization is longer than GEMS transport.

Méthode : Adult patients transported by HEMS or GEMS from the scene of injury in the Pennsylvania State Trauma Registry were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS, keeping only pairs in which the HEMS patient had longer total prehospital time than the matched GEMS patient. Mixed-effects logistic regression evaluated the effect of transport mode on survival while controlling for demographics, admission physiology, transfusions, and procedures. Interaction testing between transport mode and existing trauma triage criteria was conducted and models stratified across significant interactions to determine which criteria identify patients with a significant survival benefit when transported by HEMS even when slower than GEMS.

Résultats : From 153,729 eligible patients, 8,307 pairs were matched. Helicopter emergency medical services total prehospital time was a median of 13 minutes (interquartile range, 6-22) longer than GEMS. Patients with abnormal respiratory rate (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.26-4.55; p = 0.01), Glasgow Coma Scale score of 8 or less (OR, 1.61; 95% CI, 1.16-2.22; p < 0.01), and hemo/pneumothorax (OR, 2.25; 95% CI, 1.06-4.78; p = 0.03) had a significant survival advantage when transported by HEMS even with longer prehospital time than GEMS. Conversely, there was no association between transport mode and survival in patients without these factors (p > 0.05).

Conclusion : Patients with abnormal respiratory rate, Glasgow Coma Scale score of 8 or less, and hemo/pneumothorax benefit from HEMS transport even when GEMS transport was faster. This may indicate that these patients benefit primarily from HEMS care, such as advanced airway and chest trauma management, rather than simply faster transport to a trauma center.

Conclusion (proposition de traduction) : Les patients présentant une fréquence respiratoire anormale, un score de de Glasgow inférieur ou égal à 8 et un hémo/pneumothorax bénéficient du transport des services médicaux d'urgence par hélicoptère, même lorsque le transport des services médicaux d'urgence au sol était plus rapide.
Cela peut indiquer que ces patients bénéficient principalement des soins médicaux d'urgence d'Helicopter, comme la gestion avancée des voies respiratoires et des traumatismes thoraciques, plutôt qu'un transport plus rapide vers un centre de traumatologie.

Commentaire : Il semble bien que, plutôt que le moyen de transport, ce soit la prise en charge des détresses sur place qui soit à l'origine des meilleurs résultats !

The intraosseous have it: A prospective observational study of vascular access success rates in patients in extremis using video review.
Chreiman KM, Dumas RP, Seamon MJ, Kim PK, Reilly PM, Kaplan LJ, Christie JD, Holena DN. | J Trauma Acute Care Surg. 2018 Apr;84(4):558-563
Keywords: Aucun

AAST 2017 Podium Paper

Introduction : Quick and successful vascular access in injured patients arriving in extremis is crucial to enable early resuscitation and rapid OR transport for definitive repair. We hypothesized that intraosseous (IO) access would be faster and have higher success rates than peripheral intravenous (PIV) or central venous catheters (CVCs).

Méthode : High-definition video recordings of resuscitations for all patients undergoing emergency department thoracotomy from April 2016 to July 2017 were reviewed as part of a quality improvement initiative. Demographics, mechanism of injury, access type, access location, start and stop time, and success of each vascular access attempt were recorded. Times to completion for access types (PIV, IO, CVC) were compared using Kruskal-Wallis test adjusted for multiple comparisons, while categorical outcomes, such as success rates by access type, were compared using χ test or Fisher's exact test.

Résultats : Study patients had a median age of 30 years (interquartile range [IQR], 25-38 years), 92% were male, 92% were African American, and 93% sustained penetrating trauma. A total of 145 access attempts in 38 patients occurred (median, 3.8; SD, 1.4 attempts per patient). There was no difference between duration of PIV and IO attempts (0.63; IQR, 0.35-0.96 vs. 0.39 IQR, 0.13-0.65 minutes, adjusted p = 0.03), but both PIV and IO were faster than CVC attempts (3.2; IQR, 1.72-5.23 minutes; adjusted p < 0.001 for both comparisons). Intraosseous lines had higher success rates than PIVs or CVCs (95% vs. 42% vs. 46%, p < 0.001).

Conclusion : Access attempts using IO are as fast as PIV attempts but are more than twice as likely to be successful. Attempts at CVC access in patients in extremis have high rates of failure and take a median of over 3 minutes. While IO access may not completely supplant PIVs and CVCs, IO access should be considered as a first-line therapy for trauma patients in extremis.

Conclusion (proposition de traduction) : Les tentatives d'accès intra-osseuses sont aussi rapides que les tentatives intraveineuses périphériques, mais elles ont plus de deux fois plus de chances de réussir. Les tentatives de pose de cathéter veineux central chez les patients en phase terminale ont des taux d'échec élevés et prennent une médiane de plus de 3 minutes.
Bien que l'accès intra-osseux puisse ne pas complètement supplanter les cathéters veineux centraux et intraveineux périphériques, l'accès intra-osseux doit être considéré comme un traitement de première intention chez les patients traumatisés en phase terminale.


Echocardiographic changes with non-invasive ventilation and CPAP in obesity hypoventilation syndrome.
Corral J, Mogollon MV, Sánchez-Quiroga MÁ, Gómez de Terreros J, Romero A, Caballero C, Teran-Santos J, Alonso-Álvarez ML, Gómez-García T, González M, López-Martínez S, de Lucas P, Marin JM, Romero O, Díaz-Cambriles T, Chiner E, Egea C, Lang RM, Mokhlesi B, Masa JF; Spanish Sleep Network. | Thorax. 2018 Apr;73(4):361-368
Keywords: non invasive ventilation; sleep apnoea


Introduction : Despite a significant association between obesity hypoventilation syndrome (OHS) and cardiac dysfunction, no randomised trials have assessed the impact of non-invasive ventilation (NIV) or CPAP on cardiac structure and function assessed by echocardiography.

Méthode : We performed a secondary analysis of the data from the largest multicentre randomised controlled trial of OHS (Pickwick project, n=221) to determine the comparative efficacy of 2 months of NIV (n=71), CPAP (n=80) and lifestyle modification (control group, n=70) on structural and functional echocardiographic changes.
METHODS: Conventional transthoracic two-dimensional and Doppler echocardiograms were obtained at baseline and after 2 months. Echocardiographers at each site were blinded to the treatment arms. Statistical analysis was performed using intention-to-treat analysis.

Résultats : At baseline, 55% of patients had pulmonary hypertension and 51% had evidence of left ventricular hypertrophy. Treatment with NIV, but not CPAP, lowered systolic pulmonary artery pressure (-3.4 mm Hg, 95% CI -5.3 to -1.5; adjusted P=0.025 vs control and P=0.033 vs CPAP). The degree of improvement in systolic pulmonary artery pressure was greater in patients treated with NIV who had pulmonary hypertension at baseline (-6.4 mm Hg, 95% CI -9 to -3.8). Only NIV therapy decreased left ventricular hypertrophy with a significant reduction in left ventricular mass index (-5.7 g/m2; 95% CI -11.0 to -4.4). After adjusted analysis, NIV was superior to control group in improving left ventricular mass index (P=0.015). Only treatment with NIV led to a significant improvement in 6 min walk distance (32 m; 95% CI 19 to 46).

Conclusion : In patients with OHS, medium-term treatment with NIV is more effective than CPAP and lifestyle modification in improving pulmonary hypertension, left ventricular hypertrophy and functional outcomes. Long-term studies are needed to confirm these results.

Conclusion (proposition de traduction) : Chez les patients atteints de syndrome d'hypoventilation de l'obésité, le traitement à moyen terme par la VNI est plus efficace que la CPAP et la modification du mode de vie pour améliorer l'hypertension pulmonaire, l'hypertrophie ventriculaire gauche et les résultats fonctionnels. Des études à long terme sont nécessaires pour confirmer ces résultats.

Mois d'avril 2018